[ANSWERED 2024] Select a child or adolescent patient that you examined during the last 3 weeks who presented with a disorder for which you have not already created a Focused SOAP Note in Weeks 3 or 7

Select a child or adolescent patient that you examined during the last 3 weeks who presented with a disorder

Focused SOAP Note and Patient Case Presentation

For this Assignment you will document information about a patient that you examined during the last 3 weeks, using the Focused SOAP Note Template provided. You will then use this note to develop and record a case presentation for this patient. Be sure to incorporate any feedback you received on your Week 3 and Week 7 case presentations into this final presentation for the course.

• Select a child or adolescent patient that you examined during the last 3 weeks who presented with a disorder for which you have not already created a Focused SOAP Note in Weeks 3 or 7. (For instance, if you selected a patient with anorexia nervosa in Week 7, you must choose a patient with another type of disorder for this week.)
• Create a Focused SOAP Note on this patient using the template provided in the Learning Resources. There is also a completed Focused SOAP Note Exemplar provided to serve as a guide to assignment expectations.Please Note:
  • All SOAP notes must be signed, and each page must be initialed by your Preceptor. Note: Electronic signatures are not accepted.
  • When you submit your note, you should include the complete focused SOAP note as a Word document and PDF/images of each page that is initialed and signed by your Preceptor.
  • You must submit your SOAP note using SafeAssign. Note: If both files are not received by the due date, faculty will deduct points per the Walden Grading Policy.
• Then, based on your SOAP note of this patient, develop a video case study presentation. Take time to practice your presentation before you record.
• Include at least five scholarly resources to support your assessment, diagnosis, and treatment planning.
• Ensure that you have the appropriate lighting and equipment to record the presentation.

The Assignment

Record yourself presenting the complex case for your clinical patient.

Do not sit and read your written evaluation! The video portion of the assignment is a simulation to demonstrate your ability to succinctly and effectively present a complex case to a colleague for a case consultation. The written portion of this assignment is a simulation for you to demonstrate to the faculty your ability to document the complex case as you would in an electronic medical record. The written portion of the assignment will be used as a guide for faculty to review your video to determine if you are omitting pertinent information or including non-essential information during your case staffing consultation video.

In your presentation:

• Dress professionally and present yourself in a professional manner.
• Display your photo ID at the start of the video when you introduce yourself.
• Ensure that you do not include any information that violates the principles of HIPAA (i.e., don’t use the patient’s name or any other identifying information).
• Present the full complex case study. Include chief complaint; history of present illness; any pertinent past psychiatric, substance use, medical, social, family history; most recent mental status exam; current psychiatric diagnosis including differentials that were ruled out; and plan for treatment and management.
• Report normal diagnostic results as the name of the test and “normal” (rather than specific value). Abnormal results should be reported as a specific value.
• Be succinct in your presentation, and do not exceed 8 minutes. Specifically address the following for the patient, using your SOAP note as a guide:
  • Subjective: What details did the patient provide regarding their chief complaint and symptomology to derive your differential diagnosis? What is the duration and severity of their symptoms? How are their symptoms impacting their functioning in life?
  • Objective: What observations did you make during the psychiatric assessment?
  • Assessment: Discuss their mental status examination results. What were your differential diagnoses? Provide a minimum of three possible diagnoses and why you chose them. List them from highest priority to lowest priority. What was your primary diagnosis, and why? Describe how your primary diagnosis aligns with DSM-5 diagnostic criteria and supported by the patient’s symptoms.
  • Plan: In your video, describe your treatment plan using clinical practice guidelines supported by evidence-based practice. Include a discussion on your chosen FDA-approved psychopharmacologic agents and include alternative treatments available and supported by valid research. All treatment choices must have a discussion of your rationale for the choice supported by valid research. What were your follow-up plan and parameters? What referrals would you make or recommend as a result of this treatment session?
  • In your written plan include all the above as well as include one social determinant of health according to the HealthyPeople 2030 (you will need to research) as applied to this case in the realm of psychiatry and mental health. As a future advanced provider, what are one health promotion activity and one patient education consideration for this patient for improving health disparities and inequities in the realm of psychiatry and mental health? Demonstrate your critical thinking.
  • Reflection notes: What would you do differently with this patient if you could conduct the session over? If you are able to follow up with your patient, explain whether these interventions were successful and why or why not. If you were not able to conduct a follow up, discuss what your next intervention would be.

Expert Answer and Explanation

SOAP Note for Anxiety Disorder 

Subjective:

CC (chief complaint): “I have anger and severe anxiety with mood swings.”

HPI: MM is a 16-year-old African American female who presents for assessment. The patient complains of anger and severe anxiety with mood swings. She has experienced anxiety and worry for the last year and cannot control her worry once worried. She sometimes feels restless, irritable, and fatigued. She noted that she has a poor relationship with her mother and this worries her.

She also notes that she is not open with her mother and finds it hard to share her feelings. She says that there was a time when argued with her mother and punched the door and threw a chair at her. She also poured soda on the ground and left after she was kicked out by her mother. she noted that she became violent because she was frustrated. She also gets in trouble in school and was once suspended for illicit drug use. She rates her anxiety is a scale of 7/10. 

Substance Current Use: She reports using illicit drugs once. 

Medical History: She was diagnosed with anxiety disorder. 

• Current Medications: She takes Lexapro and Vistaril for anxiety.
• Allergies: No allergies. 
• Reproductive Hx: No reproductive problems. 

ROS: 

• GENERAL: She reports no chills, fever, or weight changes. 
• HEENT: No visual problems, no hearing loss, no runny nose and congesting, no swelling of the tonsils or sore throat. 
• SKIN: No rashes. 
• CARDIOVASCULAR: No chest pain, pressure, or discomfort. 
• RESPIRATORY: No cough or shortness of breath. 
• GASTROINTESTINAL: No diarrhea, vomiting, or nausea. No abdominal pain. 
• GENITOURINARY: No urinary problems. 
• NEUROLOGICAL: No headache or ataxia. 
• MUSCULOSKELETAL: No joint or muscle pain. No muscle or joint stiffness. 
• HEMATOLOGIC: No bleeding. 
• LYMPHATICS: No swelling of the lymph nodes. 
• ENDOCRINOLOGIC: No heat or cold problems. 

Objective:

Vital Signs: BP 102/80, RR 18, P 66, Ht. 4’6, Wt. 48kgs, Temp 35.8. 

Physical Exam

• Cardiovascular: Regular rhythm and rates. No heart murmurs. 
• Respiratory: No fluids in the lungs. No cracks on the chest walls. No breathing distress.  
• Skin: No rashes. 

Diagnostic results: 

Generalized Anxiety Disorder 7-item (GAD-7): OASIS is a tool used to assess impairment linked to any type of anxiety disorder. Sandora et al. (2021) noted that OASIS is a valid and reliable tool for screening people for anxiety disorders. 

Assessment:

Mental Status Examination: The patient appears her stated age. Her weight is normal and is consistent with her height. She answers questions correctly. Her speech is normal. She reports a normal mood which is consistent with affect. She denies hallucinations, delusions, or obsessions. She shows irritable behavior. She is alert and oriented to place, time, and people. She has poor concentration, especially when she is worried. She denies suicidal or homicidal thoughts. Judgment and insight are fair. Memory is intact. 

Diagnostic Impression: 

• Generalized Anxiety Disorder (GAD) DSM-5 300.02 (F41.1): The primary diagnosis for this case is GAD. GAD is a long-term mental health problem that makes one feel worried and anxious about a lot of issues (Price et al., 2019). Price et al. (2019) noted that GAD makes one feel anxious most of the time. The symptoms of GAD include excessive and uncontrolled worry and anxiety most days for more than 6 months accompanied by at least three symptoms of, irritability, restlessness, easily fatigued, muscle tension, difficulty concentrating, and sleep problems (American Psychiatric Association, 2013). GAD is the primary diagnosis because the patient has excessive and severe anxiety and worry, restlessness, irritability, and fatigue, which are the main symptoms of the disease. 
• Intermittent Explosive Disorder (IED) DSM-5 312.34 (F63.81): The second diagnosis is IED. IED is an impulsive-conduct disorder characterized by verbal aggressions and behavioral outbursts (Coccaro et al., 2018). Patients with the disorder have temper tantrums and engage in verbal arguments. This disorder has been included because the patient has an anger problem and verbally argued with her mother (APA, 2013). However, the disorder has been ruled out because it can better be experienced as a symptom of anxiety disorder. 
• Oppositional Defiant Disorder. 313.81 (F91.3): The last diagnosis is ODD. ODD makes have been diagnosed because the patient has anger problems, argued with her mother, and is sometimes irritable (Dachew et al., 2021). However, the disorder has been ruled out because her anger and defiant behavior are geared toward her mother and not someone outside the family (APA, 2013). 

Reflections:

I agree with the preceptor’s diagnosis because it is supported by DSM-5 criteria. I have learned from the case that mental health professionals should make diagnostic decisions based on the DSM-5 criteria to avoid misdiagnosis. I have also learned that a combination of pharmacological and non-pharmacological therapy is more effective than one of the treatments in isolation. I would increase the dosage of the medication if the patient shows the same signs after the follow-up. 

Case Formulation and Treatment Plan: 

Based on the assessment findings, the patient has GAD. She should continue taking Lexapro and Vistaril for anxiety. A study by Strawn et al. (2020) showed that Lexapro reduces anxiety symptoms. Aleo et al. (2021) also found that a combination of Vistaril and Lexapro improves the mental health of individuals with anxiety. The patient should return to the clinic after two weeks for a follow-up. She should also be urged to start cognitive behavior therapy and family therapy. 

References

Aleo, E., Picado, A. L., Abancens, B. J., Soto Beauregard, C., Tur Salamanca, N., Esteban Polonios, C., & San Pedro de Urquiza, B. (2021). Evaluation of the effect of hydroxyzine on preoperative anxiety and anesthetic adequacy in children: Double blind randomized clinical trial. BioMed Research International, 2021. https://doi.org/10.1155/2021/7394042

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders, Fifth Edition. American Psychiatric Publishing Association.

Coccaro, E. F., Shima, C. K., & Lee, R. J. (2018). Comorbidity of personality disorder with intermittent explosive disorder. Journal of Psychiatric Research, 106, 15-21. https://doi.org/10.1016/j.jpsychires.2018.08.013

Dachew, B. A., Scott, J. G., Heron, J. E., Ayano, G., & Alati, R. (2021). Association of maternal depressive symptoms during the perinatal period with oppositional defiant disorder in children and adolescents. JAMA Network Open, 4(9), e2125854-e2125854. doi:10.1001/jamanetworkopen.2021.25854

Price, M., Legrand, A. C., Brier, Z. M., & Hébert-Dufresne, L. (2019). The symptoms at the center: Examining the comorbidity of posttraumatic stress disorder, generalized anxiety disorder, and depression with network analysis. Journal of Psychiatric Research, 109, 52-58. https://doi.org/10.1016/j.jpsychires.2018.11.016

Sandora, J., Novak, L., Brnka, R., van Dijk, J. P., Tavel, P., & Malinakova, K. (2021). The abbreviated overall anxiety severity and impairment scale (Oasis) and the abbreviated overall depression severity and impairment scale (odsis): Psychometric properties and evaluation of the czech versions. International Journal of Environmental Research and Public Health, 18(19), 10337. https://doi.org/10.3390/ijerph181910337

Strawn, J. R., Mills, J. A., Schroeder, H., Mossman, S. A., Varney, S. T., Ramsey, L. B., Poweleit, E. A., Desta, Z., Cecil, K., & DelBello, M. P. (2020). Escitalopram in adolescents with generalized anxiety disorder: A double-blind, randomized, placebo-controlled study. The Journal Of Clinical Psychiatry, 81(5), 20m13396. https://doi.org/10.4088/JCP.20m13396

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RUBRIC: 

• Time
• Discuss Subjective data:• Chief complaint• History of present illness (HPI)• Medications• Psychotherapy or previous psychiatric diagnosis• Pertinent histories and/or ROS
• Discuss Objective data:• Physical exam documentation of systems pertinent to the chief complaint, HPI, and history• Diagnostic results, including any labs, imaging, or other assessments needed to develop the differential diagnoses
• Discuss results of Assessment:• Results of the mental status examination• Provide a minimum of three possible diagnoses in order of highest to lowest priority and explain why you chose them. What was your primary diagnosis and why? Describe how your primary diagnosis aligns with DSM-5 diagnostic criteria and is supported by the patient’s symptoms.
• Discuss treatment Plan:• A treatment plan for the patient that addresses chosen FDA-approved psychopharmacologic agents and includes alternative treatments available and supported by valid research. The treatment plan includes rationales, a plan for follow-up parameters, and referrals. The discussion includes one social determinant of health according to the HealthyPeople 2030, one health promotion activity and one patient education consideration for this patient for improving health disparities and inequities in the realm of psychiatry and mental health.
• Reflect on this case. Discuss what you learned and what you might do differently.
• Focused SOAP Note documentation
• Presentation style.

CASE STUDY TO USE FOR THE ASSIGNMENT:

-Hospital or Specialty Care Facility

Age: Adolescent (13-17 years)

Sex: Female

Visit InformationStudent Level of Function: Joint Care – Level 3

Category of Care: Direct Patient Care

Practice Management

Type of visit: Consultation

Diagnosis

1 Anxiety Disorder

2 Impulse-Control Disorder

Student Notes

9/29/2022  Patient # 35 16-year-old female who presents for assessment. She believes that she has \”anger and severe anxiety with mood swings.\” She is worried about her poor relationship with her mother and that she is not open enough with her and feels uncomfortable telling her how she feels. She states that there was an argument where she punched the door, threw a chair at her mother, poured soda on the ground, and left after her mom kicked her out.

She states that her violence was out of frustration. She states that she sometimes gets in trouble at school and once suspended for illicit drug use. Medications Lexapro and Vistaril for anxiety with CBT and family therapy ordered. Follow up in two weeks.