Case study
Chief complaint. I feel overwhelmed, anxious, mood swing and unable to sleep for a week’
HPI. K is 36 years old AA female who presented to the clinic for follow up appointment, history of PTSD depression and anxiety. Kimberly stated that she has been down for about a week now, has not been answering her phone, sad mood. she stated that she has not picked up her medications because she does not want to take any medication and has not seen her therapist. Patient report continuous high level of stress since grandmother moved to hospice care. Report biological mother died last year and was raised by grandmother due to been physical abused by biological mother, Reports was molested by her cousin, stated I hated and dislike my mother and I do have nightmares about her. Patient reports sometimes she gets chest tightness and feeling of impending doom and runs for cover sometimes. She reports feeling depressed and lack of motivation and lack of sleep sometimes, reports she stays awake at night thinking about her grandmother. She reports a difficulty relationship with her boyfriend. She lives with her boyfriend and her two young children 5-year-old, 3-year-old. She works as an animal caretaker and currently on disability due to finger injury. Sister has depression, mother bipolar. K denies legal issues, denies suicidal intentions or ideation, denies homicidal ideation and intention, denies seeing things or hearing voices.
Allergies: No known drug allegations
Current medication Citalopram 20 mg by mouth daily Hydroxyzine HCI 25 mg by mouth twice daily as needed.
Medical history: COPD Hypertension
Mental Status Exam. She is alert and oriented to person, time, place, and situation. Her speech is clear and normal in tone. Her mood appears to be depressed and affect congruent to her mood. She denies visual or auditory hallucinations. No signs of delusional or elevated mood noted.
Assignment : Focused SOAP Note and Patient Case Presentation
Psychiatric notes are a way to reflect on your practicum experiences and connect them to the didactic learning you gain from your NRNP courses. Focused SOAP notes, such as the ones required in this practicum course, are often used in clinical settings to document patient care.
For this Assignment, you will document information about a patient that you examined during the last three weeks, using the Focused SOAP Note Template provided. You will then use this note to develop and record a case presentation for this patient.
To Prepare
Create a Focused SOAP Note on this patient using the template provided in the Learning Resources..
Please Note:
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.
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
. 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.
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.
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 again? 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.
Submit your Video and Focused SOAP Note Assignment. You must submit two files for the note, including a Word document and scanned pdf/images of each page that is initialed and signed by your Preceptor.
Please address the highlights and add four references. Thanks
