Pediatric Anxiety and OCD -Case Sudy

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QUESTION
Case Study
Cora is a seven-year-old girl, the second of two children of a middle-class family living in a suburban area of a northwest city. Cora has one sister that is two years older than her. Her mother’s pregnancy was normal, with no complications and Cora’s birth was normal. Cora had colic the first three months, cried extensively, and was difficult to comfort. After three months she became passive and cried very little with comfort from her mother. Her growth and development appeared to be normal. She met all the developmental milestones in her first three years. She interacted normally with her sister and parents, except that she would become tearful and anxious when her parents would get a babysitter.
At age four, she was in nursery school and appeared to function normally except during the first month when Cora had difficulty when her father would drop her off at school. The nursery school was a small private school with a lot of personal attention given to each child. Although shy, she made friends and liked going to nursery school after she became adjusted to the new setting. Her parents liked the school so much that they decided to keep Cora in kindergarten at this school with her same teachers and friends. However, tuition at the school became a problem after Cora’s mother became sick with lupus and was unable to work.
At age six, Cora’s parents enrolled her in first grade at the public elementary school in their neighborhood. For the last two weeks, she has refused to go to school and has missed six school days. She began routinely brushing her hair before bed and insisted on making sure each side was brushed with an even number of strokes. She also had her mother tuck her in bed on the right side and her father come after on the left side each night. She would become very tearful and upset if the routine was not followed. She is awake almost all night worrying about going to school and asks the same questions over and over about the environment, teachers, and other students. As the start of the school day approaches, she cries and screams that she cannot go, chews holes in her shirt, pulls her hair, digs at her face, punches the wall, throws herself on the floor, as well as experiences headaches, stomachaches, and vomiting. Over the past two weeks, she has become gloomy, has stopped reading for fun, and frequently worries about her mother’s Lupus and that she may die. She asks her every night if she has dreamed about her funeral. In addition, Cora is phobic of dogs, avoids speaking and writing in public, and wets the bed every night.
Her parents immediately made an appointment to see her PCP. Her doctor conducted a thorough physical exam, found no physical abnormalities, and then referred her to you, a Family PMHNP.
Family history of mental health includes the following: mother has a history of panic disorder; her father has a history of treatment with medications for ADHD as a child, and she has a cousin diagnosed with Asperger’s syndrome.
Instructions
For your assignment, write a soap note that addresses the following prompts using evidence-based references to support your answers:
SOAP note should include: Use the Soap note template and answer all questions on the template and answer the following question as well
1.What is the Chief compliant.
2.What is the History of present illness
3.What is your provisional diagnosis, as well as the possible differentials?
4.Justify your answer with DSM-5 criteria (be short, brief, and to the point).
5.Is Cora too young to diagnose, or is there a basis for early identification and intervention?
6.What psychiatric scales or assessment tools might you use with this patient? With the parents? List and describe briefly.
7.What would be your treatment plan for medications, if any? If you do choose to offer medication as part of the treatment plan, please address the following medications issues:
Target symptoms
Receptors affected
Psychiatric and system effects
Possible parental concerns
8.What would be your school-based treatment plan, if any?
9.What would be the implications for the families of children and adolescents with these diagnostic pictures?
10.How does the mother’s health play into the picture of Cora’s diagnosis? What type of therapy would you recommend for Cora (and her family) to work through her issues?
11.Identify resources for patients/families with this diagnosis in the form of community groups, web-sites, advocacy, as well as treatment resources available in your service area.
12.What are you worried about (if anything)? Consider this question in terms of treatment, assessment, alliance, compliance, effectiveness, safety, and other factors.
NU674 Unit 9 Assignment – Case Study Rubric
NU674 Unit 9 Assignment – Case Study Rubric
Criteria Ratings Pts
This criterion is linked to a Learning OutcomeSubjective Data
10 pts
Level 5
Includes all relevant subjective data necessary for differentiation of the client’s problem. Data is presented in a systematic, organized manner consistently.
7 pts
Level 3
Includes most subjective data with omission of two minor details or one major detail. Most data is presented in a systematic, organized manner.
4 pts
Level 1
Includes subjective data but omits four minor details or two major details. Some data is presented in a systematic, organized manner.
0 pts
Level 0
Does not meet the Section
10 pts
This criterion is linked to a Learning OutcomeObjective Data
10 pts
Level 5
Objective data is complete and consistently presented in an organized manner.
7 pts
Level 3
Objective data is complete and presented in an organized manner most of the time.
4 pts
Level 1
Objective data is not complete or is not presented in an organized manner.
0 pts
Level 0
Does not meet the Section
10 pts
This criterion is linked to a Learning OutcomeAssessment
10 pts
Level 5
Assessment, including differential and/or diagnosis (if appropriate), is complete and appropriate to client. Diagnostics are complete and appropriate to clients.
7 pts
Level 3
Assessment, including differential and/or diagnosis (if appropriate), is complete but some may not be appropriate for clients.
4 pts
Level 1
Assessment, including differential and/or diagnosis (if appropriate), is not complete but is appropriate.
0 pts
Level 0
Does not meet the Section
10 pts
This criterion is linked to a Learning OutcomePlan
10 pts
Level 5
Plan includes all relevant measures 95% to 100%. Pharmacologic Non-pharmacologic Education Referral Follow-up
7 pts
Level 3
Plan includes all relevant measures 89% to 94% Pharmacologic Non-Pharmacologic Education Referral Follow-up.
4 pts
Level 1
Plan includes four of the five relevant measures, but the four are complete.
0 pts
Level 0
Does not meet the Section
10 pts
This criterion is linked to a Learning OutcomeProfessional Application
10 pts
Level 5
Case incorporates four evidence-based practice articles.
7 pts
Level 3
Case incorporates three evidence-based practice articles.
4 pts
Level 1
Does not include an evidence-based practice article but has two or more advanced practice articles.
0 pts
Level 0
Does not meet the Section
10 pts
This criterion is linked to a Learning OutcomeCollege-level academic writing
10 pts
Level 5
Includes no more than three grammatical, spelling, or punctuation errors that do not interfere with the readability. Meets the assignment length requirements.
7 pts
Level 3
Includes no more than four grammatical, spelling, or punctuation errors that do not interfere with the readability. Meets the length requirements.
4 pts
Level 1
Includes five or more grammatical, spelling, and punctuation errors make understanding parts of assignment difficult but does not interfere with readability. Meets the length requirements.
0 pts
Level 0
Does not meet the Section
10 pts
Total Points: 60

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