Patient Case Presentation

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QUESTION
Assignment 2: 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.
To Prepare
• Select a patient of any age (either a child or an adult) that you examined during the last 3 weeks.
• 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:
o You must submit your SOAP note using SafeAssign authentication.
• Include at least five scholarly resources to support your assessment, diagnosis, and treatment planning.
• Your focus soap notes for a 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. 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?
• Allergies
• Review Of System
• 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: What was your plan for psychotherapy? What was your plan for treatment and management, including alternative therapies? Include pharmacologic and nonpharmacologic treatments, alternative therapies, and follow-up parameters, as well as a rationale for this treatment and management plan. Also be sure to include at least one health promotion activity and one patient education strategy.
• 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.
• Remember to use the sampler/template attached
CASE STUDY INFORMATION
Patient seen today via zoom. Patient provides verbal consent for this telehealth visit. Patient affirms that she is within the state of Maryland for this entire telehealth session. Patient is a 17-year-old AA female who is alert and oriented to person, place, time and situation.
Patient presented with her mom for follow up treatment of Major depressive disorder, Recurrent episode (Moderate), Generalized Anxiety Disorder and PTSD. The pt voiced feeling very tired from her “Third round of writing my school essay” that apparently was returned for final details. The pt states that she takes power naps throughout her essay re-writing process and caring for her child. The pt was pleased to report that she will begin reading her new novel this weekend, somehow at the same time of her essay re-write. This probably was not the best decision, however the pt states that she feels that she can manage it.
The patient is cleanly dressed female with makeup and her speech is regular rate, volume and prosody. She appears to be sitting comfortably and she exhibits good eye contact and is pleasantly engaging. Mood is euthymic with appropriate full range of affect. Cognition was grossly intact. Insight & judgment are good. The patient denies SI or HI and has no intent or plans for same.
The pt continues with her attempts at overcoming hurdles of school. Her mother tries to help out with the cooking, although the mother has full time employment that limits her contributions. Patient report sexual abused over the years by a family member/uncle. She has a one year on old baby.
Allergies/Adverse Effects: penicillin – swelling and rash, clindamycin – swelling and rash
morphine – swelling and rash, codeine – swelling and rash
Psychiatric admissions: Wash Adventist when pt. was 5yrs old, Kaiser for treatment – every 2 months
Substance Hx: Self-medicated with alcohol around 14 yo with blackouts and binges and none since then; Marijuana- Pt reported that she smoked marijuana when she was a ten
Plan/Recommendations:
1. We discussed the possible risks, benefits and alternatives of Cymbalta (duloxetine) 30 mg po BID for targeting depression and the pt gave her informed consent.
2. We discussed the possible risks, benefits and alternatives of Abilify (aripiprazole) 5 mg po daily to as a mood stabilizer
3. We discussed the possible risks, benefits and alternatives of Prozac 10 mg po daily anxiety and the pt gave her informed consent.
4. Patient was advised to remain abstinent from alcohol and non-prescribed drugs.
5. Patient was educated about the importance of compliance with treatment

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