Pt BB is a 27 yo woman with previous treatment for depression, presenting of worsening depressed and mood
Pt BB is a 27 yo woman with previous treatment for depression, presenting of worsening depressed and mood
Pt case:
Pt BB is a 27 yo woman with previous treatment for depression, presenting of worsening depressed and mood. pt also indicated a history of trauma, which she did not want to disclose. pt was cooperative and relatively forthcoming with most details, but remained guarded. Indicated that she has had suicidal thoughts since childhood (as well as depression) and at this point feels it is part of her identity. Pt is able to contract for safety. Has concerns about taking medications, and not wanting to be a “zombie”; pt had one previous trial of lexapro years ago and developed a rash. No current psychiatric medications. Counseled pt about potential benefit of another SSRI trial, specifically zoloft.
In addition to her depressive symptoms (fatigue, interrupted sleep, anhedonia, low mood), she does describe a pattern of obsessional thinking, dating back to childhood, in which she will attempt to imagine worst-case scenarios in order to prevent them from happening. Also self-reports obsessional thinking about her identity, “my queerness”, which she endorses as tiring and excessive; also states she can ruminate on relationships to a degree that she finds excessive. At times can also struggle with making decisions, including about daily tasks such as eating. Indicates she does feel safe again endorsing chronic, lifelong Suicidal Ideation but no present intent or plan. PT HAS NO ALLRGIES. sHE IS TYPE 1 DIABETIC. AND TAKES Levimir 17 units qhs: Hx. Humalog (carb controlled at home + sliding scale): Hx. Plant to begin Medication Trileptal 300mg BID, and Zoloft 50 qam. Follow up appointment in 2 week. Referred to new therapist.
FOCUSED SOAP NOTE AND PATIENT CASE PRESENTATION, PART 1
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.
RESOURCES
Be sure to review the Learning Resources before completing this activity.
Click the weekly resources link to access the resources.
TO PREPARE
- Review the Kaltura button from the Classroom Support Center (accessed via the Help button) for help creating your self-recorded Kaltura video.
- 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.
PleaseNote:- 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.
BY DAY 7 OF WEEK 9
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.
SUBMISSION INFORMATION – PART 1: VIDEO SUBMISSION
To submit your video response entry:
- Click on Start Assignment near the top of the page.
- Next, click Text Entry and then click the Embed Kaltura Media button.
- Select your recorded video under My Media.
- Check the box for the End-User License Agreement and select Submit Assignment for review.
SUBMISSION INFORMATION – PART 2: FOCUSED SOAP NOTE SUBMISSION
To submit Part 2 of this Assignment, click on the following link:
Requirements: use template
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