Assignment 2: 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.
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
ADHD SOAP Note
John Doe, a 9-years-old boy of Caucasian origin.
CC “The boy’s mother complains that her child has problem focusing on assigned tasks and is easily distracted since November, 2020.”
HPI: John Doe, a 9-years-old boy of Caucasian origin was brought to my office by her mother who noted that her child has problem focusing on assigned tasks and is easily distracted for six months. The patient also notes that the kid has been making “silly” mistakes lately in school and at home. His grades have dropped drastically since January. Associated signs include reluctant to conduct homework, forgetfulness, is always disorganized, and losses most of his things including books, pencils, and school sweater. His symptoms are characterized with poor attention. “This is the first time I have brought him to the facility.
Current Medications: No medication.
Allergies: Allergic to red meet.
PMHx: School immunization schedule up to date. No major health condition.
Soc and Substance Hx: He is an elementary student from one of the local schools and likes to sing. Denies tobacco or alcohol use.
Fam Hx: He is the first child in a family of five. His father is health and does not have any health condition and mother is obese. His younger brother has common cold and the second one is healthy.
Surgical Hx: No previous surgical procedures.
Mental Hx: No history of mental problems.
Violence Hx: No history of violence.
GENERAL: Negative for weight loss, fatigue, fever, or loss of appetite.
SKIN: Negative for itching.
CARDIOVASCULAR: Negative for chest pain or discomfort.
RESPIRATORY: No sputum, cough, or breathing issues.
NEUROLOGICAL: No headache.
PSYCHIATRIC: Denies sleep problems but mother reports that the boy fails to follow instructions, lacks listening skill, and always looks confused.
Vital signs: Temp 38.5, Ht. 4’, weight 36kgs, BP 97/69, HR 40, RR 20.
Constitutional: Patient is clean and well-dressed to the time of the year and weather. He has good relationship with his mother. He answers questions properly but is most of the times distracted starts to look outside or his clothes.
Head: Hair is distributed evenly, pupils are reactive to accommodation and light; round and equal. Ears: Pearly grey bilaterally with positive light reflex. Nose: clear discharge; no septum deviation. Neck: full range of motion and supple. Teeth are all present.
Cardiovascular: S1, S2 heart rate and rhythm regular. No murmurs.
Respiratory: No cracks of chest wall, chest walls symmetric, no wheezes, rhonchi.
Psychiatric: The patient cannot count up to a hundred when told to do so. He seeks not attentive when I ask him some questions. He so forgetful.
Diagnostic and Statistical Manual, Fifth edition (DSM-5) (American Psychiatric Association, 2013): ADHD, inattentive presentation.
- ADHD, inattentive presentation
- Learning disorder
- Conduct disorder
- Oppositional defiant disorder
The primary diagnosis for this case is ADHD, inattentive presentation. This diagnosis has been supported by the mental status exam and subjective data. The patient’s mother notes that the patient has problem focusing on assigned tasks, is easily distracted, reluctant to conduct homework, forgetfulness, is always disorganized, and losses most of his things for six months (Mowlem et al., 2018). mental status exam shows that the patient is inattentive. These symptoms are reflected in the DSM-5’s inattentive presentation of ADHD (APA, 2013).
Based on the DSM-5, the patient has ADHD, inattentive type. Hence, I recommend Ritalin LA 20 mg orally daily in the MORNING (Faraone, 2018). The medication is a CNS stimulant that reduces ADHD symptoms by increasing dopamine presence in the brain (Moran et al., 2019)
Health Promotion and Education
The patient’s mother should be urged to ensure that the patient take medication as prescribed to improve its efficacy.
The patient should be brought back to the help facility after four weeks for assessment and evaluation of treatment plan’s efficiency.
The patient responded well to the medication and his ADHD symptoms had reduced by 50% by third visit. However, I would recommend that his mother take him for cognitive-behavior therapy for further mental health (van Emmerik-van Oortmerssen et al., 2019).
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (DSM-5®). American Psychiatric Pub.
Faraone S. V. (2018). The pharmacology of amphetamine and methylphenidate: Relevance to the neurobiology of attention-deficit/hyperactivity disorder and other psychiatric comorbidities. Neuroscience and biobehavioral reviews, 87, 255–270. https://doi.org/10.1016/j.neubiorev.2018.02.001
Moran, L. V., Ongur, D., Hsu, J., Castro, V. M., Perlis, R. H., & Schneeweiss, S. (2019). Psychosis with Methylphenidate or Amphetamine in Patients with ADHD. The New England journal of medicine, 380(12), 1128–1138. https://doi.org/10.1056/NEJMoa1813751
Mowlem, F., Agnew-Blais, J., Taylor, E., & Asherson, P. (2019). Do different factors influence whether girls versus boys meet ADHD diagnostic criteria? Sex differences among children with high ADHD symptoms. Psychiatry research, 272, 765-773. https://doi.org/10.1016/j.psychres.2018.12.128
van Emmerik-van Oortmerssen, K., Vedel, E., Kramer, F. J., Blankers, M., Dekker, J. J., van den Brink, W., & Schoevers, R. A. (2019). Integrated cognitive behavioral therapy for ADHD in adult substance use disorder patients: results of a randomized clinical trial. Drug and alcohol dependence, 197, 28-36. https://doi.org/10.1016/j.drugalcdep.2018.12.023
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