25 Oct 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 Te

Case study presentation

Cc Psych eval

HISTORY: Aiden is a 5-year-old boy. This evaluation was requested because "the primary care

doctor want us to have an evaluation for ADHD". Mother report that patient has "been having a lot

of issues at school. He walks around the class, hit, push, shove other students, interupt others,

unable to wait his turn or complete his work. he cannot work in group setting. he even pushed

someone yesterday at school and he was send home early. the other person has injury. the teacher

had to put his chair at her table just to prevent distraction but it has not helped". mother report that

patient's classroom teacher and herself completed the vanderbilt form that was provided by pcp.

Information Received From: patient and mother

Behavior Described In:

Aiden exhibits hyperactive and attentional difficulties both in school and at home.

ADHD Symptoms:

Aiden exhibits symptoms of inattention. Careless mistakes are typical. He reports difficulty

sustaining attention. He does not seem to listen when spoken to directly. He often needs directions

repeated. Projects or tasks are often not completed. He needs extra time to complete his

assignments. Aiden reports being disorganized. He finds it difficult to keep his book bag or school

locket organized. Tasks requiring sustained mental effort are difficult for Aiden to accomplish. His

mind easily wanders or becomes distracted. Aiden is easily distracted by other people. by the

radio. by noises. He describes being inattentive. He often needs directions repeated. He has a

short attention span. Aiden needs supervision or frequent redirection.

Aiden exhibits signs of hyperactivity. He exhibits restlessness or fidgety behavior. This

behavior is evident during school hours. He has a tendency to frequently leave his seat. Playing

quietly is difficult for Aiden . He is always “on the go” , and is unable to be still for an extended

period of time. He is easily bored and changes activities frequently. Aiden 's excessive movement

has been noted. He is fidgety or squirms when required to sit still for a period of time. He

frequently jumps or climbs.

Aiden exhibits signs of impulsive behavior. He frequently interrupts others. He has

problems waiting for his turn. He often acts in a reckless manner (has sustain multiple injury from

jumping, hiting his head etc) .

Severity:

The attentional difficulties described cause moderate impairment in Aiden 's functioning.

Respiratory: hx of asthma

Review of all other systems reviewed were negative. No Test Results were received.

The Vanderbilt Assessment Scale:

A questionnaire that scans for symptoms of ADHD, ODD, Conduct Disorder, and

anxiety/depression in children. Aiden 's assessment results are as follows:

*Parent's Assessment:

Scoring indicates the presence of ADHD, combined Hyperactive/Inattentive type.

*Teacher's Assessment: Scoring indicates the presence of ADHD, combined

Hyperactive/Inattentive type.

PAST PSYCHIATRIC HISTORY:

Psychiatric Hospitalization:

Aiden has never been psychiatrically hospitalized.

Outpatient Treatment:

Has never received outpatient mental health treatment.

Suicidal/Self Injurious:

Aiden has no history of suicidal or self injurious behavior.

Psychotropic Medication History:

Psychotropic medications have never been prescribed for Aiden

EXAM: Aiden presents as happy, distracted, well groomed, normal weight child. He exhibits

speech that is normal in rate, volume, and articulation and is coherent and spontaneous. Language

skills are appropriate for age.. Affect is appropriate, full range, and congruent with mood.

Associations are intact and logical. There are no apparent signs of hallucinations, delusions,

bizarre behaviors, or other indicators of psychotic process. cognitive functioning appropriate for

age. Insight into problems appears fair. Judgment appears to be poor. He is easily distracted. A

short attention span is evident. There is physical hyperactivity. Aiden is fidgety. Aiden is restless

during assessment. Aiden was intrusive during the examination. Supine blood pressure is 98 / 52.

Supine pulse rate is 69. Weight is 65 lbs. (29.5 Kg). TREATMENT PLAN she was

Hesitant due to cultural background, educational material on medication and diagnosis given to

mother who was encouraged to call and make appointment when she is ready to begin treatment.

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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.

To Prepare

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..

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.

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.

The Assignment

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.

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.

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Week (enter week #): (Enter assignment title)

Student Name

College of Nursing-PMHNP, Walden University

NRNP 6665: PMHNP Care Across the Lifespan I

Faculty Name

Assignment Due Date

Subjective:

CC (chief complaint):

HPI:

Substance Current Use:

Medical History:

· Current Medications:

· Allergies:

· Reproductive Hx:

ROS:

· GENERAL:

· HEENT:

· SKIN:

· CARDIOVASCULAR:

· RESPIRATORY:

· GASTROINTESTINAL:

· GENITOURINARY:

· NEUROLOGICAL:

· MUSCULOSKELETAL:

· HEMATOLOGIC:

· LYMPHATICS:

· ENDOCRINOLOGIC:

Objective:

Diagnostic results:

Assessment:

Mental Status Examination:

Diagnostic Impression:

Reflections:

Case Formulation and Treatment Plan: 

References