Focused SOAP Note And Patient Case Presentation

The DSM-5 is a diagnostic tool. It has evolved over the decades, as have the classifications and criteria within its pages. It is used not just for diagnosis, however, but also for billing, access to services, and legal cases. Not all practitioners are in agreement with the content and structure of the DSM-5, and dissociative disorders are one such area. These disorders can be difficult to distinguish and diagnose. There is also controversy in the field over the legitimacy of certain dissociative disorders, such as dissociative identity disorder, which was formerly called multiple personality disorder.

Subjective

The patient is a 21-year-old African American female who was seen today for her initial evaluation via telehealth session with her consent obtained. The patient stated, “I’m seeking a psychiatrist because my primary care physician suggested for me to see a psychiatrist to help me with my anger issues”. She stated that she has not being diagnosed for any mental problem before and not on any medication. The patient stated that she gets angry very quickly, depressed, and very anxious, sometimes without any reason she would lash out on people. “I just had my birthday, and I went out for a dinner with my friends, and I had a good time”. “I hear voices, but not that type of crazy voices that tell you to do somethings”. “It is just from my inner thought, maybe thinking in my head and talking out loud to myself”. She said she just gets irritated here and there from some people. She denies suicidal or homicidal ideation or intent presently. She also denies delusional or hallucination presently.

Objective

The patient is alert and oriented x 4 to person, place, time, and the situation. The patient was seen today in the clinic for initial evaluation via telehealth. The patient appeared very clean and dressed neatly. She has normal eye contact with normal psychomotor activity. Her attention is intact and very cooperative. Her speech is normal, her thought process is goal-directed, and her thought contents are circumstantial. Perceptions, insight, and judgment are good, intact cognitive, and language is normal and appropriate. She has euthymic and euphoric moods, and the affect is congruent to her mood. Memory intact denies suicidal or homicidal ideation or intent. She denies delusions and hallucinations. The patient scored 15/27 on the PHQ scale.

Assessment

The patient reported doing good and working two jobs to support herself. She said that she works as a pharmacy technician Monday through Friday and works as a concierge on weekends. The patient stated that she grew up with both parents but now they are divorced. She now lives with her mother and her siblings. The patient stated that she is seeking a psychiatrist because her primary care physician suggested for her to see a psychiatrist to help her to manage her anger issues. She stated that she has not being diagnosed for any mental problem before and not on any medication. The patient stated that she gets angry very quickly, depressed, and very anxious, sometimes without any reason she would lash out on people. She said that her siblings get on her nerves sometimes and she gets irritated especially when they are together for so long. The patient stated that she completed high school and graduated. She said that she was never bullied, nor sexually assaulted. She said that she gets very anxious most of the time. The voices she hears are from her inner thought, and not that type of crazy voices that tells you to do something. She stated that she has a poor eating habit and that she overeats most of the time. She said that she sleeps about 6 hours a day. She stated that she used to be sexually active but not in any relationship now. She said she is not married and has no children. She has few friends. The patient stated that the grandmother on her mother’s side has depression, and now she is having dementia as she is getting older. She said she verbally lashes at people sometimes for no reason. Upon assessment, her PHQ-9 scale score is 15/27. She stated that she weighs 200lbs and her height is 5’4’’. Upon assessment, the patient is diagnosed with schizoaffective disorder and anxiety disorder. The patient is not on any medication presently. The patient is referred to a psychotherapist and will be scheduled to see a therapist weekly. The patient is encouraged to engage in exercise to build up her serotonin. She is also encouraged to be taking deep breathing, not eat after 7 pm, and keep electronics away at bedtime. Also, she encouraged to keep a journal of her daily activities and will review it next appointment in 4 weeks. She is encouraged to call a suicide hotline or call 911 or call the psychiatrist’s office when wants to talk. She verbalized understanding.

Plan of care:

The patient will have decreased feelings of depression and anxiety over the next 90 days.

The patient is educated on the use of positive coping skills like exercising, deep breathing, and journaling daily.

The patient is referred to a psychotherapist weekly.

Follow up in 4 weeks on 5/17/22.

Call 911 for suicidal or homicidal ideation.

“I just had my birthday, and I went out for diner with my friends, and I had a good time”.

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

· Review the Kaltura Media Uploader resource in the left-hand navigation of the classroom 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.

· 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.

The Assignment

Record yourself presenting the complex case study for your clinical patient. 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: What was your plan for psychotherapy (include one health promotion activity and patient education)? 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.

· 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.