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Select a child/adolescent patient from your clinical experience that presents with a significant concern. Create a focused SOAP note for this patient using the template in the Resources. All SOAP notes must be . When you submit your SOAP note, you should include the complete SOAP note as a Word document and PDF/images of each page
CC (chief complaint): I have been having difficulty sleeping and anxiety.
HPI: Patient is a 18-year-old African American woman with history of hypertension presents with experiencing anxiety symptoms and difficulty sleeping. Patient states symptoms of anxiety has gotten worse over the years, her jitteriness, chest pain, feeling of impending doom and anxiety get worse when she drinks caffeine or waiting for lab result, its gets bad she has to run for cover sometimes. She says her lack of sleep makes her irritable and hard for her to concentrate or function the next day. Patient states was prescribed Lexapro, Benadryl and Ambien in the past by PCP, not on any medication currently, she has two children, no legal issues, pastor wife, denies hallucination, denies suicidal ideation.
chest pain, diarrhea, increase heart rate, excessive worrying, difficulty sleeping, shaking trembling
Severity is estimated to be medium based on patient risk of morbidity without treatment and her description of interference with functioning
Past Psychiatric History:
● General Statement: The patient states that she has been experiencing anxiety and difficulty sleeping and panic for years. She states the following as her prevalent symptoms. Chest discomfort or chest pain when under stress, diarrhea, sleep disturbance that is, difficulty falling or staying asleep, increase in heart rate, excessive worrying, and shaking or trembling. The patient states that these symptoms occur daily.
● Caregivers (if applicable): family
● Hospitalizations: None
● Medication trials: Lexapro, Benadryl, Ambien.
● Psychotherapy or Previous Psychiatric Diagnosis: Has history with anxiety symptoms.
Substance Current Use and History: None
Family Psychiatric/Substance Use History: The patient’s mother had anxiety.
Psychosocial History: Patient was born in Nigerian and migrated to the America years ago, patient has history of hypertension anxiety symptoms, mother diagnosed with anxiety. She is married with four children including twins. Patient is a nurse practitioner by profession, she has no legal or criminal issues, she is a Christian and a pastor’s wife, denies substance use, smoking or drinking, denies physical, sexual, or emotional abuse, denies suicidal ideas or intention, denies homicidal intention or ideas.
. Create a focused SOAP note for this patient using the template in the Resources.
Then, based on your SOAP note of this patient, develop a video case study presentation. Set aside time to practice what you will say beforehand and ensure that you have the appropriate lighting and equipment to record the presentation.
Your presentation should include
objectives for your audience,
at least three possible discussion questions/prompts for your classmates to respond to, and at least five scholarly resources to support your diagnostic reasoning and treatment plan.
Record yourself presenting the complex case study for your clinical patient. In your presentation:
State 3–4 objectives for the presentation that are targeted, clear, use appropriate verbs from Bloom’s taxonomy, and address what the audience will know or be able to do after viewing.
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.
Pose three questions or discussion prompts, based on your presentation, that your colleagues can respond to after viewing your video.
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-TR diagnostic criteria and is 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. Discuss an identified social determinate of health impacting this patient’s mental health status and provide your recommendation for a referral to assist this patient in meeting this identified need (students will need to conduct research on this topic both in the literature and for community resources).
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. Please include objective for this paper.