Assignment 2: Focused SOAP Note and Patient Case Presentation To Prepare Review the Kaltura Media Uploader resource for help creating your self-recorded Kaltura video Select an adult patient that yo

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Assignment 2: Focused SOAP Note and Patient Case Presentation

To Prepare

Review the Kaltura Media Uploader resource for help creating your self-recorded Kaltura video

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  • Select an adult patient that you examined during the last 4 weeks who presented with a disorder other than the disorder present in your Week 3 Case Presentation.
  • 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.

Assignment 2: Focused SOAP Note and Patient Case Presentation To Prepare Review the Kaltura Media Uploader resource for help creating your self-recorded Kaltura video Select an adult patient that yo
NRNP/PRAC 6665 & 6675 Comprehensive Focused SOAP Psychiatric Evaluation Template 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 © 2021 Walden University Page 3 of 3
Assignment 2: Focused SOAP Note and Patient Case Presentation To Prepare Review the Kaltura Media Uploader resource for help creating your self-recorded Kaltura video Select an adult patient that yo
This study source was downloaded by 100000794395091 from on 10-13-2022 08:45:42 GMT -05:00 Week 7: Assignment 2 Focused SOAP Note and Patient Case Presentation Subjective: CC (chief complaint): “Everything scares me, I feel like I live with fear every day.” HPI: JT is a 12-year-old Caucasian female, presented for her initial assessment with her mother. Mother states that JT had symptoms of generalized fear and anxiety around the age of 7 but JT seemed to get better, her symptoms returned around the age of 11. Mother reports no identifiable stressors and denies panic attacks. JT is currently tearful and depressed. JT stated that about a year ago I started “getting an overactive mind”. Mother responded with, “she started some rituals and obsessions around that time as well”. Because of her symptoms, JT began to withdrawal from her friends, had fear of being in her classroom and thus was pulled from school and is currently homeschooled. JT denies suicidal ideation or homicidal ideation. JT admits to have compelling thoughts; almost, but not clearly, a voice making her sense that something horrible will happen or something or somebody will die. JT explained that she has to clean her rabbits cage perfectly or her rabbit will die. She also stated that she has to walk a number of steps and she needs to stop on a specific number in order to prevent something horrible from happening, like her parents dying. She also expressed that she doesn’t like things facing her at an angle and likes to straighten things to make her feel better. I was obvious that things on the providers desk were triggering her and she began to straighten things within reach. Mother reported that these obsessions interrupt and distract JT daily. Past Psychiatric History: General Statement: JT reports anxiety and fear when she was 7 and then again about a year ago. Caregivers (if applicable): JT lives with both parents and her younger brother. Hospitalizations: JT has never been hospitalized. Medication trials: None Psychotherapy or Previous Psychiatric Diagnosis: JT has had no psychotherapy or previous psychiatric diagnosis. Social and Personal History: JT was an excellent student prior to dropping out for home schooling. No drug or alcohol abuse or use. Has a younger brother. Family Psychiatric/Substance Use History: Mother, a physician: with generalized anxiety This study source was downloaded by 100000794395091 from on 10-13-2022 08:45:42 GMT -05:00 Grandmother: Bipolar Maternal Great-grandmother: committed suicide Maternal Aunt: has schizophrenia Paternal Cousin: committed suicide Medical History: Normal blood tests and physical exam. She is a generally healthy 12-year-old with no hospitalizations. Allergies: None Reproductive Hx: Normal no concerns, prepubescent. ROS:  GENERAL: No fevers, sweats, shakes, chills or change in weight.  HEENT: Eyes: 20/20 vision no report of vision changes. No diplopia, amaurosis fugax  Ears, Nose, and Throat: No epistaxis or tinnitus.  SKIN: SP reported no rashes, eruptions or itching.  CARDIOVASCULAR: No edema, chest pain, or palpitations.  RESPIRATORY: JT denies shortness of breath, cough, wheezing, or sputum.  GASTROINTESTINAL: No anorexia, nausea, vomiting, or diarrhea. No abdominal pain or blood.  GENITOURINARY: Denies frequency, nocturia, dysuria, or hematuria.  NEUROLOGICAL: Negative for any focal neurologic complaints.  MUSCULOSKELETAL: No joint swelling, stiffness, pain or myalgias.  HEMATOLOGIC: No abnormal prolonged bleeding or bruising.  LYMPHATICS: No enlarged nodes.  ENDOCRINOLOGIC: Negative for excessive thirst, urination, heat or cold intolerance, diabetes or thyroid disease. Objective: General Appearance: JT appears her stated age, she is lean with a thin build but well nourished. Diagnostic results: No labs, X-rays, or other diagnostics are needed to develop the differential diagnoses at this time. Mental Status Examination: JT is 12-year-old Caucasian female presented for her initial assessment with her mother. She complains of daily fears and anxieties. JT is polite and engaged in the session, maintaining good eye contact and willing to communicate with the provider but is distracted by the alignment of objects on the provider’s desk. JT appears to be her stated age; she is lean with a thin build but well-nourished. JT shows no manifestations of suicidal ideation or homicidal ideation as well as no obvious manifestations of ongoing or prevailing hallucinations, delusions or other indicators of a psychotic process as her associations are intact, logical, and appropriate. JT has no history of substance abuse. JT is casually and appropriately dressed, for situation and season. JT’s speech was normal in rate, volume, and articulation that is coherent and spontaneous with no obvious blocking or pressured speech. Language skills are intact and appropriate for age. Mood presented This study source was downloaded by 100000794395091 from on 10-13-2022 08:45:42 GMT -05:00 dysthymic for the social situation with moments of tearfulness. JT presented with thoughts that were coherent, logical, and goal directed with an understanding of her current issues and possible negative manifestations affecting her home and social functioning. Diagnostic Impression F41.1 – Generalized Anxiety Disorder, GAD – JT reports daily anxiety that effects both her home environment and her school setting. She states that her fears are difficult to control. No reported panic attacks or specific fears. Excessively worried about future events; specifically having a sense that horrible things will happen to something or somebody resulting in death. F42.0 – Obsessive-Compulsive Disorder, OCD – JT admits to have compelling thoughts; making her sense that something horrible is about to happen, resulting in something or someone dying. She has to clean her rabbits cage perfectly or she believes her rabbit will die. She has to walk a certain number of steps and stop on a certain number in order to prevent horrible things from happening. Lastly, she is compelled is make sure objects are not facing her at and angle and thus spends a significant amount of time daily straightening things around her house and places she visits. F93.0 Separation anxiety disorder, SAD – JT has a hard time being away from her mother, believing something horrible will happen to her. Because she gets such great anxiety when she is separated from her caretaker, she has been pulled from school and is now homeschooled. JT has also withdrawn from friends as this can take her away from her mother as well. Reflections, Case Formulation and Treatment Plan Reflecting on JT it looks like OCD with comorbid GAD, possibly in a patient who had premorbid behavioral inhibition, although no clear history of separation anxiety. If anything, JT has separation anxiety now. Characteristic of anxiety disorders in children, it appears as though JT has an ever-evolving polymorphic anxiety disorder that morphs from GAD to OCD and beyond. So far, JT does not admit to panic attacks, and does not have major depression. Social anxiety may play a role in her avoidance of school, as well as separation anxiety, but undetermined. OCD, being the primary diagnosis, is defined as repetitive intrusive thoughts and/or rituals that are unwanted and which interfere significantly with function or cause marked distress. The compulsions are designed to neutralize or prevent some dreaded event which JT seems to have developed. Generalized Anxiety Disorder in a child, once called overanxious disorder, is a generalized and persistent anxiety that is not the result of separation or recent stress. Often characterized by self-consciousness. The patient may also display obsessive concern over past behavior, future events, personal health, and competence in athletics, social, or academic arenas but not obsessions or compulsions. This study source was downloaded by 100000794395091 from on 10-13-2022 08:45:42 GMT -05:00 inhibition is an early temperamental trait characterized by the tendency to withdraw when exposed to unfamiliar situations. Children who are inhibited may have a lower threshold of responsivity in the limbic and hypothalamic circuits and, as a result, they react with greater sympathetic activation when exposed to novel situations (Paulus, Backes, Sander, Weber, & Gontard, 2015). Multiple anxiety disorders are found at increased rates in children classified as behaviorally inhibited (Paulus, Backes, Sander, Weber, & Gontard, 2015). Thus, behavioral inhibition may indicate increased vulnerability for anxiety disorders (Paulus, Backes, Sander, Weber, & Gontard, 2015). Behavioral inhibition is also linked to a familial predisposition to anxiety disorders, because behavioral inhibition in children is associated with increased rates of anxiety disorders in their first-degree relatives (Paulus, Backes, Sander, Weber, & Gontard, 2015). The provider recommended JT be started on escitalopram 10 mg and lorazepam 0.5 mg once or twice a day as needed for anxiety. I would have recommended fluoxetine as well as weekly follow-ups for monitoring; as suggested by the FDA when prescribing SSRIs to children 6-12. It is controversial in the minds of come mental health experts to prescribe benzodiazepines at all, and even more controversial to prescribe them to children. SSRIs and benzodiazepines are effective in children and adults alike (Witek, Rojas, Alonso, Minami, & Silva, 2005). It is important to note though, that there is good documentation and efficacy of SSRIs in children and adolescents for OCD (Kemal, & Ipek, 2016). Based on the severity of JT’s symptoms, the provider felt like her anxiety disorder deserved the right to be treated and to have her symptoms go into sustained remission so that normal development of JT can proceed, even at the cost of taking controversial medications. This study source was downloaded by 100000794395091 from on 10-13-2022 08:45:42 GMT -05:00 Powered by TCPDF ( Kemal Utku Yazici, & Ipek Percinel. (2016). Escitalopram in Preschool-Age Children Diagnosed with Obsessive Compulsive Disorder: A Case Report. Iranian Journal of Psychiatry , 11(1). Paulus, F., Backes, A., Sander, C., Weber, M., & Gontard, A. (2015). Anxiety Disorders and Behavioral Inhibition in Preschool Children: A Population-Based Study. Child Psychiatry & Human Development , 46(1), 150–157. Witek, M. W., Rojas, V., Alonso, C., Minami, H., & Silva, R. R. (2005). Review of Benzodiazepine use in Children and Adolescents. Psychiatric Quarterly , 76(3), 283–296. Preceptor Signature: Vernon Kubiack

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