case study

CategoryItemValueClient InformationSitePrivate PracticeAgeAdult (18- 64 years)GenderMaleVisit InformationStudent Level of FunctionSupervision – Level 2Category of CareDirect Patient CarePractice ManagementType of visitConsultationDiagnosis1 Personality DisorderStudent Notes

36 years old male who is in Miami on vacation from New York and has been off his medication, today patient became very paranoid and delusional. Patient presents accompanied by his girlfriend Treatment: -Increase Aripripazole to 10 mg daily for mood dysregulation. -Start Clonazepam 0.5 mg twice daily. -Start Temazepam 30 mg at bedtime. 

Psychiatric notes are a way to reflect on your practicum experiences and connect them to the didactic learning you gain from your NRNP courses. Focused SOAP notes, such as the ones required in this practicum course, are often used in clinical settings to document patient care.

For this Assignment, you will document information about a patient that you examined during the last three weeks, using the Focused SOAP Note Template provided. You will then use this note to develop and record a case presentation for this patient.

RESOURCES

Be sure to review the Learning Resources before completing this activity.
Click the weekly resources link to access the resources. 

WEEKLY RESOURCES

TO PREPARE

Review this week’s Learning Resources and consider the insights they provide. Also review the Kaltura Media Uploader resource in the left-hand navigation of the classroom for help creating your self-recorded Kaltura video.

Select a patient of any age (either a child or an adult) that you examined during the last 3 weeks.

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, 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 the completed assignment signed by your Preceptor.

You must submit your SOAP note using Turnitin. 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 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 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.