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Learning Goal: I’m working on a nursing multi-part question and need an explanation and answer to help me learn.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 PrepareReview 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:
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 AssignmentRecord yourself presenting the complex case study for your clinical patient. In your presentation: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.
CASE STUDY : Diagnosis1 Mood Disorder2 Sleep DisorderStudent NotesRP is a 17 years old Asian American female, seen at the clinic along with her guardian for psychiatric evaluation. RP has been exhibiting symptoms of depression and sleep disorder for about a year, since when she was stopped from visiting her grandmother in Asia. RP shows less interest in school activities, crying a lot, especially at night. RP is always sad, lack of sleep, changes in appetite and weight. Per RP guardian who were present during the intake, RP was stopped from going to Asia because she started keeping bad friends, who were influencing her with bad characters. RP denies suicidal or homicide, RP report use of illicit substances but stated that she has stopped, denied history of trauma to the head. Denies AH/VH and SI/HI. RP was started on Lexapro 10mg QAM, and Trazodone 50mg QHS. RP was advised to follow up with clinic in 4 weeks. RP was informed, if you think you are experiencing psychiatric emergency, including suicidal or homicidal thoughts, plans, or actions, call the Crisis Response at 410-433-5175 or National Suicide Prevention Hotline at 1-800-273-8255. If unable to reach any of these numbers, call 911 or go to the nearest ER.

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