Please review the complete instruction. There is a PDF example and use the template to complete the assignment.
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COMPLEX CASE STUDY 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.
· See case study below.
· Present the full complex case study. Use the attached document to complete the assignment. 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 reading your study presentation.
· 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-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.
· At least 5 references
· APA 7
· Use the template to complete the assignment
· Review the attached PDF example from a previous course as a guide for this assignment,
· Remember to include the objectives and 3 questions for my peer to answers.
Psych Chief Complain–MDD
Reason for Admission in Patient’s Own Words: “I feel like I’m confused, I think my new meds are making me sick.”
HPI / Subjective
Patient is a 67-year-old white Hispanic male with a PPHx of Depression and anxiety and PMHx bilateral lower extremity edema who presented to our clinic as a follow up after D/C from Crisis 2 weeks ago accompanied by Adult Living Facility (ALF) Administrator. Today patient was found to be AAO x 3, in NAD, calm, Cooperative. Patient was noted to be disorganized, tangential, having difficulty concentrating, acting bizarre and unfocused. Patient reported his mood as “I’m just so confused, and I don’t know what’s really happening with me” with congruent dysthymic affect. When asked why they came to the clinic, patient stated “I was sent here from Fellowship house because I wasn’t eating as much as I used to. My appetite has gone. I think the new medications I’m taking are not good for me.” Patient reported he was discharged one week ago from Westchester hospital on a new medication regimen which he felt was helping him sleep better and improve his depression but was not letting him think clearly and was taking away his appetite. Patient referred he had been depressed a few weeks prior to last admission and has since felt that these medications are not helping him overall. Patient endorsed symptoms of depression including excessive sleep, loss of interest, feelings of guilt, low energy, difficulty concentrating, poor appetite, irritability, and psychomotor retardation. Patient denied symptoms of mania including increased energy, elevated mood, grandiosity, and distractibility, decreased need for sleep, impulsivity, and flights of ideas, talkativeness, and increase in goal-oriented activities. Patient denied perceptual disturbances including auditory or visual hallucinations. Patient denied any suicidal ideas, intentions, or plans. Patient denied any homicidal ideas, intentions, or plans.
Past Psychiatric History:
Patient endorsed multiple previous admissions to various psychiatric hospitals. Patient referred last admission was for approximately 5 days at Westchester hospital and was discharged with his current home medications. In addition to this, patient takes marijuana daily. Patient denied any history of Long-Acting Injections or state hospital admissions. Patient referred a “remote” history of suicide attempts in the past.
Substance use History: Patient denied any tobacco or alcohol use. Patient denied any history of intentional or unintentional overdose, rehab admissions, or problems with addiction. Positive for marijuana
Family Psychiatric History: Patient denied any family history of psychiatric diagnosis or treatments. Patient denied any family history of completed or attempted suicide. Patient denied any family history of substance use issues, state hospital admissions, psychotropic medications, LAI, ECT, or rehab admissions.
Collateral information: Adult Living Facility, Administrator
Collateral referred since discharge one week ago patient has been improving however has been noted to be acting bizarre. Collateral refers patient only eating 1 or 2 meals per day, is self-withdrawn, sleeps more, and has been less interactive with staff and other members of the ALF. Collateral stated patient has been complaint with his medications and has been attending Fellowship House Regularly.
Past Medical History
Alcoholism, the patient denies current alcohol abuse
chlorproMAZINE HCl Oral Tablet 200 MG
Dose: 200 MG BY MOUTH AT BEDTIME
Furosemide Oral Tablet 20 MG
Dose: 20 MG BY MOUTH DAILY IN THE MORNING
OXcarbazepine Oral Tablet 150 MG
Dose: 150 MG BY MOUTH THREE TIMES A DAY
Potassium Chloride ER Oral Tablet Extended Release 20 MEQ
Dose: 20 MEQ BY MOUTH DAILY IN THE MORNING
QUEtiapine Fumarate Oral Tablet 400 MG
Dose: 400 MG BY MOUTH AT BEDTIME
No Known Allergies
Divorce, 2 adult sons, living outstate
Mother Deceased Cerebrovascular accident @ 53
Mental Status Exam
Awake, Alert, Oriented to person, time and place, Oriented to time, Oriented to place, Oriented to person
Looks older, Wearing Casual Clothing
Normal Rate, Normal Volume
Posture normal, Gait normal
Loosening of associations, Disorganized
Catastrophizing, Helplessness, Hopelessness, Obsessional thoughts, Paranoid delusions
Denies idea, intention and plan
Poor or Impaired
Poor or Impaired
Imparied Recent (5 minutes), Remote, Immediate
Above average or Normal
Able to comprehend questions
DSM V DIAGNOSIS
Major Depressive Disorder, recurrent, severe without psychotic features F33.2
Abnormal Psychomotor Behavior
The clinician provided psychoeducation to clarify areas of difficulty. The clinician provided support and structure. Psychoeducation was provided regarding medication compliance, and the patient was receptive. The patient was encouraged to continue follow-up psychotherapy to monitor his symptoms. Individual psychotherapy is scheduled in two weeks.
NRNP/PRAC 6665 & 6675 Focused SOAP Psychiatric Evaluation Exemplar
INSTRUCTIONS ON HOW TO USE EXEMPLAR AND TEMPLATE—READ CAREFULLY
If you are struggling with the format or remembering what to include, follow the
Focused SOAP Note Evaluation Template
as your guide. It is also helpful to review the rubric in detail in order not to lose points unnecessarily because you missed something required. After reviewing full details of the rubric, you can use it as a guide.
Subjective section, provide:
· Chief complaint
· History of present illness (HPI)
· Past psychiatric history
· Medication trials and current medications
· Psychotherapy or previous psychiatric diagnosis
· Pertinent substance use, family psychiatric/substance use, social, and medical history
Read rating descriptions to see the grading standards!
Objective section, provide:
· Physical exam documentation of systems pertinent to the chief complaint, HPI, and history
· Diagnostic results, including any labs, imaging, or other assessments needed to develop the differential diagnoses.
Read rating descriptions to see the grading standards!
Assessment section, provide:
· Results of the mental status examination,
presented in paragraph form.
· At least three differentials with supporting evidence. List them from top priority to least priority. Compare the
DSM-5-TR diagnostic criteria for each differential diagnosis and explain what
DSM-5-TR criteria rules out the differential diagnosis to find an accurate diagnosis.
Explain the critical-thinking process that led you to the primary diagnosis you selected. Include pertinent positives and pertinent negatives for the specific patient case
Read rating descriptions to see the grading standards!
Reflect on this case. Include: Discuss what you learned and what you might do differently. Also include in your reflection a discussion related to legal/ethical considerations (
demonstrate critical thinking beyond confidentiality and consent for treatment
!), social determinates of health, health promotion and disease prevention taking into consideration patient factors (such as age, ethnic group, etc.), PMH, and other risk factors (e.g., socioeconomic, cultural background, etc.).
(The FOCUSED SOAP psychiatric evaluation is typically the
follow-up visit patient note. You will practice writing this type of note in this course. You will be focusing more on the symptoms from your differential diagnosis from the comprehensive psychiatric evaluation narrowing to your diagnostic impression. You will write up what symptoms are present and what symptoms are not present from illnesses to demonstrate you have indeed assessed for illnesses which could be impacting your patient. For example, anxiety symptoms, depressive symptoms, bipolar symptoms, psychosis symptoms, substance use, etc.)
EXEMPLAR BEGINS HERE
CC (chief complaint): A
brief statement identifying why the patient is here. This statement is verbatim of the patient’s own words about why presenting for assessment. For a patient with dementia or other cognitive deficits, this statement can be obtained from a family member.
HPI: Begin this section with patient’s initials, age, race, gender, purpose of evaluation, current medication and referral reason. For example:
N.M. is a 34-year-old Asian male presents for medication management follow up for anxiety. He was initiated sertraline last appt which he finds was effective for two weeks then symptoms began to return.
P.H., a 16-year-old Hispanic female, presents for follow up to discuss previous psychiatric evaluation for concentration difficulty. She is not currently prescribed psychotropic medications as we deferred until further testing and screening was conducted.
Then, this section continues with the symptom analysis for your note. Thorough documentation in this section is essential for patient care, coding, and billing analysis.
Paint a picture of what is wrong with the patient. First what is bringing the patient to your follow up evaluation? Document symptom onset, duration, frequency, severity, and impact. What has worsened or improved since last appointment? What stressors are they facing? Your description here will guide your differential diagnoses into your diagnostic impression. You are seeking symptoms that may align with many
DSM-5 diagnoses, narrowing to what aligns with diagnostic criteria for mental health and substance use disorders.
Substance Use History: This section contains any history or current use of caffeine, nicotine, illicit substance (including marijuana), and alcohol. Include the daily amount of use and last known use. Include type of use such as inhales, snorts, IV, etc. Include any histories of withdrawal complications from tremors, Delirium Tremens, or seizures.
Current Medications: Include dosage, frequency, length of time used, and reason for use. Also include OTC or homeopathic products.
Include medication, food, and environmental allergies separately. Provide a description of what the allergy is (e.g., angioedema, anaphylaxis). This will help determine a true reaction vs. intolerance.
Menstrual history (date of LMP), Pregnant (yes or no), Nursing/lactating (yes or no), contraceptive use (method used), types of intercourse: oral, anal, vaginal, other, any sexual concerns
ROS: Cover all body systems that may help you include or rule out a differential diagnosis. Please note: THIS IS DIFFERENT from a physical examination!
You should list each system as follows:
EENT: etc. You should list these in bullet format and document the systems in order from head to toe.
Example of Complete ROS:
GENERAL: No weight loss, fever, chills, weakness, or fatigue.
HEENT: Eyes: No visual loss, blurred vision, double vision, or yellow sclerae. Ears, Nose, Throat: No hearing loss, sneezing, congestion, runny nose, or sore throat.
SKIN: No rash or itching.
CARDIOVASCULAR: No chest pain, chest pressure, or chest discomfort. No palpitations or edema.
RESPIRATORY: No shortness of breath, cough, or sputum.
GASTROINTESTINAL: No anorexia, nausea, vomiting, or diarrhea. No abdominal pain or blood.
GENITOURINARY: Burning on urination, urgency, hesitancy, odor, odd color
NEUROLOGICAL: No headache, dizziness, syncope, paralysis, ataxia, numbness, or tingling in the extremities. No change in bowel or bladder control.
MUSCULOSKELETAL: No muscle, back pain, joint pain, or stiffness.
HEMATOLOGIC: No anemia, bleeding, or bruising.
LYMPHATICS: No enlarged nodes. No history of splenectomy.
ENDOCRINOLOGIC: No reports of sweating, cold, or heat intolerance. No polyuria or polydipsia.
Diagnostic results: Include any labs, X-rays, or other diagnostics that are needed to develop the differential diagnoses (support with evidenced and guidelines).
Mental Status Examination: For the purposes of your courses, this section must be presented in paragraph form and not use of a checklist! This section you will describe the patient’s appearance, attitude, behavior, mood and affect, speech, thought processes, thought content, perceptions (hallucinations, pseudohallucinations, illusions, etc.)., cognition, insight, judgment, and SI/HI. See an example below. You will modify to include the specifics for your patient on the above elements—DO NOT just copy the example. You may use a preceptor’s way of organizing the information if the MSE is in paragraph form.
He is an 8-year-old African American male who looks his stated age. He is cooperative with examiner. He is neatly groomed and clean, dressed appropriately. There is no evidence of any abnormal motor activity. His speech is clear, coherent, normal in volume and tone. His thought process is goal directed and logical. There is no evidence of looseness of association or flight of ideas. His mood is euthymic, and his affect appropriate to his mood. He was smiling at times in an appropriate manner. He denies any auditory or visual hallucinations. There is no evidence of any delusional thinking. He denies any current suicidal or homicidal ideation. Cognitively, he is alert and oriented. His recent and remote memory is intact. His concentration is good. His insight is good.
You must begin to narrow your differential diagnosis to your diagnostic impression. You must explain how and why (your rationale) you ruled out any of your differential diagnoses. You must explain how and why (your rationale) you concluded to your diagnostic impression. You will use supporting evidence from the literature to support your rationale. Include pertinent positives and pertinent negatives for the specific patient case.
Also included in this section is the reflection. Reflect on this case and discuss whether or not you agree with your preceptor’s assessment and diagnostic impression of the patient and why or why not. What did you learn from this case? What would you do differently?
Also include in your reflection a discussion related to legal/ethical considerations (
demonstrating critical thinking beyond confidentiality and consent for treatment!), social determinates of health, health promotion and disease prevention taking into consideration patient factors (such as age, ethnic group, etc.), PMH, and other risk factors (e.g., socioeconomic, cultural background, etc.).
Includes documentation of diagnostic studies that will be obtained, referrals to other health care providers, therapeutic interventions including psychotherapy and/or psychopharmacology, education, disposition of the patient, and any planned follow-up visits. Each diagnosis or condition documented in the assessment should be addressed in the plan. The details of the plan should follow an orderly manner.
*See an example below. You will modify to your practice so there may be information excluded/included. If you are completing this for a practicum, what does your preceptor document?
Risks and benefits of medications are discussed including non- treatment. Potential side effects of medications discussed (be detailed in what side effects discussed). Informed client not to stop medication abruptly without discussing with providers. Instructed to call and report any adverse reactions. Discussed risk of medication with pregnancy/fetus, encouraged birth control, discussed if does become pregnant to inform provider as soon as possible. Discussed how some medications might decreased birth control pill, would need back up method (exclude for males).
Discussed risks of mixing medications with OTC drugs, herbal, alcohol/illegal drugs. Instructed to avoid this practice. Encouraged abstinence. Discussed how drugs/alcohol affect mental health, physical health, sleep architecture.
Initiation of (list out any medication and why prescribed, any therapy services or referrals to specialist):
Client was encouraged to continue with case management and/or therapy services (if not provided by you)
Client has emergency numbers: Emergency Services 911, the Client’s Crisis Line
1-800-_______. Client instructed to go to nearest ER or call 911 if they become actively suicidal and/or homicidal. (only if you or preceptor provided them)
Reviewed hospital records/therapist records for collaborative information; Reviewed PMP report (only if actually completed)
Time allowed for questions and answers provided. Provided supportive listening. Client appeared to understand discussion. Client is amenable with this plan and agrees to follow treatment regimen as discussed. (this relates to informed consent; you will need to assess their understanding and agreement)
Follow up with PCP as needed and/or for:
Labs ordered and/or reviewed (write out what diagnostic test ordered, rationale for ordering, and if discussed fasting/non fasting or other patient education)
Return to clinic:
Continued treatment is medically necessary to address chronic symptoms, improve functioning, and prevent the need for a higher level of care.
You are required to include at least three evidence-based, peer-reviewed journal articles or evidenced-based guidelines which relate to this case to support your diagnostics and differentials diagnoses. Be sure to use correct APA 7th edition formatting.
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