Focused SOAP Note and Patient Case Presentation

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.
• 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.
• Include at least five scholarly resources to support your assessment, diagnosis, and treatment planning.
• 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.
• Specifically address the following for the patient, using your SOAP note as a guide:
o 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?
o Objective: What observations did you make during the psychiatric assessment?
o 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.
o 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?
o 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.
o 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.

LEARNING RESOURCES
Required Readings
• Carlat, D. J. (2024). The psychiatric interview (5th ed.). Wolters Kluwer.
o Chapter 33, “How to Educate Your Patient”
o Chapter 34, “Negotiating a Treatment Plan”

Patient Information:
Pt W.V. is a 6 year old male
Chief Complaint
“I need some answers for my sons behavior per mom”
History of Present Illness
W.V. is a 6-year-old Hispanic boy that was seen today with mom and dad present at in person appointment.
Report from mom indicates that patient has been fidgeting a lot and repeats words and actions all the time
Worse after he has had sweets to eat.
Patient was quiet for a while in the chair but soon starts to fidget and play with his fingers (appears to be counting and
making letter signs repeatedly
Was able to answer to questions once mom repeated them in spanish
Appears to be delayed with responses due to being bilingual
Responses to questions asked on the Vanderb questionnaire by mom is in conclusive at this time as teacher at school is
unable to complete since school just started and she is not too familiar with patient
Asked for a couple more weeks in school before she can truly be in a position to complete it
We decided to proceed with starting patient on ADHD medications at this time due to symptoms observed by provider
and moms explanation at school concerns
Provider was able to assist with getting information for center close to home to assess for Autism
Mom was appreciative as she feels like she has not got much help from other professionals
Childrens hospital has a 2 year wait list for appointment at this time
Tic noted at session

Emotional/Behavioral:
Sleep/Appetite: no sleeping problems; no difficulty falling asleep; no difficulty staying asleep; no binge eating; not prurging; no restrictive diet; no enuresis; no encopresis;
Depression/Mania: depressed; no crying spells; no anhedonia; no recent weight loss; no recent weight gain; no change in appetite; no insomnia; no hypersomnia; not feeling tired; no inattention for at least 6 months, inconsistent with
developmental level; no indecisiveness; no feelings of worthlessness and guilt; no thoughts of suicide; no feelings of
grandeur; no decreased need for sleep; speech not pressured; no racing thoughts; no impulsive behavior;
Anxiety: anxiety; not with persistent worry; no restlessness; irritable; with muscle tension or jitters; not tiring easily;
no unreasonable fears with compelling desire to avoid (phobia); no persistent senseless or very distasteful thoughts; no
flashbacks; no avoidance of stimuli; no hypervigilance; no obsessions; no compulsion;
Behavior Problems:
ADHD: inattention for at least 6 months, inconsistent with developmental level ; no; no; no; difficulty with organizing tasks and activites; ADHD checklist; no; easily distracted from extraneous stimuli; not forgetful in daily activites;
Hyperactivity-Impulsivity: no; hyperactivity for at least 6 months, inconsistent with developmental level ; no; no; no; restlessness; no; no; no; no;
Oppositional Defiant: no tantrums; no; no; no; no; not touchy or easily annoyed; not angry/resentful; no; no oppositional behavior; no hostility toward authority figures; impulsive behavior not resulting in serious assault or property damage;
Conduct Disorder: does not bully/threaten/intimidate; no impulsive initiation of fights; no violent behavior with a weapon; no physical cruelty to people; no cruelty to animals; not stealing unneeded objects; has not forced someone into sexual activity; no vandalism; not setting fires; not broken into house or buildings; does not lie/con/manipulate; no forgery/shoplifting; does obey rules/curfew; no running away; no school absenteeism;
Prior Psychological Treatment
no psychological counseling; psychiatric therapy; no previous hospitalizations; no psychotropic agents;
Social History
living situation unknown; no caregiver; living arrangement unknown; no pets in household;
Behavioral History: not a current every day smoker; not a current some day smoker; not a former smoker; has smoked; smoker, current status known; not unknown if ever smoked;
Alcohol: not using alcohol;
Drug Use: no drug use;
Habits: not sedentary; exercising regularly; exercise duration is unknown; exercise frequency is unknown;
Religion/Culture/Race: religious status; cultural background; racial background;
Sexual History: no sexual history reported;
Family History
family history reviewed; father not deceased; mother not deceased; unspecified number of children; parents not divorced; no family history of early deaths; no drug use; not using alcohol; no family history of mental illness (not intellectual disabilities); no diagnosis of suicide attempt; no death in family; no serious illness in family;
Home Environment: composition of household; persons reside in household ; no parent/child estrangement; no discipline problems; no family problems; parents not divorced; no problems with siblings; no problems with parent or guardian; no problems with support person; no multiple divorces or separations; no social services;
Pediatric History: not adopted; not firstborn; secondborn; not youngest in family; number of siblings 2;
Legal/Law Issues: no history of legal problems; no current legal problems; no violent event;
Past Medical History
Diagnoses: no diagnosis of heart disease; no diagnosis of transient ischemic attack; no diagnosis of diabetes mellitus; no diagnosis of coronary artery disease; no diagnosis of migraine headache; no allergy; no diagnosis of cancer; no diagnosis of head injury; no diagnosis of systemic HTN; no diagnosis of cancer; no diagnosis of post-traumatic stress disorder; no anxiety; no dissociative disorder; no diagnosis of disorders of consciousness; no diagnosis of depersonalization disorder; no diagnosis of impulse control disorder;
Recent Events: no self-inflicted injuries; no diagnosis of eating disorder; no diagnosis of substance abuse;
Reported Medical History: no prior surgery;
Reported Physical Trauma: no motor vehicle traffic accident;
Education History: education history; educational level; not coping effectively; no self-damaging behavior; no problems with one’s peer group;
Work History: work history unknown; occupation unknown;
Financial Status: financial status unknown;
Functional Status: psychosocial support is sufficient;
Review of Systems
Psychological Symptoms: no interpersonal relationship problems; currently dating; no social isolation; no socially inappropriate behavior; not re-experiencing/re-inacting traumatic event; ability to express warmth and tenderness; no death of close friend;
Mental Status
General Appearance: general appearance normal; clothing unremarkable; normal grooming;
Alertness: alert; not drowsy; attitude not distractible; not dissociated; not stuporous;
Orientation: to time, place, and person; not disoriented;
Memory: no memory loss;
Intelligence: estimated intelligence normal;
Insight: no impaired insight;
Judgement: judgement not impaired;
Mood: mood dysthymic; mood not euphoric; affect not sad; mood anxious; mood not fearful; mood not angry; does not look angered;
Affect: affect; flat; Speech and Language: no speech difficulty;
Thought Process: no thought content impairment;
Behavior: no tics; normal gait and stance; attitude not uncooperative; mood calm; no compulsive behavior; not overly dramatic; attitude not hostile;
Risk Assessment: no diagnosis of suicide attempt; not entertaining thoughts of suicide; no homicide risk;
Abuse: not sexually abused; no physically abused; no violent traumatic event during childhood; no violent traumatic event as an adult; no reporting of individual safety concerns; no interpersonal problems with a parent;
Developmental History: good prenatal care; mother did not smoke during pregnancy; mother did not use alcohol prepartum; mother did not use IV drug prepartum; mother did not use DES prepartum; mother did not use cocaine prepartum; not premature birth; full term pregnancy; no premature delivery; no delayed milestones; immunizations up to date;
Attachment: no failure to develop normal attachment behavior; ability to express anger; no difficulty relating with others; no suspiciousness and marked evasiveness; no paranoid ideations concerned with hidden motives of others; patient’s reaction to provider: no suspicion, distrust, or dislike; not disinhibited; no suicidal ideation; no illusions (altered perception of real events / objects); no delusions; no derealization; no emotional lability; no difficulty communicating;
Session Notes:
Assessment and Plan
1. ADHD (attention deficit hyperactivity disorder), combined type F90.2 (314.01):
AdderalL 5 mg tablet: 1 tablet once a day for 14 days for ADHD and Tic disorder,
2. Tic disorder, transient of childhood F95.0 (307.21):
Plan
Next appointment set for 2 weeks
START: Adderall 5mg once a day
Discussed the risk of mixing medication with OTC drugs, herbal, alcohol or other illegal drugs.
Discussed how drugs/ETOH affects mental health, physical health and sleep among others.
Medication management follow up visit – Patient to schedule
Patient is agreeable with this plan and agrees to follow treatment regimen as discussed.
Please see emergency numbers:
National client’s crisis line/suicide hotline number – available 24/7:1-800-273-8255.
Patient explained If symptoms worsen or have thoughts of harming yourself or others,
Call 911 or go to the nearest emergency room.
Safety plan Reviewed.
In case of mental health emergency, please contact a crisis response number as listed below or call 911 or go to your nearest emergency room.
• Baltimore City Crisis Response: 410-433-5175
• Baltimore County Crisis Response: 410-931-2214
• Anne Arundel County Crisis Response: 410-768-5522
• Harford County Crisis Response: 1 (800)-639-8783
• Howard County Crisis Response: 410-531-6677
• Montgomery County Crisis Response: 240-777-4000
• Prince Georges County Crisis Response: 301-429-2185
Also contact National Suicide Prevention Lifeline is a national network of local crisis centers that provides free and
confidential emotional support to people in suicidal crisis or emotional distress 24 hours a day, 7 days a week.

Collepals.com Plagiarism Free Papers

Are you looking for custom essay writing service or even dissertation writing services? Just request for our write my paper service, and we'll match you with the best essay writer in your subject! With an exceptional team of professional academic experts in a wide range of subjects, we can guarantee you an unrivaled quality of custom-written papers.

Get ZERO PLAGIARISM, HUMAN WRITTEN ESSAYS

Why Hire Collepals.com writers to do your paper?

Quality- We are experienced and have access to ample research materials.

We write plagiarism Free Content

Confidential- We never share or sell your personal information to third parties.

Support-Chat with us today! We are always waiting to answer all your questions.