Select a child/adolescent or adult patient from your clinical experience that presents with a significant concern Create a focused SOAP note for this patient using the template in the Resources

COMPLEX CASE STUDY PRESENTATION
TO PREPARE
• Review this week’s Learning Resources and consider the insights they provide.
• Select a child/adolescent or adult patient from your clinical experience that presents with a significant concern. Create a focused SOAP note for this patient using the template in the Resources. All SOAP notes must be signed by your Preceptor. Please Note: Electronic signatures are not accepted. If both files are not received by the due date, Faculty will deduct points per the Walden Late Policies.
• Your presentation should include objectives for your audience, at least 3 possible discussion questions/prompts for your classmates to respond to, and at least 5 scholarly resources to support your diagnostic reasoning and treatment plan.

THE ASSIGNMENT
• 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.
• 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.
• Pose three questions or discussion prompts, based on your presentation, that your colleagues can respond to after viewing your video.
• 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-TR diagnostic criteria and is supported by the patient’s symptoms.
o 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).
o 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.

LEARNING RESOURCES
Required Readings
• Carlat, D. J. (2017). The psychiatric interview (4th ed.). Wolters Kluwer.
o Chapter 26, “Assessing Alcohol Use Disorder”
• Document: Focused SOAP Note Template (Word document) Document: Focused SOAP Note Exemplar (Word document)
• Stahl, S. M. (2021a). Stahl’s essential psychopharmacology: Neuroscientific basis and practical applications (5th ed.). Cambridge University Press.
o Chapter 13, “Impulsivity, Compulsivity, and Addiction”
• Office of Disease Prevention and Health Promotion. (n.d.). Social Determinates of Health.Links to an external site. Healthy People 2030. U.S. Department of Health and Human Services. https://health.gov/healthypeople/priority-areas/social-determinants-health
Recommended Reading:
• American Psychiatric Association. (2018). Practice guideline for the pharmacological treatment of patients with alcohol use disorderLinks to an external site.. https://psychiatryonline.org/doi/book/10.1176/appi.books.9781615371969
Links to an external site.
• American Society of Addiction Medicine. (2020). Clinical practice guidelines on alcohol withdrawal managementLinks to an external site.. https://www.asam.org/docs/default-source/quality-science/the_asam_clinical_practice_guideline_on_alcohol-1.pdf?sfvrsn=ba255c2_2
Links to an external site.
• American Society of Addiction Medicine. (2020). National practice guideline for the treatment of opioid use disorder: 2020 focused updateLinks to an external site.. http://eguideline.guidelinecentral.com/i/1224390-national-practice-guideline-for-the-treatment-of-opioid-use-disorder-2020-update/0Links to an external site.
• Boland, R. Verdiun, M. L. & Ruiz, P. (2022). Kaplan & Sadock’s synopsis of psychiatry (12th ed.). Wolters Kluwer.

THE PATIENT INFORMATION:
Pt K.M is 27 years-old female

History of Present Illness

Reports that she has been struggling with depression for a little while
States that prior to 2021 when she felt like a different person
Gets aggressive and violent when she drinks and has been seeking help.
Started drinking at a young age and stopped when she turned 21 and started again at 23
24-26 heavily drinking which was triggered with her moving here from CA, after covid.
In relationship with current partner for the past 3 years and has witnessed her violence
Her partner states that this mood could have been triggered
Pt States that her partner is a police officer
Mentioned that she struggled with low mood, hopelessness, fatigue, problems with sleep.
Mentioned that she was sexually abused by men in her family father, uncle and other men in her family.
Dad was also physically violent with her mom.
Parents divorced in 2015, and pt does not communicate with her father anymore
Mentioned that she is one of 4 children
Mentioned that was treated by therapist for a year and two months. Once or twice a month. Last visit was March 29th. She referred me to a psychiatrist in June of 2023 who I have been seeing since July 2024 and have been prescribed Sertaline HcL and Hydroxyzine HcL. Both started at low doses and have been 100 mg since Jan 2024.
Currently taking Zoloft 100mg
Psychiatrist wanted her to increase her dose as she was having memory problems.
Takes the following medication:
Nasacrot AQ 2 sprays in the morning for allergies and Azelastine 2 sprays at night for allergies both prescribed by PCP.
Sertraline Hcl 100 mg one tablet to one tablet and a half a day. Hydroxyzine Hcl 50 mg two tablets when needed. Both prescribed former Psychiatrist

Was sober for a few months. just started drinking again with friends
More physically active
Uses alcohol frequently. goes to dinners and drinks alcohol with colleagues
Have cut down alcohol intake drastically for seven months now. Maybe two drinks a month the last two months.

Family history:
Alcoholism – grandpa and dad
Bipolar – sister and others
Diabetes – mom, grandma, aunt and others

Use to get up in the morning and want a drink but not anymore
Gets violent with herself or her partner when she drinks “During drunkenness I’ve tried to hurt myself multiple times before. Punching. Jumping. Etc.”
Patient was administered the PHQ-9 depression assessment test. Patient scored between 15-19, indicating that a
Moderately Severe. Depression is present. Actual score is 19 . difficult for patient to do your work, take care of things at home, or get along with other people.

The GAD-7 is a self-administered questionnaire and screen to detect and determine the severity of Generalized Anxiety
Disorder. Patient obtained a result between 15-21, suggesting a Severe Anxiety Disorder. Scores above 10 suggest the
need for further evaluation. Actual score is 19. difficult for patient to do your work, take care of things at home, or get along with other people.

Sleep has been on and off for all her life
Reports that she can go days at a time without sleep. Mentioned that there are times she is completely exhausted and cant sleep and other times she just falls asleep with no issues
Mentioned that some of her symptoms were getting better but that past month or so it has got bad again.
Family issues in the past during the summer that could have affected her and can have the effect on her at this time.
Relationship has had its up and down but he has remained supportive of her
They have had their issues as he is lazy and messy and he would not help in getting things done
Sometimes she feels like she is not his priority and they don’t go out much
He would make more time for others than for her
He goes out of town with his best friend and not with her
Travels for work and back home when she can
Got her Bachelors degree in Political Science and was not difficult for her
States that she is closed to her mom and facetime daily
Close to her brothers
Not talking to her sister right now

Emotional/Behavioral:
Sleep/Appetite: sleeping problems; difficulty falling asleep; 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; change in appetite; no insomnia; no hypersomnia; not feeling tired; no inattention for at least 6 months, inconsistent with developmental level; indecisiveness; feelings of worthlessness and guilt; no thoughts of suicide; no feelings of grandeur; no decreased need for sleep; speech not pressured; racing thoughts; impulsive behavior;
Anxiety: anxiety; with persistent worry; no restlessness; not irritable; 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; hypervigilance; obsessions; no compulsion;

Behavior Problems:

ADHD: no inattention for at least 6 months, inconsistent with developmental level; no; no; no; no difficulty with
organizing tasks and activites; ADHD checklist normal; no; not easily distracted from extraneous stimuli; not forgetful in
daily activites;
Hyperactivity-Impulsivity: no; no hyperactivity for at least 6 months, inconsistent with developmental level; no; 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; psychotropic agents;

Social History
living situation; no caregiver; with spouse; 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; exercise frequency is unknown;
Religion/Culture/Race: religious status; cultural background; racial background unknown;
Sexual History: sexual history;

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;
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 known 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; anxiety; no dissociative disorder; no diagnosis of disorders of consciousness; no diagnosis of depersonalization disorder; 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 not reported; not coping effectively; no self-damaging behavior; no problems with one’s peer group;
Work History: work history 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; inability to express warmth and tenderness;
no death of close friend;

Mental Status
General Appearance: general appearance normal; clothing unremarkable; grooming normal;
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 sad; mood anxious; mood not fearful; mood not angry; does not look angered;
Affect: affect; irritable;
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: sexually abused; physically abused; violent traumatic event during childhood; 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; 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:

Comments:

Assessment and Plan:
1. MDD (major depressive disorder), recurrent episode, severe F33.2 (296.33):
90833 – PSYTX W PT W E/M 30 MIN (Performed)
Fulfilled
2. GAD (generalized anxiety disorder) F41.1 (300.02):
3. Insomnia disorder G47.00 (780.52):
4. Alcohol abuse with alcohol-induced mood disorder F10.14 (291.89):

Plan:
Next appointment in 4 weeks
INCREASE Zoloft from 100mg to 200mg
CONTINUE HYDROXYZINE AS NEEDED
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 in 4 weeks
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. Phone:
1-800-273-8255 Website: http:/

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.