Week 2 Assignment: Focused SOAP Note and Patient Case Presentation
Week 2 Assignment: Focused SOAP Note and Patient Case Presentation
Photo Credit: Pexels
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 Prepare
Review the Kaltura Media Uploader resource in the left-hand navigation of the classroom for help creating your self-recorded Kaltura video.
ORDER A CUSTOMIZED, PLAGIARISM-FREE Week 2 Assignment: Focused SOAP Note and Patient Case Presentation HERE
Good News For Our New customers . We can write this assignment for you and pay after Delivery. Our Top -rated medical writers will comprehensively review instructions , synthesis external evidence sources(Scholarly) and customize a quality assignment for you. We will also attach a copy of plagiarism report alongside and AI report. Feel free to chat Us
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:
All SOAP notes must be signed, and each page must be initialed 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 each page that is initialed and signed by your Preceptor.
You must submit your SOAP note using SafeAssign. 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.
A Sample Of This Assignment Written By One Of Our Top-rated Writers
Week 2: Focused SOAP Note and Patient Case Presentation
Subjective:
CC (chief complaint): “Intense fear when being separated from parents.”
HPI: T.F is a 6-year-old White male accompanied by his mother to the psychiatric clinic after being referred by his pediatrician. The mother reports that the boy develops intense fear when being separated from her or the father. He develops excessive anxiety every morning when going to school and usually cries a lot when being dropped off at school. The parents often have to trick him so he can let go of them. The mother states that the boy’s behavior became evident when he was about three years when the mother finished her sabbatical leave and left him under the care of a nanny. The mother initially thought the child’s anxiety when the parents were leaving in the morning was because he was afraid of the nanny. Consequently, the mother has hired multiple numerous, but the boy’s behavior persisted. However, this got worse when he joined preschool five months ago, and the boy always pleads that he does not go to school. Besides, he often complains of stomachaches and headaches when going to school or when separated from his family. The boy’s class teacher denies that he is being bullied in school. Furthermore, the boy insists on sleeping in his parent’s bedroom, which has become a growing concern. He gets nightmares and cries a lot when he sleeps in his room. The boy has a persistent and excessive fear of being left alone at home without the parents or elder siblings being around.
Substance Current Use: None
Medical History:
- Current Medications: None
- Allergies: None
- Reproductive Hx: None
ROS:
- GENERAL: Denies weight changes, fatigue, fever, or chills.
- HEENT: Denies eye pain, excessive tearing, ear pain/discharge, sneezing, nasal discharge, or sore throat.
- SKIN: Denies skin rashes, bruises, or lesions.
- CARDIOVASCULAR: Denies SOB, palpitations, chest discomfort, or edema.
- RESPIRATORY: Denies SOB, chest pain, cough, or sputum.
- GASTROINTESTINAL: Positive for abdominal pain. Denies nausea, vomiting, epigastric pain, diarrhea, or constipation.
- GENITOURINARY: Denies dysuria, incontinence, or urinary frequency/urgency.
- NEUROLOGICAL: Reports headaches. Negative for dizziness, muscle weakness, tingling sensations, or black spells.
- MUSCULOSKELETAL: Denies muscle pain, joint pain, or joint stiffness.
- HEMATOLOGIC: Denies bleeding or bruising.
- LYMPHATICS: Denies lymph node swelling.
- ENDOCRINOLOGIC: Denies profuse sweating, heat/cold intolerance, acute thirst, increased hunger, or polyuria.
Objective:
Diagnostic results: No tests ordered.
Assessment:
Mental Status Examination:
The boy is neat and appropriately dressed. He is alert and leans close to his mother throughout the session. He appears anxious and maintains minimal eye contact with the provider. His self-reported mood is nervous, and his affect is appropriate. He talks in low volumes and talks minimally. He demonstrates a logical and coherent thought process. No hallucinations, delusions, obsessions, or suicidal ideations were noted. His short-term and long-term memory is intact.
Diagnostic Impression:
Separation Anxiety Disorder (SAD): SAD is characterized by persistent and excessive anxiety that surpasses what is expected for a child’s developmental level. It is related to separation or impending separation from an attachment figure (Dogan et al., 2021). The DSM-5 diagnostic criteria for SAD require the child to demonstrate unwarranted or excessive anxiety or fear following separation from anyone they are attached to. This is demonstrated by at least 3 of the following: Excessive distress when separated from home, or attachment figures, or the thought of losing these individuals; Unfortunate events like being sick when away from these individuals; Reluctance or refusal to go to school; Sleeping difficulties; Nightmares about separation (Dogan et al., 2021). SAD is the presumptive diagnosis based on the child’s history of developing excessive anxiety when being separated from his parents, being reluctant to go to school, having nightmares when sleeping in his room, and complaints of headaches and stomachaches when being separated from his parents.
Pediatric Generalized Anxiety Disorder (GAD): Pediatric GAD is characterized by constant, excessive, and unrealistic worry that is not focused on a particular object or circumstance. The child may experience somatic symptoms like shortness of breath, palpitations, sweating, nausea, diarrhea, increased urination, cold and clammy hands, dry mouth, and trouble swallowing (Mohammadi et al., 2020). The anxiety, worry, and somatic symptoms cause clinically significant distress or impairment in social or academic functioning. Pediatric GAD is a differential based on the child’s excessive anxiety when being separated from his parents. However, the child’s anxiety is attributed to separation from an attachment figure, which rules out GAD as the likely diagnosis.
Pediatric Panic Disorder (PD): Pediatric PD is characterized by a child having recurring panic attacks and constant worries about having more attacks for longer, which occurs for more than one month. Children with panic disorder often avoid visiting places or engaging in activities out of fear of a panic attack (Strawn et al., 2021). PD is a differential diagnosis based on the child having excessive anxiety and experiencing headaches and stomachaches when in situations that cause anxiety. Nonetheless, the client has no history of panic attacks, making it a less likely primary diagnosis.
Reflections:
The preceptor made the most appropriate clinical impression since the client exhibited symptoms consistent with separation anxiety disorder. I learned that various childhood disorders and behaviors are characteristic of separation anxiety and school refusal, while others mimic them. In a different situation, I would use structured interview scales like the Anxiety Rating Scale for Children, the Children’s Separation Anxiety Scale (CSAS-P), and the Anxiety Disorders Interview Schedule for Children, which aid in confirming the diagnosis of separation anxiety (Méndez et al., 2022). The provider has an ethical duty to promote the best outcome for the patient by implementing best practices and protecting the patient from any harm.
Case Formulation and Treatment Plan:
The client was initiated on CBT comprising psychoeducation and exposure to anxiety-producing stimuli and situations. Besides, the psychotherapy incorporated training in somatic management skills, such as diaphragmatic breathing and progressive muscle relaxation (James et al., 2018).
With an appropriate psychotherapy treatment approach, the client is expected to exhibit reduced fear and anxiety when away from attachment figures. This will help him regain full social functioning skills with no distress, even when separated from his parents (James et al., 2018).
Follow-up: The patient will be followed up after four weeks to assess his progress with psychotherapy.
References
Dogan, B., Kocabas, O., Sevincok, D., Baygin, C., Memis, C. O., & Sevincok, L. (2021). Separation Anxiety Disorder in Panic Disorder Patients with and without Comorbid Agoraphobia. Psychiatry, 84(1), 68-80. https://doi.org/10.1080/00332747.2021.1875730
James, A. C., Reardon, T., Soler, A., James, G., & Creswell, C. (2018). Cognitive behavioral therapy for anxiety disorders in children and adolescents. The Cochrane Database of Systematic Reviews, 2018(10), CD013162. https://doi.org/10.1002/14651858.CD013162
Méndez, X., Espada, J. P., Ortigosa, J. M., & García-Fernández, J. M. (2022). Validation of the Children’s Separation Anxiety Scale – Parent Version (CSAS-P). Frontiers in psychology, 13, 783943. https://doi.org/10.3389/fpsyg.2022.783943
Mohammadi, M. R., Pourdehghan, P., Mostafavi, S. A., Hooshyari, Z., Ahmadi, N., & Khaleghi, A. (2020). Generalized anxiety disorder: Prevalence, predictors, and comorbidity in children and adolescents. Journal of anxiety disorders, p. 73, 102234. https://doi.org/10.1016/j.janxdis.2020.102234
Strawn, J. R., Lu, L., Peris, T. S., Levine, A., & Walkup, J. T. (2021). Research Review: Pediatric anxiety disorders – what have we learned in the last 10 years? Journal of child psychology and psychiatry, and allied disciplines, 62(2), 114–139. https://doi.org/10.1111/jcpp.13262
[elementor-template id="165244"]