Grand rounds discussion: complex case study presentation/prac 6675:

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 This week you participate in the second of three clinical discussions called grand rounds. In one of these 3 weeks, you will be a presenter as well as help facilitate the online discussion; in the others you will be an active discussion participant. When it is your week to present, you will create a focused SOAP note and a short didactic (teaching) video presenting a real (but de-identified) complex patient case from your practicum experience.

You should have received an assignment from your Instructor letting you know which week of the course you are assigned to present. 

To prepare: 

  • Review this week’s Learning Resources and consider the insights they provide. Also review the Kaltura Media Uploader resource in the left-hand navigation of the classroom for help creating your self-recorded Kaltura video.
  • Select a child/adolescent 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, and each page must be initialed by your Preceptor. When you submit your SOAP note, you should include the complete 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.
    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.
  • Then, based on your SOAP note of this patient, develop a video case study presentation. Set aside time to practice what you will say beforehand and ensure that you have the appropriate lighting and equipment to record the presentation.
  • Your presentation should include objectives for your audience, at least three possible discussion questions/prompts for your classmates to respond to, and at least five scholarly resources to support your diagnostic reasoning and treatment plan.

 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 3 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 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. 
  • 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.

CAAP

CHIEF COMPLAINT
Inpatient psychiatric evaluation for depression with suicidal ideation

LEGAL STATUS
Involuntary

HISTORY OF PRESENT ILLNESS
Per Crisis note:

Pt is a 17 yo M with past psychiatric history of Bipolar disorder and ODD in the foster care system who presented to Crisis under BA. Per BA, patient has been feeling depressed and voiced suicidal ideation in the presence of law enforcement. On interview patient is calm but appears dysphoric and tired, endorsing multiple stressors. Pt voiced concern about 1:1 sitter in group home stating that a few days ago he realized that she was “grooming him.” Patient reports that the 1:1 sitter will no longer be at group home and that he feels safe living there. About 1.5 months ago pt presented to Larkin Hospital for similar presentation. At the time, his medications were changed to Quetiapine, Oxcarbazepine, and Bupropion. Pt endorses medication compliance however pt mother (Christine Long 786-333-1039) could not be reached. Pt denies suicidal/homicidal thoughts/intent/plan. Patient denies AVH and no delusions were elicited. No manic sx were elicited.

The patient was seen this morning, discussed with the ancillary staff, and the chart was reviewed. Upon interview today, pt continued to endorse stressor regarding the 1:1 attendant that was “grooming him” stating she was making purchases for him, sending him inappropriate sexual text messages despite the pt blocking her from his social media accounts. Pt endorses that these events have made him feel depressed and anxious. He is uncomfortable with his social situation, considering DCF told him that his mother had put him up for foster care, was unhappy with foster-parents, currently living in foster group home, and incident with 1:1 attendant in the past, feeling hopeless. Pt endorses passive SI, with no plan, denies HI, denies AVH. Pt is currently in a group home in Citrus, with case manager Jazmin (786-769-4961), who also endorses pt has been regularly taking Quetiapine 100mg PO Bedtime, Oxcarbazepine 150mg PO BID, Bupropion 150mg daily. Pts mother (786 333-1039) was called who states she has not been in much contact with the pt. Patient endorses fair sleep/appetite, denies any manic symptoms, denies perceptual disturbances, denies paranoia, and is not grossly delusional.

TARGET SYMPTOMS
Quality: depression with suicidal ideation
Duration: days
Severity: severe, interfering with ability to care for self / interfering with safety of self
Context: precipitating stressor for admission
Modifying factors: medication optimization, therapeutic milieu
Associated S/S: see HPI and MSE

REVIEW OF SYSTEMS
General: does not endorse fevers or weight change
HEENT: does not endorse sore throat or congestion
Cardiovascular: does not endorse chest pain or palpitations
Respiratory: does not endorse cough or wheezing
Gastrointestinal: does not endorse nausea, vomiting, or changes in bowel habits
Genitourinary: does not endorse dysuria or change in bladder habits
Neurological: does not endorse dizziness or numbness
MSK: does not endorse muscle or joint pain

(from chart review and updated as appropriate)
PAST PSYCHIATRIC HISTORY:  
Inpatient: multiple hospitalizations; most recent CAAP hospitalization in 5/8/22
Outpatient: yes, but does not follow up
Pt has h/o aggression, no prior SA or SIB
Has been kicked out of multiple residential programs (last in May 2021 out of state but he was kicked out for aggressive behavior)
previously tried on haldol, risperdal, prolixin, thorazine
Abuse: currently living in foster group home; has a case manager.
Substance abuse: denies

SUBSTANCE USE HISTORY:    
Tobacco: Regularly smokes vape pen
Alcohol: denies
Cannabis: 1-2x month
Cocaine: denies
Opioids: denies
Benzodiazepines: denies
Amphetamines: denies
Hallucinogens: denies
Detox/Rehab: denies

PAST MEDICAL HISTORY:    
none
  
ALLERGIES:
No Known Medication Allergies; NKA

FAMILY HISTORY:
Bipolar disorder: Grandmother (M).
Depression: Grandmother (M).

SOCIAL HISTORY:
History of emotional, sexual, and/or physical abuse: endorses sexual abuse with prior 1:1 attendant
Living Situation: group home (foster care)
Legal History: denies
Support system: poor

PSYCHIATRIC SPECIALTY EXAMINATION
Vital Signs
Temperature 36.6 (14:04)
Systolic Blood Pressure 124 (14:04)
Diastolic Blood Pressure 78 (14:04)
Pulse 78 (14:04)
SpO2 100 (14:04)
Respiratory Rate 18 (14:04)

Mental Status Exam
Appearance: adequate grooming and hygiene
Behavior: calm and cooperative with interview
Eye Contact: good
Motor Activity: no PMA/PMR/AIMs noted
Speech: normal rate and rhythm, appropriate volume, spontaneous, comprehensible
Mood: “im upset”
Affect: depressed, restricted, congruent.
Thought Process: organized, goal directed
Thought Content:
– Delusions: No delusions elicited
– Perceptual Disturbances: denies perceptual disturbances, not overtly RTIS
Suicidal Ideation/Thought/Intent/Plan: denies
Homicidal Ideation/Thought/Intent/Plan: denies
Cognition
– Attention/Concentration: fair/fair to interview
– Orientation: awake, alert, oriented to person, location, date, situation
Insight/Judgment: poor/poor

Laboratory Test Results
Laboratory or Other Results This Visit (last charted value for your 07/04/2022 visit)


Infectious Disease Testing

07/04/2022 4:05 PM
SARS CoV 2 RNA, RT PCR: Negative

Assessment
Diagnosis or problem list prompting current evaluation:
Diagnoses

Bipolar disorder, unspecified (F31.9)

Oppositional defiant disorder (F91.3)

End of Diagnoses List

Plan
1. Patient has acute psychiatric symptoms and is in need of treatment and stabilization. Psychiatric symptoms intolerable to patient and/or society and at risk of re-hospitalization. Patient continues to require 24 hour observation, nursing care, and inpatient treatment and cannot be treated in a less restrictive environment.
2. Medications:
Medications (6) Active
Scheduled: (3)
buPROPion 150 mg, ORAL, DAILY
OXcarbazepine 150 mg Tab 150 mg 1 tab, ORAL, BID
QUEtiapine IR 100 mg Tab 100 mg 1 tab, ORAL, BEDTIME
Continuous: (0)
PRN: (3)
magnesium hydrox (MOM) Liquid 30 mL 30 mL, ORAL, Q12H
mg hydrox/al hydrox/simeth Susp 30 mL 30 mL, ORAL, Q6H
nicotine 2 mg Loz 2 mg 1 lozenge, TRANSMUCOSAL, Q2H
3. Tobacco Cessation: n/a
4. Labs/Imaging: none
5. Consults: none
6. Court Date: none / TBD
7. Social work evaluation for disposition and follow-up.
8. Patient was educated about reasons for prescribing the above medications, expected benefits and likelihood of clinical improvement, as well as potential side effects and relevant risks; treatment alternatives and side effects of the alternatives expected course without treatment and results of not receiving care. Patient was educated on how to take the medications.

Case seen and discussed with Dr. Bez

Addendum By Yasin Bez, MD

Psychiatry Attending Attestation:

I saw and evaluated the patient and discussed the management plan with the resident/fellow. I reviewed the note and agree with the documented findings and plan of care.

Visitor restrictions due to Covid-19 are in place.
Patient with no notable/reported exposures, no known sick contacts, no reported recent travel and is not stated to be an at-risk population. Patient has not displayed any symptoms of cough, GI distress, Rhinorrhea, Anosmia, or fever while on the unit. COVID testing was negative.

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
AND
the Rubric
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.

In the 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

· Allergies

· ROS

Read rating descriptions to see the grading standards!

In the 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!

In the 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

Subjective:

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.

Or

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.

Allergies: 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.

Reproductive Hx: 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: General: Head: 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.

Objective:

Diagnostic results: Include any labs, X-rays, or other diagnostics that are needed to develop the differential diagnoses (support with evidenced and guidelines).

Assessment:

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. 


Diagnostic Impression: 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.).



Case Formulation and Treatment Plan 

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.



References (move to begin on next page)

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.

© 2022 Walden University Page 1 of 3

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
AND
the Rubric
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.

In the 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

· Allergies

· ROS

Read rating descriptions to see the grading standards!

In the 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!

In the 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

Subjective:

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.

Or

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.

Allergies: 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.

Reproductive Hx: 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: General: Head: 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.

Objective:

Diagnostic results: Include any labs, X-rays, or other diagnostics that are needed to develop the differential diagnoses (support with evidenced and guidelines).

Assessment:

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. 


Diagnostic Impression: 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.).



Case Formulation and Treatment Plan 

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.



References (move to begin on next page)

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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