Report normal diagnostic results as the name of the test

SOAP NOTE Question/Assgn

 

Review the case study below:

 

1. Your presentation must include four objectives/goals for your audience.

 

1. At least 3 possible discussion questions/prompts for your classmates to respond to.

 

1. At least 5 scholarly resources to support your diagnostic reasoning and treatment plan.

 

 

1. . 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.

 

1. 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.

 

 

1. Pose three questions or discussion prompts, based on your presentation, that your colleagues can respond to after viewing your video.

 

 

 

 

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?

0. Objective: What observations did you make during the psychiatric assessment?

0. 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 is supported by the patient’s symptoms.

0. 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.

0. 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.

 

 

Case study

 

CC: I cannot stop being afraid of failing

 

The patient 18-year-old Hispanic female (in her last year of high school) with history of OCD, came to the clinic alone for medication management. The patient reports poor sleeping pattern, does not wake up rested, she finds herself sometimes hyperventilating when she faces difficulties with school exams and cannot stop being worried of failing. She reports few episodes dizziness while at school. She also shared that she has been experiencing excessive worry for more than 7 months. She feels worried when she is unable to complete cleaning routines.

States she does have some camps coming up for sports during the summer but remain worried about being able to participate. States she likes being awake at night because no one is around. Denies current SI, HI, AVH. No side effects to medications reported, no other questions or concerns.

 

Use these Diagnosis and differencials in this order.

 

Primary diagnosis: OCD

Deferential 1: Severe social phobia

Deferential 2: Panic disorder

Deferential 3: GAD