In Weeks 4, 7, and 9 of the course, you will participate in clinical discussions called grand rounds. In one of these three 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.

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In Weeks 4, 7, and 9 of the course, you will participate in clinical discussions called grand rounds. In one of these three 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. 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.
  • Then, based on your SOAP note of this patient, develop a video case study presentation.
  • 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.
  • 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.
  • Be succinct in your presentation, and do not exceed 8 minutes. 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 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.
    • 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.

Expert Answer and Explanation

Subjective:

CC (chief complaint): “I have difficulty falling asleep, am always sad, and am easily distracted.’

HPI: The patient is a 26-year-old female who presented to the office complaining of anxiety, depression, and insomnia. The patient notes that she has been having problems with falling asleep, is easily distracted, is always sad, and has difficulties completing tasks. The patient also complains that she has trouble wanting to see people and associating with people.

The patient notes that she finds comfort in isolating herself. She reports anhedonia and cried during the interview. She also reports severe anxiety. She says that her anxiety became more severe when she had that the person who raped her was released from jail. The symptoms have negatively affected her life. Her therapist pulled her out of work, and she hardly made friends with people. She rates her anxiety and depression as 8/10.

Substance Current Use: She reports no current use of illicit drugs.

Medical History: The patient has no medical problems.

  • Current Medications: She is not on any medications at the moment.
  • Allergies: She reports no allergies.
  • Reproductive Hx: No reproductive problems.

ROS:

  • GENERAL: She denies fatigue, weight loss, chills, or fever.
  • HEENT: Eyes: No yellow sclerae, visual loss, or double vision. Ears, Nose, Throat: No hearing problems, runny nose, congestion, sore throat, or sneezing.
  • SKIN: No rash or itching.
  • CARDIOVASCULAR: No chest pain, edema, chest discomfort, or palpitations.
  • RESPIRATORY: No shortness of breath.
  • GASTROINTESTINAL: No diarrhea, vomiting, abdominal blood, or pain.
  • GENITOURINARY: She reports no odd urine color, no odor of urine, or burning on urination.
  • NEUROLOGICAL: No dizziness, headache, syncope, ataxia, paralysis, numbness, or tingling in the extremities.
  • MUSCULOSKELETAL: No joint or muscle stiffness or pain.
  • HEMATOLOGIC: No anemia, HIV, bleeding, or bruising.
  • LYMPHATICS: No enlarged nodes.
  • ENDOCRINOLOGIC: No reports of health intolerance, cold, or sweating abnormities.

Objective:

Vital Signs: BP 102/90, P 67, RR 17, Ht. 5’4″, Wt. 67kgs, Temp 36.5.

Physical Exam 

  • HEENT: Noncontributory.
  • Skin: No rash or itching.
  • Cardiovascular: Regular heart rhythm and heart rate. No cracks on the chest walls. No edema.
  • Respiratory: Normal breathing sounds, no wheezing, no fluids in the lungs, crackles, and no inspiratory crackles.

Diagnostic results:

  1. Beck Anxiety Inventory (BAI): Lemos et al. (2019) noted that BAI is used to measure the severity of patients’ anxiety. The authors found that the tool’s reliability is (Cronbach’s α=0.92) in terms of internal consistency. The patient scored 37, meaning that she has severe anxiety.
  2. Beck’s Depression Inventory (BDI): BID is a screening tool used to screen for depression (García-Batista et al., 2018). The patient scored 23, meaning that she has moderate depression.

Assessment:

Mental Status Examination: 

The patient is well-dressed, and her clothing is consistent with the day’s weather. She was well-behaved during the interview. However, she was crying while answering questions. She maintained eye contact during the interview. She reports sadness and affect consistent with her mood. Her speech is intact. She denies hallucinations, delusions, suicidal thoughts, or homicidal thoughts. Her memory is intact. Through process is also intact.

Diagnostic Impression:

  1. Generalized Anxiety Disorder (GAD) DSM-5 300.02 (F41. 1)
  2. Mood disorder, ICD 10 Code: F33.2 – Major Depressive Disorder, Severe, Recurrent
  3. Insomnia Disorder DSM-5 780.52 (G47.00)

The primary diagnosis for this case is GAD. According to Price et al. (2019), GAD is associated with extreme anxiety, which cannot be controlled easily. The anxiety must be characterized by at least three symptoms: fatigue, irritability, difficulty sleeping, impaired concentration, restlessness, and muscle pain.

The patient is diagnosed with anxiety because she reports extreme anxiety because she heard that the person who raped her was recently released from jail. The second diagnosis is MDD. MDD is one of the mood disorders that affect a patient’s mood. The disease is part of the diagnosis because the patient reports sadness and anhedonia (Cherukupally et al., 2020).

However, it is not the main disorder because the patient scored 23 in BDI. The last diagnosis is insomnia. Insomnia was included because the patient had sleeping problems. However, the disorder is a secondary disorder because it is caused by GAD (Price et al., 2019).

Published by Henry