Choose a case or disorder and Create a Focused SOAP Note\/case presentation of a child or Adolescent. Use the attached template.<\/p>\n
Week (enter week #): (Enter assignment title)<\/p>\n
Student Name<\/p>\n
College of Nursing-PMHNP, Walden University<\/p>\n
PRAC 6665: PMHNP Care Across the Lifespan I<\/p>\n
Faculty Name<\/p>\n
Assignment Due Date<\/p>\n
Subjective:<\/p>\n
CC (chief complaint):<\/p>\n
HPI:<\/p>\n
Substance Current Use:<\/p>\n
Medical History:<\/p>\n
\u00b7 Current Medications:<\/p>\n
\u00b7 Allergies:<\/p>\n
Reproductive Hx:
\nROS:<\/p>\n
\u00b7 GENERAL:<\/p>\n
\u00b7 HEENT:<\/p>\n
\u00b7 SKIN:<\/p>\n
\u00b7 CARDIOVASCULAR:<\/p>\n
\u00b7 RESPIRATORY:<\/p>\n
\u00b7 GASTROINTESTINAL:<\/p>\n
\u00b7 GENITOURINARY:<\/p>\n
\u00b7 NEUROLOGICAL:<\/p>\n
\u00b7 MUSCULOSKELETAL:<\/p>\n
\u00b7 HEMATOLOGIC:<\/p>\n
\u00b7 LYMPHATICS:<\/p>\n
\u00b7 ENDOCRINOLOGIC:<\/p>\n
Objective:<\/p>\n
Diagnostic results:<\/p>\n
Assessment:<\/p>\n
Mental Status Examination:<\/p>\n
Diagnostic Impression:<\/p>\n
PRIMARY DIAGNOSIS<\/p>\n
3 DIFFERENTIAL DIAGNOSIS<\/p>\n
Reflections:<\/p>\n
Case Formulation and Treatment Plan: NRNP\/PRAC 6665 & 6675 Comprehensive Focused SOAP Psychiatric Evaluation Template<\/p>\n
Week (enter week #): (Enter assignment title)<\/p>\n
Student Name<\/p>\n
College of Nursing-PMHNP, Walden University<\/p>\n
PRAC 6665: PMHNP Care Across the Lifespan I<\/p>\n
Faculty Name<\/p>\n
Assignment Due Date<\/p>\n
Subjective:<\/p>\n
CC (chief complaint):<\/p>\n
HPI:<\/p>\n
Substance Current Use:<\/p>\n
Medical History:<\/p>\n
\u00b7 Current Medications:<\/p>\n
\u00b7 Allergies:<\/p>\n
\u00b7 Reproductive Hx:<\/p>\n
ROS:<\/p>\n
\u00b7 GENERAL:<\/p>\n
\u00b7 HEENT:<\/p>\n
\u00b7 SKIN:<\/p>\n
\u00b7 CARDIOVASCULAR:<\/p>\n
\u00b7 RESPIRATORY:<\/p>\n
\u00b7 GASTROINTESTINAL:<\/p>\n
\u00b7 GENITOURINARY:<\/p>\n
\u00b7 NEUROLOGICAL:<\/p>\n
\u00b7 MUSCULOSKELETAL:<\/p>\n
\u00b7 HEMATOLOGIC:<\/p>\n
\u00b7 LYMPHATICS:<\/p>\n
\u00b7 ENDOCRINOLOGIC:<\/p>\n
Objective:<\/p>\n
Diagnostic results:<\/p>\n
Assessment:<\/p>\n
Mental Status Examination:<\/p>\n
Diagnostic Impression:<\/p>\n
Reflections:<\/p>\n
Case Formulation and Treatment Plan:<\/p>\n
PRECEPTOR VERFICIATION:<\/p>\n
I confirm the patient used for this assignment is a patient that was seen and managed by the student at their Meditrek approved clinical site during this quarter course of learning.<\/p>\n
Preceptor signature: ________________________________________________________<\/p>\n
Date: ________________________<\/p>\n
References<\/p>\n
________________________________-
\nWeek 6: Case Presentation of an Adolescent with Anxiety Disorder<\/p>\n
Student Name: [Your Name]
\nCollege of Nursing-PMHNP, Walden University
\nPRAC 6665: PMHNP Care Across the Lifespan I
\nFaculty Name: [Faculty Name]
\nAssignment Due Date: [Assignment Due Date]<\/p>\n
Subjective:<\/p>\n
CC (chief complaint):
\nThe patient, a 16-year-old male, presents with complaints of excessive worry and fearfulness, which has been interfering with his daily activities and school performance.<\/p>\n
HPI:
\nThe patient’s parents report that the adolescent has been increasingly anxious over the past six months. He frequently complains of stomach aches and headaches, especially before school or social events. His parents note that he avoids social gatherings and extracurricular activities that he once enjoyed. The patient denies any suicidal or self-harming thoughts.<\/p>\n
Substance Current Use:
\nThe patient denies any current or past substance use.<\/p>\n
Medical History:
\nThe patient has a past medical history of asthma, for which he uses an albuterol inhaler as needed.<\/p>\n
Current Medications:<\/p>\n
Albuterol inhaler PRN for asthma symptoms.
\nAllergies:
\nNo known drug allergies.<\/p>\n
Reproductive Hx:
\nN\/A (not applicable) for this age group.<\/p>\n
ROS:<\/p>\n
\u00b7 GENERAL: The patient’s general health is fair, with no recent weight changes.
\n\u00b7 HEENT: No visual or auditory disturbances reported.
\n\u00b7 SKIN: No rashes, lesions, or changes in skin appearance.
\n\u00b7 CARDIOVASCULAR: No chest pain or palpitations reported.
\n\u00b7 RESPIRATORY: Occasional asthma symptoms relieved with albuterol inhaler.
\n\u00b7 GASTROINTESTINAL: Frequent complaints of stomach aches and occasional nausea.
\n\u00b7 GENITOURINARY: No genitourinary symptoms reported.
\n\u00b7 NEUROLOGICAL: No history of seizures or neurological deficits.
\n\u00b7 MUSCULOSKELETAL: No recent injuries or musculoskeletal complaints.
\n\u00b7 HEMATOLOGIC: No history of bleeding disorders or easy bruising.
\n\u00b7 LYMPHATICS: No lymphadenopathy reported.
\n\u00b7 ENDOCRINOLOGIC: No endocrine-related issues reported.<\/p>\n
Objective:<\/p>\n
Diagnostic results:<\/p>\n
General physical examination: Within normal limits for age and developmental stage.
\nMental Status Examination: The patient appears anxious, with increased psychomotor agitation during the assessment. Affect is tense and anxious, and he expresses feelings of fear and worry. Speech is rapid, with occasional difficulties in finding words. Thought process is goal-directed, but the patient demonstrates some obsessive and intrusive thoughts. No perceptual disturbances noted.
\nAssessment:<\/p>\n
Mental Status Examination:
\nThe patient presents with symptoms consistent with an anxiety disorder. He exhibits excessive worry, physical complaints, and avoidance behaviors, which are impacting his daily functioning and social life.<\/p>\n
Diagnostic Impression:
\nGeneralized Anxiety Disorder (GAD) is the primary diagnosis based on the patient’s persistent and excessive worry and fearfulness about various aspects of life, along with physical symptoms and avoidance behaviors.<\/p>\n
3 Differential Diagnoses:<\/p>\n
Social Anxiety Disorder: This was considered due to the patient’s avoidance of social gatherings and extracurricular activities he once enjoyed.
\nPanic Disorder: Although panic attacks were not reported, the patient’s physical symptoms and excessive worry could be associated with panic episodes.
\nObsessive-Compulsive Disorder (OCD): The presence of intrusive thoughts and anxiety-related compulsions warranted consideration of OCD.
\nReflections:<\/p>\n
This case highlights the importance of recognizing anxiety disorders in adolescents. It is crucial to differentiate between various anxiety disorders as they may present with overlapping symptoms. A comprehensive assessment is essential to provide an accurate diagnosis and appropriate treatment.<\/p>\n
Case Formulation and Treatment Plan:<\/p>\n
Case Formulation:
\nThe patient’s symptoms, including excessive worry, physical complaints, and avoidance behaviors, are consistent with a diagnosis of Generalized Anxiety Disorder (GAD). The patient’s history of asthma should be considered as a potential contributing factor to anxiety symptoms.<\/p>\n
Treatment Plan:<\/p>\n
Psychoeducation: Provide psychoeducation to the patient and his parents about GAD, its symptoms, and the role of anxiety in daily life.
\nCognitive-Behavioral Therapy (CBT): Initiate CBT to help the patient identify and challenge maladaptive thought patterns and develop coping strategies for anxiety.
\nRelaxation Techniques: Teach relaxation exercises such as deep breathing and progressive muscle relaxation to manage physical symptoms of anxiety.
\nMedication: Considering the severity of symptoms and impairment in daily functioning, a low-dose selective serotonin reuptake inhibitor (SSRI) may be prescribed to alleviate anxiety symptoms.
\nFollow-up: Schedule regular follow-up appointments to monitor treatment progress and adjust the treatment plan as needed.
\nPRECEPTOR VERIFICATION:<\/p>\n
I confirm the patient used for this assignment is a patient that was seen and managed by the student at their Meditrek approved clinical site during this quarter course of learning.<\/p>\n
Preceptor signature: ________________________________________________________<\/p>\n
Date: ________________________<\/p>\n
References:<\/p>\n","protected":false},"excerpt":{"rendered":"
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