Case study Presentation-NRNP 6645: Psychopathology and Diagnostic Reasoning

Weeks 4, 7, and 9 of the courses, 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.

RESOURCES

TO PREPARE: 

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. All SOAP notes must be signed by your Preceptor. When you submit your SOAP note, you should include the complete SOAP note as a Word document and PDF/images of completed assignment signed by your Preceptor. You must submit your SOAP Note using Turnitin.

Then, based on your SOAP note of this patient, develop a video case study presentation. Take 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 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.

Video assignment for this week’s presenters:

Record yourself presenting the complex case study for your clinical patient. In your presentation:

Dress professionally and present yourself in a professional manner.

Display your photo ID at the start of the video when you introduce yourself.

Ensure that you do not include any information that violates the principles of HIPAA (i.e., don’t use the patient’s name or any other identifying information).

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?

Case study Presentation-NRNP 6645: Psychopathology and Diagnostic Reasoning

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-TR 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.  Discuss an identified social determinate of health impacting this patient’s mental health status and provide your recommendation for a referral to assist this patient in meeting this identified need (students will need to conduct research on this topic both in the literature and for community resources).

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.

n 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.

RESOURCES

Be sure to review the Learning Resources before completing this activity.

Click the weekly resources link to access the resources.

WEEKLY RESOURCES

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 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. All SOAP notes must be signed by your Preceptor. When you submit your SOAP note, you should include the complete SOAP note as a Word document and PDF/images of completed assignment signed by your Preceptor. You must submit your SOAP Note using Turnitin.

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. Take 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 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.

Video assignment for this week’s presenters:

Record yourself presenting the complex case study for your clinical patient. In your presentation:

Dress professionally and present yourself in a professional manner.

Display your photo ID at the start of the video when you introduce yourself.

Ensure that you do not include any information that violates the principles of HIPAA (i.e., don’t use the patient’s name or any other identifying information).

State 3-4 objectives for the presentation that are targeted, clear, use appropriate verbs from Blooms 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-TR 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.  Discuss an identified social determinate of health impacting this patient’s mental health status and provide your recommendation for a referral to assist this patient in meeting this identified need (students will need to conduct research on this topic both in the literature and for community resources).

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.

NRNP 6645: Psychopathology and Diagnostic Reasoning

SUBJECTIVE

CC (chief complaint): ): “I get extremely angry, and I hit things.”

HPI: Patient P is a 10-year 4-month Caucasian male who presents to the office for an initial visit to our practice. Patient P was accompanied by his father. The patient was cordial and interactive and provided reliable information. He reports getting extremely angry when provoked by his Friends and little sister at school and at home and hitting things, especially his toys at home and desks at school. The behavior has been present for the last two months. The father reports that his son struggles with anger, aggressive outbursts, and aggressive behavior. Patient P has had two previous inpatient admission following violent outbursts and suicidal statements. The patient is currently taking sertraline and aripiprazole, and the father reports that the medication has been effective. The father recognizes that a behavioral modification component is essential to his son’s recovery and should be part of treatment, with which I agree. The father expresses disappointment with the current facility where the son goes to therapy since the kids only get to watch the TV and are not coached about their behavior. I encouraged the father to seek more clarification from a social worker in the facility about the long-term treatment options in the facility. The patient denies current feelings of rage. He reports the violent outbursts being a result of his frustration over not being able to understand his schoolwork and assignments.

Substance Current Use and History: The patient denies current use or abuse of substances. He denies abusing any substance in the past.

Medical History: Patient P reports having a previous history of anger and aggressive behavior. They have been hospitalized twice and are currently on medications. His last hospitalization was one year and two months ago. He was hospitalized for two weeks.

Current Medications: The patient is currently on sertraline and aripiprazole prescriptions prescribed one month ago after aggressive outbursts.

Allergies:The patient denies any known drug allergies.

Reproductive Hx:Patient P denies having sexual relations.

ROS:

  • GENERAL: Denieschanges in appetite, weight changes, fatigue, chills, fever, and sleep problems.
  • HEENT: Denies experiencing any changes in vision, eye irritation, discharge, excessive tears, or eye pain. Denies changes in hearing, ear pain, nasal obstruction, sore throat, voice hoarseness, nose bleeds, and dysphagia.
  • SKIN: Denies skin rashes, lesions, itching, skin dryness, lesions, and ulcers.
  • CARDIOVASCULAR: Denies a history of cardiovascular illnesses. Denies experiencing chest pains, palpitations, chest tightness, dizziness, dyspnea, and peripheral edema.
  • RESPIRATORY: Denies chest pain, difficulties breathing, wheezing, shortness of breath, coughing, and other respiratory diseases.
  • GASTROINTESTINAL: Deniesappetite changes, abdominal pain, nausea, vomiting, diarrhea, rectal bleeding, fecal inconsistency, bloody stool, and changes in bowel movement.
  • GENITOURINARY: Denies pain or irritation during urination, changes in the frequency of urination, and urine retention. Denies sores, penile discharge, hematuria, dysuria, and erectile dysfunction. 
  • NEUROLOGICAL: Denies changes in balance, seizures, vertigo, tremors, confusion, numbness, tingling, headaches, and fainting.
  • MUSCULOSKELETAL: Denies muscle stiffness, back and neck pain, joint pain and swelling, muscle weakness, cramping, decreased range of motion, and functional deficit.
  • HEMATOLOGIC: Denies having a family history of hemophilia. Denies having any hematologic symptoms
  • LYMPHATICS: Denies experiencing chronic fatigue, chronic infections, enlarged lymph nodes, bleeding, and abnormal bruising.
  • ENDOCRINOLOGIC: Denies experiencing heat and old intolerance, fatigue, goiter, weight changes, polyphagia, polydipsia, polyuria, dizziness, and mood lability. 

OBJECTIVE

Diagnostic results: Not applicable

ASSESSMENT

Mental Status Examination: Patient P appears neat, stated age, well-fed, and healthy. He seems calm, focused, alert and oriented to place, time, and person. No acute distress note. He is cooperative, open to discussion, friendly, soft and clear, and intellectually capable. No evidence of delusion, hallucination, and paranoia. His memory appears intact, and he demonstrates fair insight and judgment. No evidence of suicidal thoughts

Differential Diagnoses:

Intermittent explosive disorder (IED) – the patient shows a pattern of outbursts of anger that are out of proportion to events that causes them.

Oppositional defiant (ODD) – the patient struggles with anger and rage

Attention deficit/hyperactive (ADHD) – behavioral and conduct problems. The patient hits things at home and in school.

            The patient experiences aggressive outbursts that can be accounted for by several mental or disruptive behavioral disorders, including IED, ADHD, and ODD. According to Radwan and Coccaro (2020), aggressive behavior in children and adolescents is usually accounted for by IED, ADHD, and ODD. The three behavioral disorders overlap and require a healthcare provider to observe each case in detail for accurate diagnosis. IED is differentiated from ADHD by the levels of aggression. Severe aggression or aggressive outbursts from minor provocation signifies IED, while a problem in sustaining attention mainly manifests in ADHD. The pattern and frequency of aggression differentiate IED from ODD. Aggressive outbursts are more common in IEDs.

            My primary diagnosis is IED. According to DSM-5 criteria, IED is described as a recurrent behavioral outburst that usually represents a patient’s failure to control aggressive impulses that are usually manifested by verbal aggression and behavioral outbursts that involves damage and destruction of property (Sheaffer, 2023). Another DSM-5 criterion is recurrent aggressive outbursts out of proportion to the provocation. The outbursts must also not be premeditated or explained by other mental disorders. The outbursts must occur about twice a week for at least three months. The chronological age for the disorder is usually six years (Sheaffer, 2023). The patient meets the criteria since they are ten years old and have a history of aggressive outbursts; their outbursts are out of proportion to their provocation, they hit things when angry, and they have not been diagnosed with another mental disorder.

Case Formulation and Treatment Plan:

            Since the primary diagnosis based on the DSM-5 criteria is IED, the plan is to advise the patient accordingly and prescribe medication and therapy. The patient is currently taking sertraline and aripiprazole. The first line of treatment recommended is the selective reuptake inhibitor due to its ease of use and its efficiency in minimizing the symptoms (Coccaro, 2022). It is also well tolerated. The patient’s father reports that the current medications are effective. Therefore, the plan is for the patient to continue with the current medication. I will recommend cognitive behavior therapy for the patient. CBT is intended to equip the patient with coping skills. CBT utilizes techniques and techniques that address a person’s thinking, behaviors, and emotions. According to Costa et al. (2018), CBT, either in an individual or group, is effective in reducing aggressive behaviour. The patient’s environment seems like a determinant of his mental health status. His interaction with his younger sibling triggers aggressive outbursts. I recommend parent management training (PMT), which improves aversive patterns present in family interactions that engender the disruptive behaviour displayed by a child (Sukhodolsky et al., 2016). I would educate the patient on health promotion strategies for IED, which include getting enough sleep, exercising, and applying stress management skills to improve frustration tolerance. I will encourage the patient to apply the techniques learned in therapy to reduce aggressive outbursts.

Reflections: In case of future interaction with the patient, I would seek to understand his view of the support that the family members should offer, especially his parents. Parenting style is a fundamental element in children’s and adolescents’ mental health, with the literature citing perinatal quality as being a significant predictor of child externalization (Méndez et al., 2020). The next intervention for the patient in the future would be to assess the effectiveness of their treatment plan. Depending on the CBT form that has been effective, I would recommend they pursue the most effective psychotherapy.

PRECEPTOR VERIFICATION:

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’s course of learning.

Preceptor signature: ________________________________________________________

Date: ________________________

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