The patient is a 16-year-old male with a diagnosis of Attention-Deficit/Hyperactivity Disorder (ADHD), primarily inattentive presentation, who presents for follow-up regarding symptom management. He reports ongoing difficulty with focus and task completion in school, particularly during independent study periods. Parents and teachers have noted some improvement in his ability to stay on task since starting medication but report continued challenges with organization and time management. The patient denies significant side effects from his current medication but notes occasional appetite suppression. Sleep and mood are stable. Continue methylphenidate extended-release 20 mg once daily, with instructions to take the medication in the morning with food to minimize appetite effects. Educate the patient and parents on strategies to support organization, such as using a planner and setting reminders. Emphasize adherence to medication and maintaining a consistent daily routine. Plan for a follow-up in one month to evaluate symptom progression, medication efficacy, and any potential side effects.
· Review the Kaltura button from the Classroom Support Center (accessed via the Help button) for help creating your self-recorded Kaltura video.
· Select an adult patient that you examined during the last 4 weeks who presented with a disorder other than the disorder present in your Week 3 Case Presentation.
· Create a Focused SOAP Note on this patient using the template provided in the Learning Resources. There is also a completed Focused SOAP Note Exemplar provided to serve as a guide to assignment expectations. Please Note:
o All SOAP notes must be signed, by your Preceptor. Note: Electronic signatures are not accepted.
o When you submit your note, you should include the complete focused SOAP note as a Word document and PDF/images of the completed assignment signed by your Preceptor.
o You must submit your SOAP note using Turnitin. Note: If both files are not received by the due date, faculty will deduct points per the Walden Grading Policy.
· Then, based on your SOAP note of this patient, develop a video case study presentation. Take time to practice your presentation before you record.
· Include at least five scholarly resources to support your assessment, diagnosis, and treatment planning.
· Ensure that you have the appropriate lighting and equipment to record the presentation.
The Assignment
Record yourself presenting the complex case for your clinical patient.
Do not sit and read your written evaluation! The video portion of the assignment is a simulation to demonstrate your ability to succinctly and effectively present a complex case to a colleague for a case consultation. The written portion of this assignment is a simulation for you to demonstrate to the faculty your ability to document the complex case as you would in an electronic medical record. The written portion of the assignment will be used as a guide for faculty to review your video to determine if you are omitting pertinent information or including non-essential information during your case staffing consultation video.
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).
· 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.
· 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:
o 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?
o Objective: What observations did you make during the psychiatric assessment?
o Assessment: Discuss patient 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 supported by the patient’s symptoms.
o Plan: In your video, describe your treatment plan using clinical practice guidelines supported by evidence-based practice. Include a discussion on your chosen FDA-approved psychopharmacologic agents and include alternative treatments available and supported by valid research. All treatment choices must have a discussion of your rationale for the choice supported by valid research. What were your follow-up plan and parameters? What referrals would you make or recommend as a result of this treatment session?
o In your written plan include all the above as well as include one social determinant of health according to the HealthyPeople 2030 (you will need to research) as applied to this case in the realm of psychiatry and mental health. As a future advanced provider, what are one health promotion activity and one patient education consideration for this patient for improving health disparities and inequities in the realm of psychiatry and mental health? Demonstrate your critical thinking.
o Reflection notes: What would you do differently with this patient if you could conduct the session over? 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.
