SOAP Note

PLEASE FOLLOW INSTRUCTIONS AND COVER AREAS BELOW TO COMPLETE FOCUSED SOAP NOTE.

  • Review the Focused SOAP Note template, which you will use to  complete this Assignment. There is also a Focused SOAP Note Exemplar  provided as a guide for Assignment expectations.
  • Review the video, Case Study: Dev Cordoba. You will use this  case as the basis of this Assignment. In this video, a faculty member is assessing a mock patient. The patient will be represented  onscreen as an avatar.
  • Consider what history would be necessary to collect from this patient.
  • Consider what interview questions you would need to ask this patient.

The Assignment

Develop a Focused SOAP Note, including your  differential diagnosis and critical-thinking process to formulate a  primary diagnosis. Incorporate the following into your responses in the  template:

  • 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 the patient’s mental status examination  results. What were your differential diagnoses? Provide a minimum of  three possible diagnoses with supporting evidence, listed in order from  highest priority to lowest priority. Compare the DSM-5 diagnostic criteria for each differential diagnosis and explain what DSM-5 criteria  rules out the differential diagnosis to find an accurate diagnosis.  Explain the critical-thinking process that led you to the primary  diagnosis you selected. Include pertinent positives and pertinent  negatives for the specific patient case.
  • Plan: What is your plan for psychotherapy? What is 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. Also incorporate one health promotion activity and one  patient education strategy.
  • Reflection notes: What would you do differently with this  patient if you could conduct the session again? Discuss what your next  intervention would be if you could follow up with this patient.?Also  include in your reflection a discussion related to legal/ethical  considerations (demonstrate critical thinking beyond confidentiality and  consent for treatment!), health promotion, and disease prevention,  taking into consideration patient factors (such as age, ethnic group,  etc.), PMH, and other risk factors (e.g., socioeconomic, cultural  background, etc.).
  • Provide at least three evidence-based, peer-reviewed journal  articles or evidenced-based guidelines that relate to this case to  support your diagnostics and differential diagnoses. Be sure they are  current (no more than 5 years old).

** Three references required

** No plagiarism

Case Study: Dev Cordoba

Program Transcript

[MUSIC PLAYING]

DR. JENNY: Hi there. My name is Dr. Jenny. Can you tell me your name and how old

you are?

DEV CORDOBA: My name is Dev, and I am seven years old.

DR. JENNY: Wonderful. Dev, can you tell me what the month and the date is? And

where are we right now?

DEV CORDOBA: Today is St. Patrick’s Day. It’s March 17th.

DR. JENNY: Do you know where we are?

DEV CORDOBA: We’re at the school.

DR. JENNY: Good. Did your mom tell you why you’re here today to see me?

DEV CORDOBA: She thought you were going to help me be better.

DR. JENNY: Yes, I am here to help you. Have you ever come to see someone like me

before, or talked to someone like me before to help you with your mood?

DEV CORDOBA: No, never.

DR. JENNY: OK. Well, I would like to start with getting to know you a little bit better, if

that’s OK. What do you like to do for fun when you’re at home?

DEV CORDOBA: Oh, I have a dog. His name is Sparky. We play policeman in my

room. And I have LEGOs, and I could build something if you want.

DR. JENNY: I would love to see what you build with your LEGOs. Maybe you can bring

that in for me next appointment. Who lives in your home?

DEV CORDOBA: My mom and my baby brother and Sparky.

DR. JENNY: Do you help your mom with your brother?

DEV CORDOBA: No. His breath smells like bad milk all the time. [CHUCKLES] And he

cries a lot, and my mom spends more time with him.

DR. JENNY: So how do you feel most of the time? Do you feel sad or worried or mad or

happy?

DEV CORDOBA: Worried.

DR. JENNY: What types of things do you worry about?

Case Study: Dev Cordoba

DEV CORDOBA: I don’t know, just everything. I don’t know.

DR. JENNY: OK. So your mom tells me you also have a lot of bad dreams. Can you tell

me a little more about your bad dreams, like maybe what they’re about, how many

nights you might have them?

DEV CORDOBA: I dream a lot that I’m lost, that I can’t find my mom or my little brother.

They seem like they happen almost every night, but maybe not some nights.

DR. JENNY: Now that must feel horrible. Have you ever been lost before when maybe

you weren’t asleep?

DEV CORDOBA: Oh, no. No. And I don’t like the dark. My mom puts me in a night light

with the door open, so I know she’s really there.

DR. JENNY: That seems like that probably would help. Do you like to go to school? Or

would you rather not go?

DEV CORDOBA: I worry about by mom and brother when I’m at school. All I can think

about is what they’re doing, and if they’re OK. And besides, nobody likes me there.

They call me Mr. Smelly.

DR. JENNY: Well. That’s not nice at all. Why do you feel they call you names?

DEV CORDOBA: I don’t know. But my mom says it’s because I won’t take my baths.

[SIGHS] She tells me to, and it– and I have night accidents.

DR. JENNY: Oh, how does that make you feel?

DEV CORDOBA: Sad and really bad. They don’t know how it feels for their daddy to

never come home. What if my mom doesn’t come home too?

DR. JENNY: Yes, you seem to worry about that a lot. Does this worry stop you from

being able to learn in school?

DEV CORDOBA: Well, [SIGHS] my teacher is, all the time, telling me to sit down and

focus. And I get in trouble for [SIGHS] looking out the window. And she moved my chair

beside her desk, but I don’t mind because Billy leaves me alone now.

DR. JENNY: Billy. Have you ever hit Billy or anyone else?

DEV CORDOBA: No, but I did throw my book at him.

DR. JENNY: Hmm.

DEV CORDOBA: [CHUCKLES]

Case Study: Dev Cordoba

© 2021 Walden University, LLC 3

DR. JENNY: What about yourself? Have you ever hit yourself or thought about doing

something to hurt yourself?

DEV CORDOBA: No.

DR. JENNY: OK. Well, Dev, I would like to talk to your mom now. We’re going to work

together, and we’re going to help you feel happier, less worried, and be able to enjoy

school more. Is that OK?

DEV CORDOBA: Yes. Thank you.

MISS CORDOBA: Hi.

DR. JENNY: Thank you, Miss Cordoba, for bringing in Dev. I feel we can help him. So

tell me, what is your main concerns for Dev?

MISS CORDOBA: [SIGHS] Well, he just seems so anxious and worried all the time, silly

things like I’m going to die, or I won’t pick him up from school. He says I love his brother

more than him. He’ll throw things around the house, and gets in trouble at school for

throwing things.

He has a difficult time going to sleep. He wants his lights on, doors open, gets up

frequently. And he’s all the time wanting to come home from school, claims stomach

aches, and headaches almost daily. He won’t eat. He’s lost three pounds in the past

three weeks. Our pediatrician sent us to you because he doesn’t believe anything is

physically wrong.

Oh, and I almost forgot. He still wets the bed at night. [SIGHS] We’ve tried everything.

His pediatrician did give him DDVAP, but it doesn’t seem to help.

DR. JENNY: Hmm. OK. Can you tell me, any blood relatives have any mental health or

substance use issues?

MISS CORDOBA: No, not really.

DR. JENNY: What about his father? He said that he never came home?

MISS CORDOBA: Oh, yes. His father was deployed with the military when Dev was

five. I told Dev he was on vacation. I didn’t know what to tell him. I thought he was too

young to know about war. And his father was killed, so Dev still doesn’t understand that

his father didn’t just leave him. [SIGHS] I just feel so guilty that all of this is my fault.

DR. JENNY: Miss Cordoba, you did the right thing by bringing in Dev. We can help you

with him.

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