Chief complaint: “Increasing anxiety.” HPI: Patient A. B. is a 14-year-old African American female who presents today to the office with her mother for a follow-up appointment. Patient reports she has been having increasing anxiety and nightmares at night. Patient expresses other symptoms of hopelessness, easily startled or frightened when alone, low self-esteem, difficulty to maintain friendships, and avoids making a relationship with men. States she lacks interest in cheerleading, which was one of her enjoyable activities. Patient was sexually molested at the age of twelve by her maternal uncle while she was under the care of her grandmother. Denies self-harm or homicidal thoughts or ideations at this time. Reports good appetite, but inadequate sleep takes time to fall asleep and is easily awakened at night. Mental Status Examination: Patient is AOX3. Well-groomed and appears well-nourished. She has a distorted thought of herself and others. She does not make eye contact, slow speech but coherent, trouble concentrating, and increased startle. Depressed and anxious mood, flat affect. Diagnosis: F43. 1 Post-traumatic stress disorder (PTSD) F33.2 Major depressive disorder, recurrent severe without psychotic features Treatment plan Pharmacological: Hydroxyzine (Vistaril) 25 mg PO two times daily Zoloft 50 mg PO daily Started on prazosin 1 mg orally two times daily NonPharmacological: Patient was encouraged to keep up with psychotherapy, the importance of compliance with medications, to report to emergency if experiencing suicidal or homicidal thoughts. Follow up appointment in 2 weeks.
A note on grading:
Please follow the instructions below4 referenceszero plagiarismThis week you participate in the second of three clinical discussions called grand rounds. In one of these 3 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. 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 patientfrom your clinical experience that presents with a significant concern. Create a focused SOAP note for this patient using the template in the Resources.ÿAll SOAP notes must be signed, and each page must be initialed by your Preceptor. When you submit your SOAP note, you should include the complete SOAP note as a Word document and PDF/images of each page that is initialed and signed by your Preceptor. You must submit your SOAP note using SafeAssign.Please Note:ÿElectronic 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. Set aside 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 three possible discussion questions/prompts for your classmates to respond to, and at least five scholarly resources to support your diagnostic reasoning and treatment plan.