Clinical Experience Analysis

COMPLEX CASE STUDY PRESENTATION
In this Assignment, you will create a case study in which you will use to present and participate in clinical discussions called grand rounds.
To prepare:
• Review the below Learning Resources and consider the insights they provide.

Assignment:
• 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 provided. (Note to writer: Patient provided below… However, please add on to patient details as needed to complete assignment )
• Your note should include objectives for your readers/audience, ADD at least 3 possible discussion questions/prompts for your classmates to respond to, and at least 4-5 scholarly resources to support your diagnostic reasoning and treatment plan.
• 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.
• Pose 3 questions or discussion prompts, based on your presentation that your colleagues can respond to after viewing your presentation.
Patient:
15yo Female
Diagnosis:

• F42: Obsessive-compulsive disorder
• F5102: Adjustment insomnia
• F411: Generalized anxiety disorder
• F29: Unspecified psychosis not due to a substance or known physiological condition
  Medications:
• ARIPiprazole 5 mg Take 0.5 tablets orally 2 times a day
• FLUoxetine HCl 20 mg Daily
• HydrOXYzine HCl 25 mg HS
  In office telemedicine: Patient/Mother presents for follow-up for medication management for the following diagnosis: OCD Insomnia and Social Phobia
  Patient continues to note improvements in her mood and behavior, with no instances of irritability, mood swings, or psychosis reported. Patient denies experiencing sleepiness when taking the first dose of Abilify during the daytime. Her sleep and appetite remain stable, and there are no reports of unusual behaviors.
  While she continues to tolerate her medications, she acknowledges forgetting to take the 2nd dose of the Abilify. Patient and mother were reminded of the importance of consistent adherence to patient’s treatment regimen. It was suggested that she consider setting an alarm in the afternoon to remind her to take the second dose of Abilify at 6 pm for medication compliance
  Patient was informed about the risks, benefits, and potential adverse effects of the prescribed medications, and she verbally confirmed her consent.
  Denies Visual Hallucinations.
  Denies Suicidal ideations/Homicidal ideations.
  Plan:
• Continue medications as prescribed
• Maintain normal food and fluid intake.
• Partial teen program was recommended.
• Discussed the plans of possibly increasing Abilify at night and gradually tapering off Hydroxyzine.
• F/U in 4 weeks.

Resources to consider:
• Carlat, D. J. (2017). The psychiatric interview (4th ed.). Wolters Kluwer.
o Chapter 26, “Assessing Alcohol Use Disorder”
• Stern, T. A., Fava, M., Wilens, T. E., & Rosenbaum, J. F. (2016). Massachusetts General Hospital psychopharmacology and neurotherapeutics. Elsevier.
o Chapter 15, “Alcohol-Related Disorders”
o Chapter 16, “Drug Addiction”
• Office of Disease Prevention and Health Promotion. (n.d.). Social Determinates of Health.Links to an external site. Healthy People 2030. U.S. Department of Health and Human Services. https://health.gov/healthypeople/priority-areas/social-determinants-health

NOTE: Please use Resources/References not older than 5-years. (2019 – 2024)