CASE STUDY: Female, 15, separation anxiety disorder, Depression The patient is a fifteen-year-old female teenager who presents to the clinic with her mother for her first assessment. Patient is being referral to the clinic by the school counselor due to low grades and poor school assistance. During the session, both the patient and the mother are neatly dressed. Her mother seems to be worried about her daughter. The patient said, "I worry a lot about my family members. I fear that one day my parents will be abducted or fatally injured. The worries and fears make me have difficulties concentrating on personal well-being and my studies in school." The mental assessment shows that the patient is depressed, and she refuses to leave the proximity of her mother. Her mother says that her daughter has been experiencing depression or anxiety attacks. The physical assessment shows that the patient has been experiencing physical aches and pains. She maintains good eye contact. Her mood is a little anxious. The symptoms conclude that the patient has separation anxiety disorder because the symptoms have progressed for the past six months. Treatments include antidepressants, group therapy, family therapy, dialectical behavioral therapy, and cognitive-behavioral therapy. A follow-up is to be done in two weeks. Assignment 2: Focused SOAP Note and Patient Case Presentation Psychiatric notes are a way to reflect on your practicum experiences and connect them to the didactic learning you gain from your NRNP courses. Focused SOAP notes, such as the ones required in this practicum course, are often used in clinical settings to document patient care. For this Assignment, you will document information about a patient that you examined during the last three weeks, using the Focused SOAP Note Template provided. You will then use this note to develop and record a case presentation for this patient.  To Prepare · 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. · 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 o.

1. CASE STUDY:
Female, 15, separation anxiety disorder, Depression
The patient is a fifteen-year-old female teenager who presents
to the clinic with her mother for her first assessment. Patient is
being referral to the clinic by the school counselor due to low
grades and poor school assistance. During the session, both the
patient and the mother are neatly dressed. Her mother seems to
be worried about her daughter. The patient said, "I worry a lot
about my family members. I fear that one day my parents will
be abducted or fatally injured. The worries and fears make me
have difficulties concentrating on personal well-being and my
studies in school." The mental assessment shows that the patient
is depressed, and she refuses to leave the proximity of her
mother. Her mother says that her daughter has been
experiencing depression or anxiety attacks. The physical
assessment shows that the patient has been experiencing
physical aches and pains. She maintains good eye contact. Her
mood is a little anxious. The symptoms conclude that the patient
has separation anxiety disorder because the symptoms have
progressed for the past six months. Treatments include
antidepressants, group therapy, family therapy, dialectical
behavioral therapy, and cognitive-behavioral therapy. A follow-
up is to be done in two weeks.
Assignment 2: Focused SOAP Note and Patient Case
Presentation
Psychiatric notes are a way to reflect on your practicum
experiences and connect them to the didactic learning you gain
from your NRNP courses. Focused SOAP notes, such as the
ones required in this practicum course, are often used in clinical
settings to document patient care.
For this Assignment, you will document information about a
patient that you examined during the last three weeks, using the

2. Focused SOAP Note Template provided. You will then use this
note to develop and record a case presentation for this patient.
To Prepare
· 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.
· 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 diagnostic criteria and supported by the
patient’s symptoms.
·

3. 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?
· 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.
·
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.
· At least 3 references
· Review the Exemplar as a guide to complete the assignment,
and.
· Use the Focused SOAP Note Template provided to complete

4. the assignment.
[removed]
NRNP/PRAC 6665 & 6675 Focused SOAP Psychiatric
Evaluation Exemplar
INSTRUCTIONS ON HOW TO USE EXEMPLAR AND
TEMPLATE—READ CAREFULLY
If you are struggling with the format or remembering what to
include, follow the
Focused SOAP Note Evaluation Template
AND the Rubric
as your guide. It is also helpful to review the rubric in
detail in order not to lose points unnecessarily because you
missed something required. After reviewing full details of the
rubric, you can use it as a guide.
In the
Subjective section, provide:
· Chief complaint
· History of present illness (HPI)
· Past psychiatric history
· Medication trials and current medications
· Psychotherapy or previous psychiatric diagnosis
· Pertinent substance use, family psychiatric/substance use,
social, and medical history
· Allergies
· ROS
Read rating descriptions to see the grading standards!
In the
Objective section, provide:

5. · Physical exam documentation of systems pertinent to the chief
complaint, HPI, and history
· Diagnostic results, including any labs, imaging, or other
assessments needed to develop the differential diagnoses.
Read rating descriptions to see the grading standards!
In the
Assessment section, provide:
· Results of the mental status examination,
presented in paragraph form.
· At least three differentials with supporting evidence. List them
from top priority to least priority. Compare the
DSM-5-TR diagnostic criteria for each differential
diagnosis and explain what
DSM-5-TR 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.
·
Read rating descriptions to see the grading standards!
Reflect on this case. Include: Discuss what you learned and
what you might do differently. Also include in your reflection a
discussion related to legal/ethical considerations (
demonstrate critical thinking beyond confidentiality and
consent for treatment!), social determinates of health, 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.).
(The FOCUSED SOAP psychiatric evaluation is typically the
follow-up visit patient note. You will practice writing
this type of note in this course. You will be focusing more on
the symptoms from your differential diagnosis from the

6. comprehensive psychiatric evaluation narrowing to your
diagnostic impression. You will write up what symptoms are
present and what symptoms are not present from illnesses to
demonstrate you have indeed assessed for illnesses which could
be impacting your patient. For example, anxiety symptoms,
depressive symptoms, bipolar symptoms, psychosis symptoms,
substance use, etc.)
EXEMPLAR BEGINS HERE
Subjective:
CC (chief complaint): A
brief statement identifying why the patient is here. This
statement is verbatim of the patient’s own words about why
presenting for assessment. For a patient with dementia or other
cognitive deficits, this statement can be obtained from a family
member.
HPI: Begin this section with patient’s initials, age, race, gender,
purpose of evaluation, current medication and referral reason.
For example:
N.M. is a 34-year-old Asian male presents for medication
management follow up for anxiety. He was initiated sertraline
last appt which he finds was effective for two weeks then
symptoms began to return.
Or
P.H., a 16-year-old Hispanic female, presents for follow up to
discuss previous psychiatric evaluation for concentration
difficulty. She is not currently prescribed psychotropic
medications as we deferred until further testing and screening
was conducted.
Then, this section continues with the symptom analysis for your
note. Thorough documentation in this section is essential for
patient care, coding, and billing analysis.
Paint a picture of what is wrong with the patient. First what is
bringing the patient to your follow up evaluation? Document

7. symptom onset, duration, frequency, severity, and impact. What
has worsened or improved since last appointment? What
stressors are they facing? Your description here will guide your
differential diagnoses into your diagnostic impression. You are
seeking symptoms that may align with many
DSM-5 diagnoses, narrowing to what aligns with
diagnostic criteria for mental health and substance use
disorders.
Substance Use History: This section contains any history or
current use of caffeine, nicotine, illicit substance (including
marijuana), and alcohol. Include the daily amount of use and
last known use. Include type of use such as inhales, snorts, IV,
etc. Include any histories of withdrawal complications from
tremors, Delirium Tremens, or seizures.
Current Medications: Include dosage, frequency, length of time
used, and reason for use. Also include OTC or homeopathic
products.
Allergies:
Include medication, food, and environmental allergies
separately. Provide a description of what the allergy is (e.g.,
angioedema, anaphylaxis). This will help determine a true
reaction vs. intolerance.
Reproductive Hx:
Menstrual history (date of LMP), Pregnant (yes or no),
Nursing/lactating (yes or no), contraceptive use (method used),
types of intercourse: oral, anal, vaginal, other, any sexual
concerns
ROS: Cover all body systems that may help you include or rule
out a differential diagnosis. Please note: THIS IS DIFFERENT
from a physical examination!

8. You should list each system as follows:
General:Head:
EENT: etc. You should list these in bullet format and
document the systems in order from head to toe.
Example of Complete ROS:
GENERAL: No weight loss, fever, chills, weakness, or fatigue.
HEENT: Eyes: No visual loss, blurred vision, double vision, or
yellow sclerae. Ears, Nose, Throat: No hearing loss, sneezing,
congestion, runny nose, or sore throat.
SKIN: No rash or itching.
CARDIOVASCULAR: No chest pain, chest pressure, or chest
discomfort. No palpitations or edema.
RESPIRATORY: No shortness of breath, cough, or sputum.
GASTROINTESTINAL: No anorexia, nausea, vomiting, or
diarrhea. No abdominal pain or blood.
GENITOURINARY: Burning on urination, urgency, hesitancy,
odor, odd color
NEUROLOGICAL: No headache, dizziness, syncope, paralysis,
ataxia, numbness, or tingling in the extremities. No change in
bowel or bladder control.
MUSCULOSKELETAL: No muscle, back pain, joint pain, or
stiffness.
HEMATOLOGIC: No anemia, bleeding, or bruising.
LYMPHATICS: No enlarged nodes. No history of splenectomy.
ENDOCRINOLOGIC: No reports of sweating, cold, or heat
intolerance. No polyuria or polydipsia.
Objective:
Diagnostic results: Include any labs, X-rays, or other
diagnostics that are needed to develop the differential diagnoses
(support with evidenced and guidelines).
Assessment:
Mental Status Examination: For the purposes of your courses,
this section must be presented in paragraph form and not use of

9. a checklist! This section you will describe the patient’s
appearance, attitude, behavior, mood and affect, speech, thought
processes, thought content, perceptions (hallucinations,
pseudohallucinations, illusions, etc.)., cognition, insight,
judgment, and SI/HI. See an example below. You will modify to
include the specifics for your patient on the above elements—
DO NOT just copy the example. You may use a preceptor’s way
of organizing the information if the MSE is in paragraph form.
He is an 8-year-old African American male who looks his stated
age. He is cooperative with examiner. He is neatly groomed and
clean, dressed appropriately. There is no evidence of any
abnormal motor activity. His speech is clear, coherent, normal
in volume and tone. His thought process is goal directed and
logical. There is no evidence of looseness of association or
flight of ideas. His mood is euthymic, and his affect appropriate
to his mood. He was smiling at times in an appropriate manner.
He denies any auditory or visual hallucinations. There is no
evidence of any delusional thinking. He denies any current
suicidal or homicidal ideation. Cognitively, he is alert and
oriented. His recent and remote memory is intact. His
concentration is good. His insight is good.
Diagnostic Impression:
You must begin to narrow your differential diagnosis to
your diagnostic impression. You must explain how and why
(your rationale) you ruled out any of your differential
diagnoses. You must explain how and why (your rationale) you
concluded to your diagnostic impression. You will use
supporting evidence from the literature to support your
rationale. Include pertinent positives and pertinent negatives for
the specific patient case.
Also included in this section is the reflection. Reflect on this
case and discuss whether or not you agree with your preceptor’s
assessment and diagnostic impression of the patient and why or
why not. What did you learn from this case? What would you do

10. differently?
Also include in your reflection a discussion related to
legal/ethical considerations (
demonstrating critical thinking beyond confidentiality
and consent for treatment!), social determinates of health,
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.).
Case Formulation and Treatment Plan
Includes documentation of diagnostic studies that will be
obtained, referrals to other health care providers, therapeutic
interventions including psychotherapy and/or
psychopharmacology, education, disposition of the patient, and
any planned follow-up visits. Each diagnosis or condition
documented in the assessment should be addressed in the plan.
The details of the plan should follow an orderly manner.
*See an example below. You will modify to your
practice so there may be information excluded/included. If you
are completing this for a practicum, what does your preceptor
document?
Risks and benefits of medications are discussed including non-
treatment. Potential side effects of medications discussed (be
detailed in what side effects discussed). Informed client not to
stop medication abruptly without discussing with providers.
Instructed to call and report any adverse reactions. Discussed
risk of medication with pregnancy/fetus, encouraged birth
control, discussed if does become pregnant to inform provider
as soon as possible. Discussed how some medications might
decreased birth control pill, would need back up method
(exclude for males).
Discussed risks of mixing medications with OTC drugs, herbal,
alcohol/illegal drugs. Instructed to avoid this practice.

11. Encouraged abstinence. Discussed how drugs/alcohol affect
mental health, physical health, sleep architecture.
Initiation of (list out any medication and why prescribed, any
therapy services or referrals to specialist):
Client was encouraged to continue with case management and/or
therapy services (if not provided by you)
Client has emergency numbers: Emergency Services 911, the
Client's Crisis Line
1-800-_______. Client instructed to go to nearest ER or
call 911 if they become actively suicidal and/or homicidal.
(only if you or preceptor provided them)
Reviewed hospital records/therapist records for collaborative
information; Reviewed PMP report (only if actually completed)
Time allowed for questions and answers provided. Provided
supportive listening. Client appeared to understand discussion.
Client is amenable with this plan and agrees to follow treatment
regimen as discussed. (this relates to informed consent; you will
need to assess their understanding and agreement)
Follow up with PCP as needed and/or for:
Labs ordered and/or reviewed (write out what diagnostic test
ordered, rationale for ordering, and if discussed fasting/non
fasting or other patient education)
Return to clinic:
Continued treatment is medically necessary to address chronic
symptoms, improve functioning, and prevent the need for a
higher level of care.

12. References (move to begin on next page)
You are required to include at least three evidence-based, peer-
reviewed journal articles or evidenced-based guidelines which
relate to this case to support your diagnostics and differentials
diagnoses. Be sure to use correct APA 7th edition formatting.
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