Dev Cordoba Case Study NRNP 6665 Week 3

[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.

Dev Cordoba Case Study NRNP 6665 Week 3

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? 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?

EV 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] 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. MISS CORDOBA: Oh, thank you. [MUSIC PLAYING]

SED SOAP NOTE FOR ANXIETY, PTSD, AND OCD

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.

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, Objective, Assessment, Plan, Reflection notes. 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).

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-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.
  • 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).

FOCUSED SOAP NOTE FOR ANXIETY, PTSD, AND OCD

In assessing patients with anxiety, obsessive-compulsive, and trauma and stressor-related disorders, you will continue the practice of looking to understand chief symptomology in order to develop a diagnosis. With a differential diagnosis in mind, you can then move to a treatment and follow-up plan that may involve both psychopharmacologic and psychotherapeutic approaches.

In this Assignment, you use a case study to develop a focused SOAP note based on evidence-based approaches.

TO PREPARE

  • Review this week’s Learning Resources. Consider the insights they provide about assessing and diagnosing anxiety, obsessive compulsive, and trauma-related disorders.
  • 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 Walden 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-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.
  • 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).

BY DAY 7 OF WEEK 3

Submit your Focused SOAP Note.

SUBMISSION INFORMATION

Before submitting your final assignment, you can check your draft for authenticity. To check your draft, access the Turnitin Drafts from the Start Here area.

  1. To submit your completed assignment, save your Assignment as WK3Assgn_LastName_Firstinitial
  2. Then, click on Start Assignment near the top of the page.
  3. Next, click on Upload File and select Submit Assignment for review.

NRNP_6675_Week3_Assignment_Rubric

NRNP_6675_Week3_Assignment_Rubric
Criteria Ratings Pts
This criterion is linked to a Learning OutcomeCreate documentation in the Focused SOAP Note Template about your assigned patient.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
15 to >13.0 ptsExcellent 90%–100%The response throughly and accurately describes the patient’s subjective complaint, history of present illness, past psychiatric history, medication trials and current medications, psychotherapy or previous psychiatric diagnosis, pertinent histories, allergies, and review of all systems that would inform a differential diagnosis. 13 to >11.0 ptsGood 80%–89%The response accurately describes the patient’s subjective complaint, history of present illness, past psychiatric history, medication trials and current medications, psychotherapy or previous psychiatric diagnosis, pertinent histories, allergies, and review of all systems that would inform a differential diagnosis. 11 to >10.0 ptsFair 70%–79%The response describes the patient’s subjective complaint, history of present illness, past psychiatric history, medication trials and current medications, psychotherapy or previous psychiatric diagnosis, pertinent histories, allergies, and review of all systems that would inform a differential diagnosis but is somewhat vague or contains minor innacuracies. 10 to >0 ptsPoor 0%–69%The response provides an incomplete or inaccurate description of the patient’s subjective complaint, history of present illness, past psychiatric history, medication trials and current medications, psychotherapy or previous psychiatric diagnosis, pertinent histories, allergies, and review of all systems that would inform a differential diagnosis. Or the subjective documentation is missing.
15 pts
This criterion is linked to a Learning OutcomeIn the Objective section, provide:• 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
15 to >13.0 ptsExcellent 90%–100%The response thoroughly and accurately documents the patient’s physical exam for pertinent systems. Diagnostic tests and their results are thoroughly and accurately documented. 13 to >11.0 ptsGood 80%–89%The response accurately documents the patient’s physical exam for pertinent systems. Diagnostic tests and their results are accurately documented. 11 to >10.0 ptsFair 70%–79%Documentation of the patient’s physical exam is somewhat vague or contains minor innacuracies. Diagnostic tests and their results are documented but contain minor innacuracies. 10 to >0 ptsPoor 0%–69%The response provides incomplete or inaccurate documentation of the patient’s physical exam. Systems may have been unnecessarily reviewed. Or the objective documentation is missing.
15 pts
This criterion is linked to a Learning OutcomeIn 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 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.
20 to >17.0 ptsExcellent 90%–100%The response thoroughly and accurately documents the results of the mental status exam…. Response lists at least three distinctly different and detailed possible disorders in order of priority for a differential diagnosis of the patient in the assigned case study, and it provides a thorough, accurate, and detailed justification for each of the disorders selected. 17 to >15.0 ptsGood 80%–89%The response accurately documents the results of the mental status exam…. Response lists at least three distinctly different and detailed possible disorders in order of priority for a differential diagnosis of the patient in the assigned case study, and it provides an accurate justification for each of the disorders selected. 15 to >13.0 ptsFair 70%–79%The response documents the results of the mental status exam with some vagueness or innacuracy…. Response lists at least three different possible disorders for a differential diagnosis of the patient and provides a justification for each, but may contain some vagueness or innacuracy. 13 to >0 ptsPoor 0%–69%The response provides an incomplete or inaccurate description of the results of the mental status exam and explanation of the differential diagnoses. Or the assessment documentation is missing.
20 pts
This criterion is linked to a Learning OutcomeIn the Plan section, provide:• Your plan for psychotherapy• 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. • Incorporate one health promotion activity and one patient education strategy.
25 to >22.0 ptsExcellent 90%–100%The response provides an evidence-based, detailed, and appropriate plan for psychotherapy for the patient…. The response provides an evidence-based, detailed, and appropriate plan for treatment and management, including pharmacologic and nonpharmacologic treatments, alternative therapies, and follow-up parameters. A strong rationale for the plan is provided that demonstrates critical thinking and content understanding…. The response includes at least one evidence-based health promotion activity and one evidence-based patient education strategy. 22 to >19.0 ptsGood 80%–89%The response provides an evidence-based and appropriate plan for psychotherapy for the patient…. The response provides an evidence-based and appropriate plan for treatment and management, including pharmacologic and nonpharmacologic treatments, alternative therapies, and follow-up parameters. An adequate rationale for the plan is provided…. The response includes at least one health promotion activity and one patient education strategy. 19 to >17.0 ptsFair 70%–79%The response provides a somewhat vague or inaccurate plan for psychotherapy for the patient…. The response provides a somewhat vague or inaccurate plan for treatment and management, including pharmacologic and nonpharmacologic treatments, alternative therapies, and follow-up parameters. The rationale for the plan is weak or general…. The response includes one health promotion activity and one patient education strategy, but it may contain some vagueness or innacuracy. 17 to >0 ptsPoor 0%–69%The response provides an incomplete or inaccurate plan for psychotherapy for the patient…. The response provides an incomplete or inaccurate plan for treatment and management, including pharmacologic and nonpharmacologic treatments, alternative therapies, and follow-up parameters. The rationale for the plan is inaccurate or missing…. The health promotion and patient education strategies are incomplete or missing.
25 pts
This criterion is linked to a Learning Outcome• Discussion include what may be done differently with this patient if student conducted the session again. Discussed the next intervention if you could follow up with this patient. The discussion was related to legal/ethical considerations (demonstrated critical thinking beyond confidentiality and consent for treatment!), social determinates of health, health promotion, and disease prevention that take into consideration patient factors (such as age, ethnic group, etc.), PMH, and other risk factors (e.g., socioeconomic, cultural background, etc.).
5 to >4.0 ptsExcellent 90%–100%Reflections are thorough, thoughtful, and demonstrate critical thinking. Reflections contain a discussion of all elements described within assignment directions. 4 to >3.5 ptsGood 80%–89%Reflections demonstrate critical thinking. Reflections contain 2 out of 3 (legal/ethical considerations, social determinate of health, health promotion) with consideration of patient factors and risk factors. 3.5 to >3.0 ptsFair 70%–79%Reflections are somewhat general or do not demonstrate critical thinking. Reflections contain 2 out of 3 (legal/ethical considerations, social determinate of health, health promotion) without consideration of patient factors and risk factors. 3 to >0 ptsPoor 0%–69%Reflections are incomplete, inaccurate, or missing.
5 pts
This criterion is linked to a Learning OutcomeProvide 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).
10 to >8.0 ptsExcellent 90%–100%The response provides at least three current, evidence-based resources from the literature to support the assessment and diagnosis of the patient in the assigned case study. The resources reflect the latest clinical guidelines and provide strong justification for decision making. 8 to >7.0 ptsGood 80%–89%The response provides at least three current, evidence-based resources from the literature that appropriately support the assessment and diagnosis of the patient in the assigned case study. 7 to >6.0 ptsFair 70%–79%Three evidence-based resources are provided to support the assessment and diagnosis of the patient in the assigned case study, but they may only provide vague or weak justification. 6 to >0 ptsPoor 0%–69%Two or fewer resources are provided to support the assessment and diagnosis decisions. The resources may not be current or evidence based.
10 pts
This criterion is linked to a Learning OutcomeWritten Expression and Formatting – The paper follows correct APA format for parenthetical/in-text citations and reference list.
5 to >4.0 ptsExcellent 90%–100%Uses correct APA format with no errors 4 to >3.5 ptsGood 80%–89%Contains 1-2 APA format for parenthetical/in-text citations and reference list errors 3.5 to >3.0 ptsFair 70%–79%Contains 3-4 APA format for parenthetical/in-text citations and reference list errors 3 to >0 ptsPoor 0%–69%Contains five or more APA format for parenthetical/in-text citations and reference list errors
5 pts
This criterion is linked to a Learning OutcomeWritten Expression and Formatting – English Writing Standards: Correct grammar, mechanics, and punctuation
5 to >4.0 ptsExcellent 90%–100%Uses correct grammar, spelling, and punctuation with no errors 4 to >3.5 ptsGood 80%–89%Contains 1-2 grammar, spelling, and punctuation format errors 3.5 to >3.0 ptsFair 70%–79%Contains 3-4 grammar, spelling, and punctuation format errors 3 to >0 ptsPoor 0%–69%Contains five or more grammar, spelling, and punctuation format errors that interfere with the reader’s understanding
5 pts
Total Points: 100

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Dev Cordoba Case Study NRNP 6665 LEARNING RESOURCES

Required Readings

  • Boland, R. Verdiun, M. L. & Ruiz, P. (2022). Kaplan & Sadock’s synopsis of psychiatry(12th ed.). Wolters Kluwer.
    • Chapter 2, “Neurodevelopmental Disorders and Other Childhood Disorders”
      • Section 2.8, “Trauma- and Stressor-Related Disorders in Children” (pp. 167-173)
      • Section 2.13, “Anxiety Disorders of Infancy, Childhood, and Adolescence: Separation Anxiety Disorder, Generalized Anxiety Disorder, and Social Anxiety Disorder (Social Phobia)” (pp. 194-200”)
      • Section 2.14, “Selective Mutism” (pp.  201-202)
      • Section 2.15, “Obsessive-Compulsive Disorder in Childhood and Adolescence” (pp. 203-206)
    • Chapter 8, “Anxiety Disorders”
    • Chapter 9, “Obsessive-Compulsive and Related Disorders”
    • Chapter 10, “Trauma- and Stressor-Related Disorders
  • Thapar, A., Pine, D. S., Leckman, J. F., Scott, S., Snowling, M. J., & Taylor, E. A. (Eds.). (2015). Rutter’s child and adolescent psychiatry(6th ed.). Wiley Blackwell.
    • Chapter 26, “Psychosocial Adversity”
    • Chapter 27, “Resilience: Concepts, Findings, and Clinical Implications”
    • Chapter 29, “Child Maltreatment”
    • Chapter 30, Child Sexual Abuse”
    • Chapter 58, “Disorders of Attachment and Social engagement Related to Deprivation”
    • Chapter 59, “Post Traumatic Stress Disorder”
  • Zakhari, R. (2021). The psychiatric-mental health nurse practitioner certification review manual. Springer Publishing Company.
    • Chapter 6, “Physical Assessment, Diagnostic Tests, and Differential Diagnosis”
    • Chapter 12, “Anxiety Disorders”
  • Document: Career Planner GuideDownload Career Planner Guide
  • Document: Focused SOAP Note TemplateDownload Focused SOAP Note Template
  • Document: Focused SOAP Note ExemplarDownload Focused SOAP Note Exemplar

Required Media