PRAC 6665 WEEK 9 Focused SOAP Note and Patient Case

Walden University PRAC 6665 WEEK 9 Focused SOAP Note and Patient Case Presentation, Part 1-Step-By-Step Guide

This guide will demonstrate how to complete the Walden University PRAC 6665 WEEK 9 Focused SOAP Note and Patient Case Presentation, Part 1 assignment based on general principles of academic writing. Here, we will show you the A, B, Cs of completing an academic paper, irrespective of the instructions. After guiding you through what to do, the guide will leave one or two sample essays at the end to highlight the various sections discussed below.

How to Research and Prepare for PRAC 6665 WEEK 9 Focused SOAP Note and Patient Case Presentation, Part 1

Whether one passes or fails an academic assignment such as the Walden University PRAC 6665 WEEK 9 Focused SOAP Note and Patient Case Presentation, Part 1 depends on the preparation done beforehand. The first thing to do once you receive an assignment is to quickly skim through the requirements. Once that is done, start going through the instructions one by one to clearly understand what the instructor wants. The most important thing here is to understand the required format—whether it is APA, MLA, Chicago, etc.

After understanding the requirements of the paper, the next phase is to gather relevant materials. The first place to start the research process is the weekly resources. Go through the resources provided in the instructions to determine which ones fit the assignment. After reviewing the provided resources, use the university library to search for additional resources. After gathering sufficient and necessary resources, you are now ready to start drafting your paper.

How to Write the Introduction for PRAC 6665 WEEK 9 Focused SOAP Note and Patient Case Presentation, Part 1

The introduction for the Walden University PRAC 6665 WEEK 9 Focused SOAP Note and Patient Case Presentation, Part 1 is where you tell the instructor what your paper will encompass. In three to four statements, highlight the important points that will form the basis of your paper. Here, you can include statistics to show the importance of the topic you will be discussing. At the end of the introduction, write a clear purpose statement outlining what exactly will be contained in the paper. This statement will start with “The purpose of this paper…” and then proceed to outline the various sections of the instructions.

Need a high-quality paper urgently?

We can deliver within hours.

PLACE AN ORDER

How to Write the Body for PRAC 6665 WEEK 9 Focused SOAP Note and Patient Case Presentation, Part 1

After the introduction, move into the main part of the PRAC 6665 WEEK 9 Focused SOAP Note and Patient Case Presentation, Part 1 assignment, which is the body. Given that the paper you will be writing is not experimental, the way you organize the headings and subheadings of your paper is critically important. In some cases, you might have to use more subheadings to properly organize the assignment. The organization will depend on the rubric provided. Carefully examine the rubric, as it will contain all the detailed requirements of the assignment. Sometimes, the rubric will have information that the normal instructions lack.

Another important factor to consider at this point is how to do citations. In-text citations are fundamental as they support the arguments and points you make in the paper. At this point, the resources gathered at the beginning will come in handy. Integrating the ideas of the authors with your own will ensure that you produce a comprehensive paper. Also, follow the given citation format. In most cases, APA 7 is the preferred format for nursing assignments.

How to Write the Conclusion for PRAC 6665 WEEK 9 Focused SOAP Note and Patient Case Presentation, Part 1

After completing the main sections, write the conclusion of your paper. The conclusion is a summary of the main points you made in your paper. However, you need to rewrite the points and not simply copy and paste them. By restating the points from each subheading, you will provide a nuanced overview of the assignment to the reader.

How to Format the References List for PRAC 6665 WEEK 9 Focused SOAP Note and Patient Case Presentation, Part 1

The very last part of your paper involves listing the sources used in your paper. These sources should be listed in alphabetical order and double-spaced. Additionally, use a hanging indent for each source that appears in this list. Lastly, only the sources cited within the body of the paper should appear here.

Stuck? Let Us Help You

Completing assignments can sometimes be overwhelming, especially with the multitude of academic and personal responsibilities you may have. If you find yourself stuck or unsure at any point in the process, don’t hesitate to reach out for professional assistance. Our assignment writing services are designed to help you achieve your academic goals with ease.

Our team of experienced writers is well-versed in academic writing and familiar with the specific requirements of the PRAC 6665 WEEK 9 Focused SOAP Note and Patient Case Presentation, Part 1 assignment. We can provide you with personalized support, ensuring your assignment is well-researched, properly formatted, and thoroughly edited. Get a feel of the quality we guarantee – ORDER NOW.

Sample Answer for PRAC 6665 WEEK 9 Focused SOAP Note and Patient Case Presentation, Part 1

Subjective:

CC (chief complaint): “My nightmares are unbearable.”

HPI: B.L. is a 14-year-old boy who reports experiencing recurrent, involuntary, and intrusive distressing memories of a traumatic event that occurred six months ago, involving a car accident where he witnessed a severe injury to his sister. He describes frequent nightmares related to the trauma and flashbacks during the day, which lead to significant distress. The patient avoids talking about the event, avoids activities, places, and people that remind him of the trauma, and shows a marked decrease in interest in activities he previously enjoyed. He also reports feeling detached from friends and family and having difficulty experiencing positive emotions. Additionally, the patient mentions having an exaggerated startle response, difficulty concentrating, and trouble sleeping. There are no reports of substance use or self-harm. Family history includes anxiety disorders.

Substance Current Use: The patient has denied using any substance.

Medical History:

Current Medications: The patient is currently using over-the-counter sleeping pills to improve his sleeping habits and patterns. No other medication was reported.
Allergies: No known allergies

Reproductive Hx: No notable reproductive history. The patient is not sexually active.

ROS:

GENERAL: She reports no recent weight loss. Denies fever, chill, weakness, or fatigue.
HEENT: No headache or trauma, no lumps, bumps, or lesions. No double vision or vision change, no eye discharge, redness or pain, no hearing loss, no ear discharge or pain. No nasal discharge or congestion. No dysphagia or hoarseness.
SKIN: No itch, lesions, bruising, abnormal pigmentation, or rashes.
CARDIOVASCULAR: No edema or palpitations, no chest discomfort, chest pressure, or chest pain. Normal heart rate and rhythm
RESPIRATORY: No sputum, cough, or shortness of breath. No signs of respiratory distress
GASTROINTESTINAL: No abdominal pain, vomiting, and nausea. No constipation
GENITOURINARY: No hesitancy, urgency, or burning on urination
NEUROLOGICAL: No weakness, tingling, or numbness.
MUSCULOSKELETAL: No muscle stiffness, joint pain, or back pain
HEMATOLOGIC: No bruising, bleeding or anemia
LYMPHATICS: No history of splenectomy, no enlarged nodes
ENDOCRINOLOGIC: No polydipsia or polyuria. Reports no intolerance to heat or cold.

Objective:

Diagnostic results: Children’s Depression Inventory to help asses the depressive symptoms and rule out major depressive disorder and Screen for Child Anxiety Related Disorders (SCARED) to help rule out other anxiety disorders.

Assessment:

Mental Status Examination: The patient is a 14-year-old patient who visited the facility for an assessment. He is appropriately dressed and well-groomed. He is also alert and oriented in person, place, and time. The patient appears anxious and exhibits signs of hypervigilance during the interview. He is cooperative but has a restricted affect. His mood is anxious and fearful. He maintains appropriate eye contact intermittently but occasionally looks away, especially when talking about distressing memories. His speech is of normal rate and rhythm, clear and coherent, and soft-spoken. He exhibits logical and coherent thought processes. He denies visual or auditory hallucinations. There are no signs of self-harm or physical injury. He denies suicidal thoughts or ideation.

Diagnostic Impression:

Posttraumatic Stress Disorder (PTSD): This is a condition that may develop after a person witnesses or experiences a traumatic event and may present with symptoms such as alterations in reactivity and arousal, negative changes in cognition and mood, avoidance, and intrusive memories (Merians et al.,2023). The patient presented with intrusive symptoms, avoidance, negative changes in mood and cognition, trouble sleeping, and difficulty concentrating, which have persisted for six months. Therefore, PTSD is the primary diagnosis.
Acute Stress Disorder: This is an illness characterized by the development of severe anxiety and other symptoms within a month of experiencing or witnessing a traumatic event (Geoffrion et al.,2022). The patient presents with negative moods, avoidance and arousal, and intrusion symptoms such as flashbacks, nightmares, and distressing memories following exposure to trauma. However, these symptoms should occur and resolve within a month, which is not the case for this patient, whose symptoms have persisted for six months; hence, this condition is less likely.
Major Depressive Disorder: Major Depressive Disorder is a condition where a patient experiences persistent feelings of sadness which may last for at least two weeks. The patient may present with symptoms such as changes in concentration, energy level, appetite, and sleep (Malgaroli et al.,2021). The patient presented with decreased interest in activities, sleep disturbances, feelings of detachment, and difficulty experiencing positive emotions. However, the patient presented with trauma-specific symptoms such as avoidance behavior, flashbacks, and intrusive memories, which mainly point to PTSD.

Reflections: This case presents a platform for continuous learning. I agree with the assessment based on the differential diagnosis and the patient information provided. For example, the symptoms that the patient presented with are consistent with PTSD. One learning point is the need to carry out a comprehensive assessment using standardized symptom scales and clinical interviews to arrive at the diagnoses. It is also vital to consider multiple differential diagnoses and systematically rule them out based on particular criteria. One of the things I would do differently is further mental evaluations to rule out other conditions such as major depressive disorder and anxiety disorders. It is vital to consider legal and ethical aspects. For example, autonomy and assent should be considered. Even though the patient is a minor and can not offer legal consent, it is ethical to ensure that he takes part in the treatment planning as a way of respecting his autonomy (Killackey et al.,2020). It is also important to make him and his family understand the treatment options, potential benefits, and even risks associated with the treatment options. Social determinants of health are also vital in this case. One of them is family environment and support. The family’s ability to offer a supportive environment for the patient should be assessed. Lack of parental or family support may hinder the patient’s recovery. It is also vital to facilitate access to support groups and family therapy for better outcomes. As part of health promotion, psychoeducation is key. The family needs to be educated about PTSD symptoms, coping strategies, and how to fight stigma and promote adherence to the formulated treatment plan.

Case Formulation and Treatment Plan:

Further laboratory tests may be needed as part of the case formulation. A complete blood count should be used to rule out infection. Thyroid function tests should be used to rule out any thyroid dysfunction and basic metabolic panel. In the case of PTSD, the patient should be initiated on Trauma-Focused Cognitive Therapy to help address the PTSD symptoms (Ennis et al.,2020). Psychotherapy should be integrated with sertraline (25 mg) per day, which can be adjusted based on the patient’s response. A similar approach can be used for the acute stress disorder. In the case of major depressive disorder. The patient should be started on fluoxetine (25 mg) per day, which can be increased to 50 mg depending on the patient’s response and tolerance. The medication should be integrated with weekly sessions of cognitive behavioral therapy. As part of education, the patient and the family should be educated on the importance of adhering to the medication and psychotherapy plan.

PRECEPTOR VERFICIATION:

I confirm the patient used for this assignment is a patient that was seen and managed by the student at their Meditrek approved clinical site during this quarter course of learning.

References

Ennis, N., Shorer, S., Shoval‐Zuckerman, Y., Freedman, S., Monson, C. M., & Dekel, R. (2020). Treating posttraumatic stress disorder across cultures: A systematic review of cultural adaptations of trauma‐focused cognitive behavioral therapies. Journal of Clinical Psychology, 76(4), 587-611. https://doi.org/10.1016/j.cpr.2021.102049

Geoffrion, S., Goncalves, J., Robichaud, I., Sader, J., Giguere, C. E., Fortin, M., … & Guay, S. (2022). Systematic review and meta-analysis on acute stress disorder: Rates following different types of traumatic events. Trauma, Violence, & Abuse, 23(1), 213-223. Doi: 10.1177/1524838020933844

Killackey, T., Peter, E., Maciver, J., & Mohammed, S. (2020). Advance care planning with chronically ill patients: A relational autonomy approach. Nursing Ethics, 27(2), 360-371. https://doi.org/10.1177/0969733019848031

Malgaroli, M., Calderon, A., & Bonanno, G. A. (2021). Networks of major depressive disorder: A systematic review. Clinical Psychology Review, 85, 102000. https://doi.org/10.1016/j.cpr.2021.102000

Merians, A. N., Spiller, T., Harpaz-Rotem, I., Krystal, J. H., & Pietrzak, R. H. (2023). Posttraumatic stress disorder. Medical Clinics, 107(1), 85-99. https://doi.org/10.1016/j.mcna.2022.04.003