Focused soap note and patient case presentation

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Conduct disorder refers to a group of behavioral and emotional problems characterized by a disregard for others. Children with conduct disorder have a difficult time following rules and behaving in a socially acceptable way. Their behavior can be hostile and sometimes physically violent. In their earlier years, they may show early signs of aggression, including pushing, hitting and biting others. Adolescents and teens with conduct disorder may move into more serious behaviors, including bullying, hurting animals, picking fights, theft, vandalism and arson.

Children with conduct disorder can be found across all races, cultures and socioeconomic groups. They often have other mental health issues as well that may contribute to the development of the conduct disorder. The disorder is more prevalent in boys than girls.

LEARNING RESOURCES


Required Readings

· Carlat, D. J. (2017). 
The psychiatric interview (4th ed.). Wolters Kluwer.

· Chapter 32, “How to Educate Your Patient”

·

MeditrekLinks to an external site.

https://edu.meditrek.com/Default.html

Note: Use this link to log into Meditrek to report your clinical hours and patient encounters.

·
Document: 

Focused SOAP Note Template (Word document)

PATIENTS HISTORY

G.G. is a 13-year-old Hispanic boy who lived with his adopted parent. GG is a Hispanic migrant picked up at the America/Mexico border 2 years ago by the immigration officer. He stayed in a foster home and was recently adopted, by his present parent. He is in 6th grade at his new school.

He has been physically cruel to animal, steels money from his adopted mother’s pause and lies about it. He deliberately destroys things at home and when asked, he lies. The parents were summoned at the school and his teacher complained that he bullies other students, forcefully grab other student’s belongings and initiate physical fight with other students. The school psychologist recommended for him to go for psychiatric evaluation.

The Assignment

Assessment:

·  Discuss the 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.

Plan: 

· 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 Healthy People 2030

· 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 over? 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.

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