This Week You Participate In The Second Of Three Clinical Discussions
This week you participate in the second of three clinical discussions called grand rounds. In one of these 3 weeks, you will be a presenter as well as help facilitate the online discussion; in the others you will be an active discussion participant. When it is your week to present, you will create a focused SOAP note and a short didactic (teaching) video presenting a real (but de-identified) complex patient case from your practicum experience. You should have received an assignment from your instructor indicating which week you are scheduled to present. To prepare, review this week’s Learning Resources and consider the insights they provide. Also, review the Kaltura Media Uploader resource for help creating your self-recorded video.
Select a child or adolescent patient from your clinical experience who presents with a significant concern. Develop a focused SOAP note for this patient using the provided template. All SOAP notes must be signed, and each page must be initialed by your preceptor. When submitting your SOAP note, include the complete SOAP note as a Word document and PDF/images of each page that is initialed and signed by your preceptor.
Submit your SOAP note via SafeAssign. Note that electronic signatures are not accepted. Ensure that both files are uploaded by the due date; failure to do so may result in point deductions according to Walden’s Late Policies.
Using your SOAP note as a basis, develop a video case study presentation. Prepare and practice your delivery, ensuring proper lighting and equipment to record. Your presentation should include clear objectives for your audience, at least three discussion questions/prompts for classmates, and support from at least five scholarly resources to substantiate your diagnostic reasoning and treatment plan.
Specifically, for this patient, include the following:
Subjective:
Describe the patient’s chief complaint and symptomology as provided by the patient. Include details on the duration and severity of symptoms, and how these symptoms impact their daily functioning.
Objective:
Share observations made during the psychiatric assessment.
Assessment:
Summarize the mental status examination findings. List at least three differential diagnoses, prioritized from highest to lowest. Indicate the primary diagnosis and justify why it is most appropriate, referencing DSM-5 criteria supported by the patient's symptoms.
Plan:
Describe your management plan, including psychotherapy strategies (such as one health promotion activity and patient education). Outline pharmacologic and nonpharmacologic treatment options, as well as alternative therapies and follow-up plans, providing rationale for each.
Reflection notes:
Reflect on what you might do differently if re-conducting the session. Discuss follow-up outcomes if applicable or describe next steps if follow-up is not possible.
Ensure your presentation aligns with these components and demonstrates comprehensive clinical reasoning and therapeutic planning.
Paper For Above instruction
In the context of child and adolescent mental health, clinical case presentations are vital for developing diagnostic acumen and treatment strategies. This assignment tasks mental health practitioners-in-training with synthesizing clinical data into a structured SOAP note and creating an informative didactic video that encapsulates the clinical reasoning process. The focus on a de-identified patient case allows for ethical learning while ensuring patient confidentiality.
The subjective component is essential for capturing the patient's narrative—chief concerns, symptom details, duration, severity, and functional impact. This qualitative data guides the formulation of initial differential diagnoses. Observation during assessment provides objective findings, including behavioral cues, emotional responses, and mental status parameters such as appearance, alertness, speech, mood, affect, cognition, and insight.
Assessment synthesizes subjective and objective data into a coherent mental status examination, facilitating differential diagnosis. Prioritizing at least three potential diagnoses—including primary DSM-5 disorder—requires critical analysis of symptom fit, developmental considerations, and comorbidities.
Justifying the primary diagnosis necessitates aligning observed symptoms with DSM-5 criteria, ensuring an evidence-based clinical conclusion.
The plan integrates pharmacologic and nonpharmacologic interventions, including evidence-based therapies like cognitive-behavioral therapy, family interventions, and health promotion activities. Pharmacology considerations involve evaluating medication benefits and risks tailored to the patient's age and developmental stage. Alternative therapies may encompass modalities such as mindfulness, art therapy, or complementary approaches, complemented by scheduled follow-ups to monitor progress.
Reflections on clinical practice are integral for continuous improvement. Recognizing what could be adjusted—whether in communication, assessment techniques, or intervention strategies—enhances future patient care. Discussing follow-up outcomes or next steps emphasizes responsiveness to patient needs and evidence-based practice.
References
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.).
Brent, D., & Melhem, N. (2016). Pediatric depression: Critical issues. Child and Adolescent Psychiatric Clinics of North America, 25(2), 197-205.
Ginsburg, G. S., et al. (2019). Practice parameter for the assessment and treatment of children and adolescents with anxiety disorders. Journal of the American Academy of Child & Adolescent Psychiatry, 58(2), 205–220.
National Institute of Mental Health. (2021). Child and adolescent mental health. https://www.nimh.nih.gov/health/topics/child-and-adolescent-mental-health
Weisz, J. R., & Kazdin, A. E. (2010). Evidence-Based Psychotherapies for Children and Adolescents. Guilford Publications.
Zak, R., & Schuh, K. (2017). Managing pediatric depression: Strategies and considerations. Pediatrics, 139(3), e20161869.
Shaffer, D., et al. (2015). Practice parameter for the assessment and treatment of children and adolescents with depressive disorders. Journal of the American Academy of Child & Adolescent Psychiatry, 54(10), 759-777.
Cohen, J., et al. (2019). Cognitive behavioral therapy for children and adolescents with anxiety disorders. Child and Adolescent Psychiatry Clinics, 28(2), 243-259.
Young, J., & Nelson, J. (2020). Family-centered approaches to managing adolescent mental health issues. Family Practice, 37(2), 231-237.
National Child Traumatic Stress Network. (2013). Evidence-based treatments for trauma in children. https://www.nctsn.org/what-is-child-trauma/trauma-types/complex-trauma
