Focused SOAP Note for Anxiety, PTSD, and OCD Assignment

Focused SOAP Note for Anxiety, PTSD, and OCD Assignment

Focused SOAP Note for Anxiety, PTSD, and OCD Assignment

Subjective:

CC (chief complaint): “My mom said you are going to help me get better.”

HPI:

Dev Cordoba is a 7-year-old boy referred for psychiatric assessment after being referred by the pediatrician for counseling. He comes to the psychiatric clinic alongside his mother, Miss Cordoba. Miss Cordoba mentions that Dev is constantly anxious and expresses worries about ridiculous things like his mother will die or fail to pick him up from school. Dev says that his mother loves his brother more than him. He throws items around the house and has gotten into trouble at school for this. The boy admits that he is anxious most of the time about a lot of things. He states that he gets bad dreams of mostly getting lost and failing to trace his mother and younger brother.  The boy also reports losing concentration in class and often gets into problems for staring through the window. Miss Cordoba also mentions that Dev has difficulties getting to sleep because he wants the doors open and lights on, and wakes up frequently. Furthermore, Dev usually says he wants to leave school and go home nearly daily, with reports of stomach aches and headaches. He has a poor appetite and has lost three pounds within three weeks. Dev also wets the bed at night, and this has persisted even with a prescription of DDVAP.

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Substance Current Use: No history of alcohol or substance use.

Medical History: No medical history of chronic diseases. Immunizations are up to date.

• Current Medications: No current medications
• Allergies: No food or drug allergies.

• Reproductive Hx: Not applicable

ROS:

• GENERAL: Positive for appetite disturbance and weight loss. Negative for fatigue, fever, or chills
• HEENT: Positive for headaches. Negative for a head injury, sinus pain, visual loss, ear pain/discharge, nasal discharge/blockage, or throat pain.
• SKIN: Negative for rashes, itching, or bruises.
• CARDIOVASCULAR: Negative for chest pain, edema, dyspnea, or palpitations.
• RESPIRATORY: Negative for cough, sputum, chest pain, or breathing difficulties.
• GASTROINTESTINAL: Positive for loss of appetite and abdominal pain. Negative for nausea, vomiting, diarrhea, or constipation.
• GENITOURINARY: Negative for dysuria, urinary frequency/urgency, or penile discharge.
• NEUROLOGICAL: Positive for headaches. Negative for dizziness, loss of consciousness, muscle weakness, or tingling sensations.
• MUSCULOSKELETAL: Negative for muscle pain, back pain, or joint stiffness/pain.
• HEMATOLOGIC: Negative for bruises.
• LYMPHATICS: Negative for lymph node swelling.
• ENDOCRINOLOGIC: Negative for cold-heat intolerance, acute thirst, or excessive hunger.

Objective:

Diagnostic results: No lab/imaging tests were ordered.

Assessment:

Mental Status Examination:

The patient is well-groomed and appropriately dressed. He is alert and maintains adequate eye contact in the interview. His speech is clear with normal tone, rate, and volume. The patient has a coherent and logical thought process. He conveys worries about his mother and younger brother being in danger. The client has nyctophobia. No obsessions, compulsions, delusions, or hallucinations were noted. He is oriented to person, place, and time. He demonstrates good abstract thought and judgment. Insight is present.

Assessment

Pediatric Generalized Anxiety Disorder (GAD)

Pediatric GAD is characterized by excessive and uncontainable worry or anxiety about a number of things or events (Bhatia & Goyal, 2018). Excessive worry/anxiety is accompanied by symptoms such as headaches, palpitations, gastrointestinal distress, muscle tension, restlessness, concentration difficulties, and sleep disturbances (APA, 2013). Pediatric GAD is a presumptive diagnosis based on pertinent positive symptoms of excessive and unjustified patient’s worry about his mother and brother being in danger or the mother failing to pick him up from school. The patient also has positive GAD symptoms like constant headaches, stomach aches, poor concentration levels, and sleeping difficulties, which have affected his academic performance.

Separation Anxiety Disorder

Separation anxiety disorder (SAD) manifests with constant and excessive anxiety in children, which is associated with separation or impending separation from the primary caretaker or a family member. Children with SAD present with persistent excessive distress when being separated or anticipating separation from attachment figures (APA, 2013). Children also have persistent and unwarranted worry about losing their primary attachment figures or harm occurring to them. Furthermore, they convey excessive worry about getting into an unpleasant event that may result in separation from their attachment figures (Gittelman & Klein, 2019). The anxiety makes them hesitant about being away from home because of the fear of separation. Besides, children experience recurrent nightmares related to separation and report physical symptoms, like nausea, vomiting, headaches, and stomachaches, when they are separated from an attachment figure (APA, 2013).

            SAD is a differential diagnosis based on the patient’s excessive anxiety about being separated from his mother and brother. Besides, he conveys unwarranted worries about losing his mother or the mother failing to show up to school. The patient also has symptoms such as headaches and stomachaches and experiences nightmares about separation from his mother and brother. The worry about being separated from his family makes the patient frequently want to go back home.  

Pediatric Obsessive-Compulsive Disorder (OCD)

            Pediatric OCD is characterized by constant, recurrent, and unwanted thoughts or urges, which lead to compulsions and interfere with a child’s quality of life (APA 2013; Brezinka et al., 2020). The patient’s recurring obsessions about losing his mother and brother make OCD a differential diagnosis. The obsessions have led to compulsions such as sleeping with doors open and lights on and demanding to go back home when at school. However, this is an unlikely diagnosis owing to the presence of physical symptoms, which are unlikely in OCD.   

Plan

Psychotherapy plan: Weekly cognitive-behavioral therapy (CBT) for 12 sessions. The CBT will incorporate sessions with family participation to enhance the therapy process (Panganiban et al., 2019).

Follow-up: The patient will be followed-up after four weeks to assess his progress with psychotherapy and identify any issues requiring interventions.

Reflection notes

If I were to conduct this session again, I would assess for factors that may be contributing to the excessive separation anxiety like bullying in school. I would also obtain a history of any traumatic experiences, stressful life events, or disrupted attachment in the patient’s life since these factors are associated with anxiety disorders in children (Panganiban et al., 2019). If I got a chance to follow up with the patient, I would assess his attitude towards the psychotherapy sessions and inquire about any issues he could be having with the counselor. It is crucial for the PMHNP to identify any issues patients could be having with the counselor and address them to ensure they receive the maximum benefit from psychotherapy. The PMHNP should demonstrate ethical practice when interacting with this patient by seeking consent from the parent before initiating treatment. Besides, the PMHNP should maintain the confidentiality of the patient’s information, and implement interventions backed by evidence-based practice and those linked with the best outcomes and no potential risk to patients (Bipeta, 2019).

References

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (DSM-5®). American Psychiatric Pub.

Bhatia, M., & Goyal, A. (2018). Anxiety disorders in children and adolescents: Need for early detection. Journal of Postgraduate Medicine, 64(2), 75–76. https://doi.org/10.4103/jpgm.JPGM_65_18

Bipeta, R. (2019). Legal and Ethical Aspects of Mental Health Care. Indian journal of psychological medicine, 41(2), 108–112. https://doi.org/10.4103/IJPSYM.IJPSYM_59_19

Brezinka, V., Mailänder, V., & Walitza, S. (2020). Obsessive-compulsive disorder in very young children – a case series from a specialized outpatient clinic. BMC psychiatry, 20(1), 366. https://doi.org/10.1186/s12888-020-02780-0

Gittelman, R., & Klein, D. F. (2019). Childhood Separation Anxiety and Adult Agoraphobia. In Anxiety and the Anxiety Disorders. Routledge.

Panganiban, M., Yeow, M., Zugibe, K., & Geisler, S. L. (2019). Recognizing, diagnosing, and treating pediatric generalized anxiety disorder. JAAPA: official journal of the American Academy of Physician Assistants, 32(2), 17–21. https://doi.org/10.1097/01.JAA.0000552719.98489.75

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Assignment: Focused SOAP Note for Anxiety, PTSD, and OCD
In assessing patients with anxiety, obsessive-compulsive, 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.

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

To Prepare
Review this weeks€™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-TRcriteria 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).