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

Last updated on May 27th, 2025 at 12:59 pm

Develop a Focused SOAP Note, including your differential diagnosis and critical-thinking process to formulate a primary diagnosis.

FOCUSED SOAP NOTE FOR ANXIETY, PTSD, AND OCD

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).

Expert Answer and Explanation

Focused SOAP Note for Anxiety, PTSD, and OCD

Subjective:

CC (chief complaint): “I feel worried all the time.”

HPI: Dev C., a 7-year-old male of Hispanic descent, is brought in by his mother for evaluation due to persistent anxiety, nightmares, and behavioral issues. He has never seen a mental health professional before. His current medications include DDVAP for bedwetting, which has not been effective. Dev has been experiencing significant worry about his family’s well-being, nightmares about being lost, and daytime anxiety affecting his school performance.

He has a history of throwing objects when upset but has no history of self-harm. His mother reports he often expresses fears about her dying or not picking him up from school and claims she loves his baby brother more than him.

Substance Current Use: No current or past use of caffeine, nicotine, illicit substances, or alcohol.

Medical History:

• Current Medications: DDVAP (dosage and frequency not specified in the transcript, used for bedwetting).
• Allergies: None reported.
• Reproductive Hx: Not applicable.

ROS:

• GENERAL: Frequent headaches and stomachaches, recent weight loss of 3 pounds over three weeks.
• HEENT: No specific complaints reported.
• SKIN: No specific complaints reported.
• CARDIOVASCULAR: No specific complaints reported.
• RESPIRATORY: No specific complaints reported.
• GASTROINTESTINAL: Complaints of frequent stomachaches.
• GENITOURINARY: Bedwetting at night.
• NEUROLOGICAL: No specific complaints reported.
• MUSCULOSKELETAL: No specific complaints reported.
• HEMATOLOGIC: No specific complaints reported.
• LYMPHATICS: No specific complaints reported.
• ENDOCRINOLOGIC: No specific complaints reported.

Objective:

Diagnostic results:

• No labs, X-rays, or other diagnostics were performed or indicated in the transcript.

Assessment:

Mental Status Examination: Dev appears his stated age, dressed appropriately, and is cooperative throughout the interview. His mood is anxious, and his affect is congruent with his mood. Speech is normal in rate and volume. His thought processes are logical and goal-directed. He expresses worries about his mother’s safety and fears abandonment, indicative of separation anxiety. No hallucinations or delusions are reported. His cognition appears intact for his age, understanding the current date and location (Bitsko, 2022). Insight and judgment are limited but appropriate for his age. No suicidal or homicidal ideations are present.

Diagnostic Impression:

• Primary Diagnosis: Separation Anxiety Disorder (SAD) (F93.0)
  • Rationale: Dev’s persistent and excessive worry about losing his mother and his difficulty being away from her align with SAD.
• Secondary Diagnosis: Post-Traumatic Stress Disorder (PTSD) (F43.1)
  • Rationale: The traumatic loss of his father, persistent nightmares, and hypervigilance (worrying about his mother’s safety) suggest PTSD.
• Other Considerations: Enuresis (bedwetting) (F98.0), as reported by his mother.

Reflections: I agree with the preceptor’s assessment, as the patient’s symptoms and history strongly support the diagnoses of Separation Anxiety Disorder (SAD) and Post-Traumatic Stress Disorder (PTSD) (Boland et al., 2022). Dev exhibits clear signs of SAD, such as excessive worry about his mother’s safety and significant distress when separated from her. The history of his father’s death and the subsequent behavioral and emotional changes point to PTSD, evidenced by his recurrent nightmares, persistent anxiety, and hypervigilance.

This case identifies the critical need for addressing traumatic experiences early in a child’s life to mitigate long-term psychological impacts. Providing appropriate support and interventions for young patients experiencing significant anxiety and loss is essential (Thapar et al., 2015).

It ensures their emotional and psychological well-being and helps prevent the potential escalation of symptoms into more severe mental health issues as they grow. Interventions such as cognitive-behavioral therapy (CBT), family therapy, and psychoeducation can play a vital role in helping children like Dev process their trauma, develop healthy coping mechanisms, and build resilience..

Case Formulation and Treatment Plan:

Diagnostic Studies:

• Further psychological evaluation and possibly a referral to a child psychologist or psychiatrist for comprehensive assessment and therapy. This is crucial to gain a deeper understanding of Dev’s mental health status and to tailor the treatment plan effectively.

Therapeutic Interventions:

• Psychotherapy: Cognitive-behavioral therapy (CBT) focusing on anxiety management and trauma processing (Zakhari, 2021). CBT is evidence-based and can help Dev develop healthier thought patterns and coping mechanisms to manage his anxiety and trauma-related symptoms.
• Family Therapy: To help the mother support Dev and address family dynamics (Zakhari, 2021). Family involvement is essential as it provides a supportive environment and helps address any contributing factors within the family system.
• Psychoeducation: Educate the family on anxiety disorders and coping strategies (Zakhari, 2021). Knowledge empowers the family to understand Dev’s condition better and to support him effectively in his day-to-day life.
• School-based Interventions: Collaborate with school counselors to support Dev’s needs (Zakhari, 2021). Schools play a significant role in a child’s life, and having support in the educational environment can help Dev manage his symptoms and improve his academic performance.

Pharmacotherapy:

• Consider low-dose selective serotonin reuptake inhibitors (SSRIs) if psychotherapy alone is insufficient. SSRIs can help regulate mood and anxiety levels, providing chemical support to therapy when needed to manage severe symptoms (Zakhari, 2021).

Education and Disposition:

• Educate the mother on creating a stable and supportive environment. A stable home environment is vital for Dev’s recovery and ongoing mental health, as it can significantly reduce stressors that exacerbate his symptoms (Fasinu & Wilborn, 2024).
• Regular follow-up visits to monitor progress and adjust the treatment plan as necessary. Continuous monitoring ensures that the treatment is effective and allows for timely adjustments to address any emerging issues (Fasinu & Wilborn, 2024).

Planned Follow-up Visits:

• Initial follow-up in two weeks to assess response to interventions and make necessary adjustments. Early follow-up allows for quick identification of any issues with the initial treatment plan and helps in making necessary modifications to ensure the best outcomes for Dev (Fasinu & Wilborn, 2024).

References

Bitsko, R. H. (2022). Mental health surveillance among children—United States, 2013–2019. MMWR supplements, 71. https://www.cdc.gov/mmwr/volumes/71/su/su7102a1.htm

Boland, R. Verdiun, M. L. & Ruiz, P. (2022). Kaplan & Sadock’s synopsis of psychiatry (12th ed.). Wolters Kluwer.

Fasinu, P. S., & Wilborn, T. W. (2024). Pharmacology education in the medical curriculum: Challenges and opportunities for improvement. Pharmacology Research & Perspectives, 12(1), e1178. https://doi.org/10.1002/prp2.1178

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.

Zakhari, R. (2021). The psychiatric-mental health nurse practitioner certification review manual. Springer Publishing Company.

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Required Readings

Case Study: Dev Cordoba Program Transcript

[MUSIC PLAYING]

1. 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.

1. 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.

1. 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.
2. 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.

1. 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.

1. 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.

1. JENNY: So how do you feel most of the time? Do you feel sad or worried or mad or happy?

DEV CORDOBA: Worried.

1. JENNY: What types of things do you worry about?

DEV CORDOBA: I don’t know, just everything. I don’t know.

1. 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.

1. 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.

1. 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.

1. JENNY: Well. That’s not nice at all. Why do you feel they call you names?

DEV 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.

1. 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?

1. 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.

1. JENNY: Billy. Have you ever hit Billy or anyone else? DEV CORDOBA: No, but I did throw my book at him.
2. JENNY: Hmm.

DEV CORDOBA: [CHUCKLES]

1. JENNY: What about yourself? Have you ever hit yourself or thought about doing something to hurt yourself?

DEV CORDOBA: No.

1. 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.

1. 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.

1. JENNY: Hmm. OK. Can you tell me, any blood relatives have any mental health or substance use issues?

MISS CORDOBA: No, not really.

1. 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.

1. 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]