Assignment: Focused SOAP Note for Anxiety, PTSD, and OCD
In assessing patients with anxiety, obsessive-compulsive, and 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.
In this Assignment, you use a case study to develop a focused SOAP note based on evidence-based approaches.
- 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.
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).
Expert Answer and Explanation
SOAP Note for Major Depressive Disorder
CC (chief complaint): “anxious and worried all the time.”
HPI: DC is a 7-year-old African American boy who is brought to the school clinic by her mother with a CC of being “anxious and worried all the time.” The patient reports that he is worried all the time about many things, including being left by his family and being lost, and has nightmares about the same. He reports having nightmares almost daily. The patient states that she feels lonely due to his father’s absence and feels his mother is not giving him much attention compared to his brother. Her mother reports a decrease in the patient’s school performance characterized by increased absenteeism and lack of concentration in school. He has issues with wetting the bed even after being given medications to help with the issue. As a result, he finds it difficult to interact with his peers at school since they say he smells bad. DC has also been displaying violence both in school and at home. The patient’s mother reports a sudden loss in appetite, with the patient losing three pounds within the past three days. He has never had any prior visitations to a psychiatric clinic before this and was referred by the child’s pediatrician who states that there is nothing physically wrong with DC.
Past Psychiatric History:
- General Statement: The patient has never had any psychiatric assessment before and was referred back to the school clinic by his pediatrician citing the absence of physiological issues.
- Caregivers: The patient is under the care of his mother.
- Hospitalizations: No hospitalization. The patient also denies having any thoughts of hurting himself
- Medication trials: No indication from the mother of having participated in any medical trials.
- Psychotherapy or Previous Psychiatric Diagnosis: Denies having a past diagnosis of a psychological health condition.
Substance Current Use and History: Denies any history of substance use or secondary exposure to the same.
Family Psychiatric/Substance Use History: denies knowing any family member with a psychiatric or substance use history.
Psychosocial History: The patient is currently a grade two student but has very few social interactions or friends at school. The patient’s father was killed on a military mission and currently lives with her mother. The patient has a dog called sparky and LEGOs which he likes to play with.
Medical History: No history of mental conditions.
- Current Medications: Previous prescription of desmopressin.
- Allergies: no allergies reported.
- Reproductive Hx: N/A.
- GENERAL: positive for sudden weight loss, occasional loss of concentration. Denies having any fever or fatigue.
- HEENT: N/A
- SKIN: N/A
- CARDIOVASCULAR: No chest discomfort, tightness, or pain
- RESPIRATORY: No shortness of breath or wheezing sound
- GASTROINTESTINAL: N/A
- GENITOURINARY: Denies having UTI. Normal volume and consistency of urination
- NEUROLOGICAL: No neurological disorders.
- MUSCULOSKELETAL: No MS disorders noted
- HEMATOLOGIC: N/A
- LYMPHATICS: Non-contributory
- ENDOCRINOLOGIC: No endocrinologic abnormalities were noted
Vital Signs: T 35.2, HR, 70, BP 100/58, Wt. 38, Ht. 4’5, RR 18,
- HEENT: Non-contributory.
- Skin: Non-contributory.
- CV: Regular HR and rhythm. No bruits or murmurs, chest clear to osculation.
- Respiratory: No pain or distress while breathing. No wheezes noted on auscultation.
Hopkins Symptom Checklist-25 (HSCL-25): HSCL-25 is a valid and reliable tool used to assess and establish the severity of depression and anxiety for patients with diverse characteristics (Tirto & Turnip, 2019). The tool is simple to administer and interpret. From the presented case, the patient scored highest in anxiety with some indication of moderate depression.
Mental Status Examination: The patient is well-groomed and dressed. He remains active and attentive throughout the examinations. He is well oriented to time, place, occasion, and person. He can answer all questions appropriately without any difficulty for a child his age. The patient denies any suicidal ideations, paranoid thoughts, or hallucinations, but indicates consistent nightmares.
- Generalized Anxiety Disorder (GAD) DSM-5 300.02 (F41.1)
- Major depressive disorder, single episode, moderate DSM-5 296.22 (F32.1)
- Specific Phobia DSM-5 300.29
The diagnosis of this patient inclines towards GAD. GAD is a condition characterized by excessive worry about everyday activities or life events, and for children, the worry becomes uncontrolled no matter how hard they try (APA, 2013). According to Cho et al. (2019, Pg. 251), childhood GAD usually co-occurs with depression as well as other anxiety disorders. The presented case shows DC to be overly worried about different things including the well-being of his family, fear of being lost, his father’s whereabouts, his apparent nightmares, and his relationship with his classmates (APA, 2013). Additionally, the patient has a low concentration span in school and has difficulties in sleeping evidenced by persistent nightmares. GAD may also explain the nocturnal enuresis experienced by DC, which has failed to resolve even after prescription (Mota et al., 2020). Based on these factors, GAD was considered the primary diagnosis. Other than GAD, the secondary diagnosis is MDD, single episode moderate, evidenced by DCs lack of concentration, sudden drop in body weight, loss of appetite, and minimal social interactions (APA, 2013). It is not uncommon for the two conditions to coexist and should be evaluated further on thorough examinations by a psychiatrist. The last diagnosis is a specific phobia, which is characterized by an intense fear of something happening, such as being lost in the case of DC (APA, 2013). However, this was eliminated from the primary diagnosis given that the worries expressed by the patient were more broad-based instead of focused as is the case for specific phobia.
I agree with the preceptor’s diagnosis of DC that the patient has GAD with moderate depression. From this case, the attachment between psychiatric and physiological conditions in children became apparent and was my major take in this case. One of the ethical considerations for this case is respect for human dignity. Regardless of the patient’s age, they need to feel confident in themselves and comfortable throughout the interaction with the care provider.
Case Formulation and Treatment Plan:
The primary diagnosis for the patient is GAD with comorbidity of MDD. A combination of behavioral therapy and medication should be considered as part of the treatment plan. Consistent follow-up monthly should be undertaken to assess the patient’s progress.
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Author.
Cho, S., Przeworski, A., & Newman, M. G. (2019). Pediatric generalized anxiety disorder. In Pediatric anxiety disorders (pp. 251-275). Academic Press.
Mota, D. M., Matijasevich, A., Santos, I. S., Petresco, S., & Mota, L. M. (2020). Psychiatric disorders in children with enuresis at 6 and 11 years old in a birth cohort. Jornal de Pediatria, 96, 318-326.
Tirto, A. R., & Turnip, S. S. (2019). The accuracy of Hopkins Symptom Checklist–25 depression subscales on adolescents. Humanitas: Indonesian Psychological Journal, 16(1).
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