NRNP 6665 Week 3: Assignment: Focused SOAP Note for Anxiety, PTSD, and OCD Essay

NRNP 6665 Week 3: Assignment: Focused SOAP Note for Anxiety, PTSD, and OCD Essay

NRNP 6665 Week 3: Assignment: Focused SOAP Note for Anxiety, PTSD, and OCD Essay

Subjective:

CC (chief complaint): “My son has abnormal behaviors, including being so anxious, worried, and doing silly things all the time.”

HPI: Dev Cordoba is a seven-year-old male client that her mother has brought to the clinic for psychiatric review. His pediatrician has referred him for psychiatric review, as he feels that Dev has psychiatric symptoms. Dev reports feelings of being worried about everything. He also reports nightmares and bedwetting. He also sleeps with the door open to ensure her mother does not leave him. He reports excessive worry about the safety and wellbeing of her mother and brother when in school. His attention in school is reduced. He denies destructive or harmful behaviors towards others. Dev’s mother acknowledges the above complaints. She reports that Dev is always anxious and worried about silly things, including thinking she will die or not pick him from school. He also raises complaints such as stomach aches and headaches almost daily, which have affected his ability to eat. He has lost three pounds over the last three weeks. His mother also reports that he still wets his bed despite being prescribed DDVAP medication.

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Substance Current Use: none

Medical History: No history of chronic illnesses.

• Current Medications: none
• Allergies: he has no known history of food, drug, or environmental allergies

• Reproductive Hx: Not applicable

ROS:

• GENERAL: The client has dressed appropriately for the occasion. He appears slightly underweight for his age. There is no evidence of fever or fatigue.
• HEENT:  Eyes:  The patient denies visual loss, blurred vision, double vision, or yellow sclera. Ears, Nose, Throat:  The patient denies hearing loss, sneezing, congestion, runny nose, or sore throat.
• SKIN:  The client denies rash or itching.
• CARDIOVASCULAR:  The client denies chest pain, chest pressure, or chest discomfort. No palpitations or edema.
• RESPIRATORY:  The client denies shortness of breath, cough, or sputum.
• GASTROINTESTINAL:  The patient denies anorexia, nausea, vomiting, or diarrhea. No abdominal pain or blood.
• GENITOURINARY:  The patient denies burning on urination and a history of sexually transmitted infections
• NEUROLOGICAL:  The patient denies headache, dizziness, syncope, paralysis, ataxia, numbness, or tingling in the extremities. No change in bowel or bladder control. He, however, reports bedwetting at night.
• MUSCULOSKELETAL:  The client denies muscle or joint pain, joint rigidity, tenders, and difficulty in movement. He also denies fractures.
• HEMATOLOGIC:  The patient denies anemia, bleeding, or bruising.
• LYMPHATICS:  The patient denies enlarged nodes. No history of splenectomy.
• PSYCHIATRIC:  The patient denies any history of depression or anxiety.
• ENDOCRINOLOGIC:  The patient denies sweating, cold, or heat intolerance reports. No polyuria or polydipsia.
• ALLERGIES:  The patient denies any allergies to food, drugs, or environmental allergens.

Objective:

Diagnostic results: Diagnostic investigations are important to develop an accurate diagnosis for Dev. One of the recommended diagnostic investigations is administering the adjustment disorder-module 20 (ADNM-20) to determine if the client suffers from any adjustment-related disorder. The psychiatric mental health practitioner should ask questions relevant to the client. Responses will guide the determination of whether the client suffers from trauma-related, anxiety, or obsessive-compulsive disorder.

The other diagnostic investigation required is an x-ray. X-rays of the kidneys should be performed to determine the presence of any pathology contributing to bedwetting and abnormal structures of the urinary tract. The psychiatrist should also discuss the symptoms of bedwetting in detail with the mother to determine if pathological. For example, information about family history of bladder and bowel disorders, bladder and bowel habits, fluid intake, and other problems associated with bedwetting should be obtained. A physical examination is also needed to rule out any other cause of the problem. The assessment data will guide the development of an accurate diagnosis and treatment plan for Dev.

Assessment:

Mental Status Examination: The patient appears appropriately dressed for the occasion. There are no symptoms of fatigue during the assessment. Dev’s orientation to place and time is inhibited. His speech is coherent in terms of rate and tone. He reports persistent feelings of excessive fear and worry. He denies suicidal thoughts, attempts, or plans. He does not experience illusions, delusions, or hallucinations. His thought process is uninhibited.

Diagnostic Impression:

Separation Anxiety Disorder: Separation anxiety disorder is Dev’s primary diagnosis. Children often experience a separation anxiety disorder, as they fear being separated from those; they are mostly attached. According to DSMV, separation anxiety disorder is diagnosed if a patient presents several symptoms. They include excessive and inappropriate fear of being separated from those attached, recurrent excessive distress when experiencing separation, and excessive, persistent worry of losing major attachments through death or disasters (Bhatia & Goyal, 2018). There is also the experience of reluctance to stay away from home to places like school, fear of being alone, and reluctance to sleep alone or far from a major attachment figure. Patients also experience nightmares involving separation, complaints of physical symptoms such as headaches and stomachaches, with symptoms causing significant distress and impairment in social or academic performance. The symptoms are not attributable to a mental disorder, medication, or medical condition (Gittelman & Klein, 2019). Dev’s experience of most of the above symptoms, such as fear of separation, nightmares of separation, and physical symptoms, among others, make separation anxiety disorder his primary diagnosis.

Adjustment Disorder: One of Dev’s secondary diagnoses is adjustment disorder. Adjustment disorder is a mental condition that develops following traumatic experiences. The patient experiences stress, which causes disorientation and failure to live a normal life. According to DSMV, children affected by adjustment disorder experience symptoms that include insomnia, worry, difficulty concentrating, anxiety, low self-esteem, feelings of isolation, and low academic performance (Bachem & Casey, 2018). While Dev has most of the above symptoms because of separation from his father, he cannot be diagnosed with adjustment disorder since the symptoms have persisted for a long time. The symptoms of adjustment disorder should occur within three months of a traumatic experience.

Obsessive-Compulsive Disorder: Dev’s other secondary diagnosis is obsessive-compulsive disorder. According to DSMV, obsessive-compulsive disorder is an anxiety disorder characterized by recurring thoughts and behaviors. Children with obsessive-compulsive disorders often present with several symptoms. They include extreme possession with germs or dirt, repeated thoughts of checking things, interfering thoughts of hurting, violence, or killing someone, spending time thinking about things, being preoccupied with order, and being attentive to details. Children also experience excessive worry about bad things, aggressive urges or thoughts, hoarding objects, and repeatedly asking similar questions (Tobin, 2018). Dev demonstrates obsessive-compulsive disorders. They include excessive worry about something bad happening to his mother and brother, sleeping with door open to check his mother’s presence, having intrusive behaviors that affect his academic performance, and being preoccupied with an activity. However, the presence of physical symptoms such as stomachaches, nightmares, and fear of separation rules out obsessive-compulsive disorder as the possible cause of the problem.

Reflections

I believe Dev’s diagnosis of separation anxiety disorder is accurate. He has symptoms aligning with those of the disorder, as stated in DSMV. One of the things that I would do differently should I encounter this patient again is explore further his feelings and emotions. The exploration will guide the development of appropriate psychological interventions for the distressing experiences. If I could follow up this patient, my intervention would be to determine his response to the treatment and the need for any changes or improvements. Since the patient is a minor, I would act as his advocate in the treatment process. I will ensure treatment with optimum benefits and minimum harm is used to achieve the desired treatment outcomes.

Case Formulation and Treatment Plan: Dev, a seven-year-old client, has been diagnosed with separation anxiety disorder. He has been initiated on psychotherapy sessions to help him develop effective skills for managing his negative symptoms and behaviors. He has been scheduled for a follow-up visit after four weeks.

References

Bachem, R., & Casey, P. (2018). Adjustment disorder: A diagnosis whose time has come. Journal of Affective Disorders, 227, 243–253. https://doi.org/10.1016/j.jad.2017.10.034

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

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

Tobin, V. (2018). Obsessive-Compulsive Disorder in Children and Adolescents. Journal of Psychosocial Nursing and Mental Health Services, 56(3), 15–18. https://doi.org/10.3928/02793695-20180219-02

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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.

Photo Credit: Photographee.eu / Adobe Stock

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 diagnostic criteria for each differential diagnosis and explain what DSM-5 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).
By Day 7 of Week 3
Submit your Focused SOAP Note.

Submission and Grading Information
To submit your completed Assignment for review and grading, do the following:

Please save your Assignment using the naming convention “WK3Assgn