NRNP 6675 PMHNP Care Across the Lifespan II: Focused SOAP Note for Anxiety, PTSD, and OCD

NRNP 6675 PMHNP Care Across the Lifespan II: Focused SOAP Note for Anxiety, PTSD, and OCD

NRNP 6675 PMHNP Care Across the Lifespan II: Focused SOAP Note for Anxiety, PTSD, and OCD

Subjective:

CC (chief complaint): “Anxiety and worry.”

HPI: Dev is a 7-year-old  boy accompanied by his mother for psychiatric assessment because of exhibiting excessive anxiety and worry. The boy states that he worries about everything. He worries about his mother and brother when at school and is always thinking about how they are fairing and if they are fine. He gets intrusive thoughts of the mother failing to come home, like what happened to his father. The excessive worry has affected his concentration in class, and he gets into trouble with his teacher. Dev experiences frequent bad dreams whereby he dreams he is lost and cannot trace his mother or younger brother. He has to sleep with the lights on and the open to assure him the mother is truly there. Furthermore, Dev’s classmates nicknamed him ‘Smelly’ due to his body odor caused by not showering and wetting the bed.

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Dev’s mother reports that the boy always appears very anxious about ridiculous things, like she will die or fail to pick him up from school. Dev claims that his mother loves his brother. He throws things around the house and school, which has gotten him in trouble at school. Besides, he has sleeping difficulties and frequent nighttime awakenings. Dev always wants to return home from school and frequently complains of stomach aches and headaches. He also has a poor appetite leading to weight loss.

Substance Current Use: None

Medical History: No chronic illnesses.

• Current Medications: None
• Allergies: None

• Reproductive Hx: None

ROS:

• GENERAL: Poor appetite and weight loss. No fever, chills, or excessive fatigue
• HEENT: No visual problems, ear pain, tinnitus, rhinorrhea, or throat pain.
• SKIN: No rashes, bruises, or cuts.
• CARDIOVASCULAR: No dyspnea or palpitations.
• RESPIRATORY: No cough, wheezing, or sputum.
• GASTROINTESTINAL: Appetite loss and abdominal pain.
• GENITOURINARY: Nighttime urinary incontinence
• NEUROLOGICAL: Reports headaches.
• MUSCULOSKELETAL: No joint stiffness/ pain or muscle pain.
• HEMATOLOGIC: No bleeding.
• LYMPHATICS: No lymph swelling.
• ENDOCRINOLOGIC: No endocrine symptoms.

Objective:

Diagnostic results: No tests were ordered.

Assessment:

Mental Status Examination:

The boy is well-groomed and dressed appropriately for the weather and function. He is alert, maintains good eye contact, and is oriented x4. He has clear and coherent speech. His thought process is logical, coherent, and goal-directed. He conveys excessive worry regarding his mother and brother. No hallucinations, delusions, suicidal, or homicidal ideations or plans. Demonstrate good judgment, and insight is present.

Diagnostic Impression:

Pediatric Generalized Anxiety Disorder (GAD): This differential diagnosis is due to Dev’s excessive and unjustified worry about his mother and brother. He worries that they could be in danger and that the mother may fail to pick him up from school or return home like his father. He presents with other symptoms of pediatric GAD, like concentration difficulties, frequent headaches and stomachaches, and sleeping disturbances (Walter et al., 2020). The excessive anxiety has impaired school functioning since he does not pay attention and looks for excuses not to be in school.

Separation Anxiety Disorder (SAD): The patient presents with features of GAD, like getting excessively worried and anxious when separated from his mother and brother. Besides, he gets intrusive thoughts about her mother failing to return home and about her being in danger (Patel & Bryant, 2021). He also has bad dreams about getting separated from his family. The anxiety related to separation causes headaches and abdominal pain and makes him frequently want to go home from school.

Pediatric Obsessive-Compulsive Disorder (OCD): The boy has obsessions about his mother and brother being in danger and getting separated. The obsession about getting separated has led to compulsive acts like sleeping with lights on and doors open to be assured the mother is there (Nazeer et al., 2020). He also constantly wants to go back home and makes excuses to return home.

Case Formulation and Treatment Plan:

Psychotherapy: Cognitive behavior therapy (CBT) is the selected psychotherapy treatment for pediatric GAD patients. It reduces GAD symptoms and has long-lasting effects. It will involve training the patient to self-monitor his worry and related symptoms as well as assessing and reviewing interpretive and predictive worries (Patel et al., 2018).

Medication therapy: Fluoxetine  10 mg orally once daily. It has a less prominent adverse effect profile, a long half-life, and a better compliance rate (Patel et al., 2018).

Alternative therapy: Buspirone 5 mg orally once daily. It has an anxiolytic effect and has demonstrated superior effectiveness compared with a placebo (Strawn et al., 2018).

Health promotion and Health Education: Educate the patient on the importance of daily baths to avoid bad body odor. Advise the boy to limit fluid intake in the evenings to reduce bedwetting.

Follow-up: Follow up after 4 weeks to assess the client’s response to treatment, adjust medication when necessary, and evaluate for side effects.

Reflections: If I were to conduct this session again, I would use structured interviews to come up with DSM-V diagnoses. This includes using the Anxiety and Related Disorders Interview Schedule for DSM-5 (ADIS-5) and the Diagnostic Interview Schedule for Children (Walter et al., 2020). I would also assess for bullying in school, which could cause the patient to want to go home constantly. Ethical factors of beneficence and nonmaleficence should be considered. The PMHNP should select interventions established to improve anxiety in children and with the least harm to the population. The PMHNP should also seek consent from the mother and involve her in decision-making. Health promotion for this patient should include family-based interventions., to relieve anxiety and teach the child problem-solving and coping skills relevant to his age.

References

Nazeer, A., Latif, F., Mondal, A., Azeem, M. W., & Greydanus, D. E. (2020). Obsessive-compulsive disorder in children and adolescents: epidemiology, diagnosis, and management. Translational pediatrics, 9(Suppl 1), S76–S93. https://doi.org/10.21037/tp.2019.10.02

Patel, A. K., & Bryant, B. (2021). Separation Anxiety Disorder. JAMA, 326(18), 1880-1880. doi:10.1001/jama.2021.17269

Patel, D. R., Feucht, C., Brown, K., & Ramsay, J. (2018). Pharmacological treatment of anxiety disorders in children and adolescents: a review for practitioners. Translational pediatrics, 7(1), 23. doi: 10.21037/tp.2017.08.05

Strawn, J. R., Mills, J. A., Cornwall, G. J., Mossman, S. A., Varney, S. T., Keeshin, B. R., & Croarkin, P. E. (2018). Buspirone in Children and Adolescents with Anxiety: A Review and Bayesian Analysis of Abandoned Randomized Controlled Trials. Journal of Child and Adolescent Psychopharmacology, 28(1), 2–9. doi:10.1089/cap.2017.0060

Walter, H. J., Bukstein, O. G., Abright, A. R., Keable, H., Ramtekkar, U., Ripperger-Suhler, J., & Rockhill, C. (2020). Clinical Practice Guideline for the Assessment and Treatment of Children and Adolescents With Anxiety Disorders. Journal of the American Academy of Child & Adolescent Psychiatry. doi:10.1016/j.jaac.2020.05.005

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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.

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.

Walden University. (2021). Case study: Dev Cordoba. Walden University Canvas. https://waldenu.instructure.com

(Transcript of Dev Cordoba Case Study is attached as file if unable to access video through above link)

• 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).

Submit your Focused SOAP Note.