NRNP/PRAC 6665 & 6675 Comprehensive Focused SOAP Psychiatric Evaluation Template

NRNP/PRAC 6665 & 6675 Comprehensive Focused SOAP Psychiatric Evaluation Template

NRNP/PRAC 6665 & 6675 Comprehensive Focused SOAP Psychiatric Evaluation Template

Subjective:

CC (chief complaint): ‘My mother said you were going to help me feel better’

HPI: DV Corboda is a seven-year-old male that has come to the clinic accompanied by her mother for assessment. The patient reports that he is always worried about his brother and mother. He notes that he always thinks if they are okay while in school. The patient also reported dreaming almost every night of getting lost and cannot find his brother and mother. He denied any history of getting lost. The patient’s attention while in school is reduced since his teacher has to always remind him to be attentive. The teacher moved his desk besides hers to gain his attention. He reported being irritable with a history of throwing a book to another student. The mother’s report shows that her son is always worried and anxious. He also gets in trouble while at school. He also has sleeping difficulties and has lost appetite, which has led to weight loss of three pounds in three weeks. He also fakes sickness so as to stay at home. He also wets bed at night, which has not responded to treatment. The physician referred the child for psychiatric review since he does not see anything wrong physically with him. There is no any significant history of psychiatric illnesses in the family.

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Substance Current Use: There is no history of substance abuse

Medical History: The patient is currently not using any medications

• Current Medications: None
• Allergies: There is no history of food, drug, or environmental allergies

• Reproductive Hx: No history  

ROS:

• GENERAL: The patient denies fever, chills, fever, or fatigue. There is a history of three pounds weight loss over the last three weeks
• HEENT: The head is normocephalic, no blurred vision or diplopia, no hearing loss, nasal congestion, rhinorrhea, sore throat, or hoarseness.
• SKIN: There is no skin discoloration, rashes, or bruising
• CARDIOVASCULAR: There is no edema, palpitations, chest pain, or pressure
• RESPIRATORY: There is no sneezing, cough, difficulty in breathing, or shortness of breath
• GASTROINTESTINAL: There is no diarrhea, constipation or abdominal distention
• GENITOURINARY: There is no frequence, urgency, or history of any infections
• NEUROLOGICAL: There is no syncope, numbness or tingling, headache or body balance issues
• MUSCULOSKELETAL: There is no bone pain, joint pain, or stiffness
• HEMATOLOGIC: There is not bleeding or easy bruising
• LYMPHATICS: There is no lymphadenopathy
• ENDOCRINOLOGIC: There is no cold or heat intolerance, or polydipsia

Objective:

Diagnostic results: There were no diagnostic investigations ordered for the patient. However, investigations such as thyroid function tests may be required to rule out causes such as thyroid disorders. The patient reports excessive worry. As a result, assessing for generalized anxiety disorder using tools such as the Beck anxiety inventory may be necessary. Head CT scan may also be needed to determine if there is any abnormal brain development issues that may be contributing to the problem.

Assessment:

Mental Status Examination: Dev Cordoba is a seven year-old patient that has been brought for psychiatric assessment by his mother. There is no any history of psychiatric conditions. The patient is dressed appropriately for the occasion with evidence of slight weight loss. The patient reports anxiety and being worried all the times. He also has bad dreams about his brother and mother leaving him. He is cooperative, with clear, coherent and normal speech. He has logical thought process, oriented AAx4, with anxious affect. He denies any suicidal thought, plan, or attempt. There are no illusions, delusions, and hallucinations.

Diagnostic Impression: The patient’s primary diagnosis is generalized anxiety disorder. Generalized anxiety disorder is a mental health problem that is characterized by excessive fear and worry. The fear and worry is beyond the patient’s control. It affects the normal social, academic, and occupational functioning. The additional symptoms include restlessness, difficulty in concentrating, insomnia, and emotional distress (Aktar et al., 2017). The patient in the case study has these symptoms, making generalized anxiety disorder the primary diagnosis.

Post-traumatic stress disorder is the secondary diagnosis that should be considered for the patient. Post-traumatic stress disorder affects people who have been affected, witnessed, or heard about traumatic events. The trauma results in depressive symptoms such as excessive guilt, sadness, isolation, anhedonia, suicidal thoughts, insomnia, and avoidance of stimuli related to the traumatic events (Yue et al., 2022). The separation of the patient from his father may be the basis of his symptoms. The separation may also be contributing to his fear of his brother and mother abandoning him too. However, post-traumatic stress disorder is the least likely because of the lack of symptoms such as avoidance of stressful stimuli and depressed mood.

The last differential diagnosis that should be considered for the patient is attention-deficit hyperactive disorder (ADHD). ADHD is a condition characterized by symptoms such as inattention, hyperactivity, and impulsivity. The patient has low attention span, aggressive, and easily distracted (Mechler et al., 2022). However, the presence of excessive fear and worry rules out ADHD as the potential diagnosis.

Reflections: I believe that I utilized the right approaches in assessing the patient. However, I would consider using different assessment tools should I experience a similar case in the future. I will also explore the effect of social determinants of health such as race and ethinicity on the utilization of care services by the patient.

Case Formulation and Treatment Plan: Initiate the patient on fluoxetine to treat anxiety. The patient should also be iniated on cognitive behavioral therapy to help him develop effective skills for managing distressing thoughts and triggers. Combining cognitive behavioral therapy and the medication will ensure optimum outcomes and prevent symptom relapse.

References

Aktar, E., Nikolić, M., & Bögels, S. M. (2017). Environmental transmission of generalized anxiety disorder from parents to children: Worries, experiential avoidance, and intolerance of uncertainty. Dialogues in Clinical Neuroscience, 19(2), 137–147. https://doi.org/10.31887/DCNS.2017.19.2/eaktar

Mechler, K., Banaschewski, T., Hohmann, S., & Häge, A. (2022). Evidence-based pharmacological treatment options for ADHD in children and adolescents. Pharmacology & Therapeutics, 230, 107940. https://doi.org/10.1016/j.pharmthera.2021.107940

Yue, J., Zang, X., Le, Y., & An, Y. (2022). Anxiety, depression and PTSD among children and their parent during 2019 novel coronavirus disease (COVID-19) outbreak in China. Current Psychology, 41(8), 5723–5730. https://doi.org/10.1007/s12144-020-01191-4

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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 me
  

  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).
• mber 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.