Focused SOAP Note For Anxiety, PTSD, and OCD Assignment
Subjective
CC: The patient claims “I worry about my brother and mum.” The patient has nightmares every night and he often feels lost. He also feels bad that he is still bed wet.
HPI: The patient is a 7-year-old African- American native who goes to the doctor’s office with his mother who claims that his mood is unstable. The patient is being raised by a Patient is 7-year-old Caucasian male that came to the doctor’s office with his mother for unstable mental health conditions. It was evident that the patient lost his father when he was 5 years old and he is always afraid of losing his brother and others. He has a hard time focusing at school and he is always bullied, His hygiene has reduced and at times, the boy does not take a bath. He still wets his bed especially when he has a nightmare at night. Currently, the patient states that he has no other thoughts of self-harm and he claims that he has never been part of any self-harm practices.
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Substance Current Use: The patient has not been taking any drugs or other substances.
Family and social Hx: there is no family history of mental illness and the patient does not have many friends at school since he feels bad when he is bullied and called “Mr Smelly.”
Current medication: The patient is not taking any medications currently but he is taking DDVAP for bedwetting.
Allergies: The patient has no drug allergies but he is only allergic to proteins.
Reproductive Hx: The patient is still a child and there is not much information about his reproductive history Focused SOAP Note For Anxiety, PTSD, and OCD Assignment.
ROS
General: The patient has lost 4 lbs within 23 weeks and he has no other medical issues. He also denies having fatigue and a fever.
HEENT: The patient denies having itchy and painful eyes, ear pain, a runny nose, and a headache. He also denies having any pain in the mouth and having a hard time swallowing and chewing food. Cardiovascular: The patient denies having an irregular heartbeat and chest pain.
Respiratory: The patient denies having difficulty breathing and coughing.
Musculoskeletal: The patient has no body or muscle pain.
Neurological: The patient denies having any dizziness or headaches and he has a steady gait.
Skin: The patient denies any presence of itchiness or rashes on the skin.
Objective
Diagnostic Result: A urinalysis test on the patient had to be done to discover any medical condition he may have. With enuresis.
Assessment
Mental Status Examination: The patient is a 7 years old African-American male and he is oriented to his name, the month and the date and is alert. The patient is very smarty, makes direct contact with the healthcare provider, and he is cooperative meaning that he answers the questions well when asked. The speech is coherent and clear and his remote and recent memory have been intact. He denies having any visual and auditory hallucinations, being suicidal, and having any homicidal thoughts.
Diagnostic Impression: Focused SOAP Note For Anxiety, PTSD, and OCD Assignment
PTSD: This is a mental condition mainly characterized by feeling afraid after facing a scary and traumatic situation. It is most common among people who have experienced dangerous, shocking or traumatic situations. The people have constant scary thoughts, nightmares and symptoms that mostly affect their daily and normal activities (Krediet et al., 2020). The patient lost his father when he was 5 years old, that is 2 years ago and he has been facing huge challenges since this time. He has nightmares and is afraid of losing his living family members.
ADHD: This is a mental condition caused by challenges people face making it hard to maintain attention and stay focused (Faraone et al., 2021). The patient has experiences challenges paying attention to the teacher in school and, he keeps wandering out the window when the teacher is teaching and he has to be constantly reminded by the teacher to focus in class.
Separation Anxiety Disorder (SAD): Most children with anxious feelings often feel unsafe when their parents are away. Traumatic events like the death of a family member make them cling more to their living parents and they are afraid of losing them too (Mohammadi et al., 2020). Children with SAD have a very hard time focusing on school and they may feel as if there is impending doom. Most patients have tried to make excuses for being sick so that they do not go to school but stay with their parents to stay home.
Reflections:
From the discussions I had with the patient’s mother, it was clear that she felt guilty about what her son was going through. The mother said that t the patient always believed the father had gone on a vacation and he was not dead. The mother did not have enough time to explain the situation to her son. The mother also seems to be overwhelmed by the recent turn of events and she had lost her guard on taking care of the patient. The patient called Mr Smelly in school and the mother knew it but did nothing about it. The patient also did not shower sometimes and the other could have tried to make sure he showered to get rid of the bullying he was facing in school. The patient is 7 years old and the mother is responsible for correcting him when he does something wrong. Ethical principles such as beneficence would be used when the patient had to go for family therapy with his mother to improve his condition. Focused SOAP Note For Anxiety, PTSD, and OCD Assignment
Case Formulation and Treatment Plan
The kind of treatment the patient goes through would be based on the diagnosis discovered, which shows he has PTSD, ADHD and SAD. The patient will immediately begin therapy sessions combined with cognitive-behavioral sessions (CBT). The patient shows efficacy in the treatment of anxiety disorders in adolescents and children. The randomized clinical trials show that about two-thirds of the children undergo CBT making it the main diagnosis in post-treatment. Family sessions with the patient’s mother have to be part of the therapy and it will help in improving the relationship between the patient and the mother. It is also crucial for them to participate in child-directed interactions, which is a form of CBT that will assist in improving the feelings the patient may have. The interactions would involve praising the patient, the parent being warm and giving her child attention. The patient would be scheduled for an individual and family session once a week for 8 weeks. After doing this, an assessment of the patient’s behavior will be used to look at what to include in the next treatment plan. I would not give the patient any medication due to her age and self-harm ideations but I would ask the mother to give him Prozac 10mg daily for SAD and PTSD. The medication would be reviewed for 8 weeks during his next appointment. Focused SOAP Note For Anxiety, PTSD, and OCD Assignment
References
Faraone, S. V., Banaschewski, T., Coghill, D., Zheng, Y., Biederman, J., Bellgrove, M. A., … & Wang, Y. (2021). The world federation of ADHD international consensus statement: 208 evidence-based conclusions about the disorder. Neuroscience & Biobehavioral Reviews, 128, 789-818.
Krediet, E., Bostoen, T., Breeksema, J., van Schagen, A., Passie, T., & Vermetten, E. (2020). Reviewing the potential of psychedelics for the treatment of PTSD. International Journal of Neuropsychopharmacology, 23(6), 385-400.
Mohammadi, M. R., Badrfam, R., Khaleghi, A., Hooshyari, Z., Ahmadi, N., & Zandifar, A. (2020)Focused SOAP Note For Anxiety, PTSD, and OCD Assignment. Prevalence, comorbidity and predictor of separation anxiety disorder in children and adolescents. Psychiatric Quarterly, 91, 1415-1429.
Assignment 1 full
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
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
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? Focused SOAP Note For Anxiety, PTSD, and OCD Assignment
- 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.
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- 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)
https://www.studocu.com/row/document/moi-university/nursing/cordoba-focused-soap/25608927 Focused SOAP Note For Anxiety, PTSD, and OCD Assignment