Comprehensive Psychiatric Evaluation Soap Note On Obsessive-compulsive disorder-Nursing Essay Example

Comprehensive Psychiatric Evaluation Soap Note On Obsessive-compulsive disorder-Nursing Essay Example

SUBJECTIVE

CC (chief complaint): “I can’t stop thinking about germs, and it’s affecting my daily routine.”  

HPI: TY is a 12-year-old American female who presents to group sessions with her parents. She has a history of OCD, which was diagnosed two months ago. The client reports experiencing intrusive thoughts and compulsive behaviors related to cleanliness and germs for months. She reports feeling increasingly anxious and fearful about getting sick or spreading germs to others. She reports cleaning her room and clothes and taking birth frequently. She believes that her skin carries many germs compared to others and frequently reassures herself otherwise. The parents report that Ms. TY’s symptoms are impacting her daily life, including school work, participation in social activities, and routine activities of daily living. The client spends most hours cleaning and sanitizing her room, which has become a source of distress for her and the family. The client was referred for cognitive behavioral therapy with limited response. The parents are concerned and are considering further therapy. They report experiencing stress related to school and family expectations.(Comprehensive Psychiatric Evaluation Soap Note On Obsessive-compulsive disorder-Nursing Essay Example)

Past Psychiatric History:

General Statement: The client first entered treatment at age 12 for OCD.

Caregivers:  Parents

Hospitalizations: No history of previous hospitalization.

Medication trials: The patient has no history of psychiatric medication use.

Psychotherapy or Previous Psychiatric Diagnosis: The patient was diagnosed with Obsessive-Compulsive Disorder (OCD) and has undergone cognitive-behavioral therapy (CBT) in the past two months.(Comprehensive Psychiatric Evaluation Soap Note On Obsessive-compulsive disorder-Nursing Essay Example)

Substance Use History: The client denies any drug and substance abuse history.

Family Psychiatric/Substance Use History: The client’s mother has a history of depression and anxiety.

Psychosocial History: She was born and raised by both parents. She has an older brother who is a freshman. She lives with her parents and is in grade 8. The client liked biking but is no longer interested. No past or current legal issues. No history of childhood trauma. No record of violence.(Comprehensive Psychiatric Evaluation Soap Note On Obsessive-compulsive disorder-Nursing Essay Example)

Medical History: The patient has no significant medical history.

Current Medications: No current medications.

Allergies:The patient denies any known allergies.

Reproductive Hx:Regular menstruation. No history of sexual activity or pregnancies.

ROS:

GENERAL: No fatigue, weight loss/gain, or fever.

HEENT: No visual or hearing impairment. No nasal congestion or difficulty swallowing.

SKIN: Normal skin turgor.

CARDIOVASCULAR: No chest discomfort or pain.

RESPIRATORY: No shortness of breath.

GASTROINTESTINAL: No abdominal pain. No nausea, vomiting, or anorexia.

GENITOURINARY: No dysuria or hematuria.(Comprehensive Psychiatric Evaluation Soap Note On Obsessive-compulsive disorder-Nursing Essay Example)

NEUROLOGICAL: No dizziness or headache.

MUSCULOSKELETAL: No muscle stiffness or pain.

HEMATOLOGIC: No anemia.

LYMPHATICS: No enlarged nodes.

ENDOCRINOLOGIC: No polyphagia, polydipsia, or polyuria.

Physical Exam:

Completed by PCP.

Vital Signs: WNL

Laboratory Data: Negative for urine alcohol and drug tests.

Diagnostic Results: The patient completed the Yale-Brown Obsessive-Compulsive Scale (Y-BOCS) during the initial evaluation, with a score of 28 indicating severe OCD symptoms. Y-BOCS is an effective tool for evaluating OCD in children and adolescents (Storch et al., 2019).(Comprehensive Psychiatric Evaluation Soap Note On Obsessive-compulsive disorder-Nursing Essay Example)

Assessment

Mental Status Examination: The client is well-dressed and oriented in all spheres. She is knowledgeable, conversant, and cooperative. She appears anxious and fidgety. She is distressed and overwhelmed by the symptoms. Her affect is congruent with her mood. She denies any auditory or visual hallucinations. She denies any suicide or homicide ideation. She is not at risk to herself or others.(Comprehensive Psychiatric Evaluation Soap Note On Obsessive-compulsive disorder-Nursing Essay Example)

Differential Diagnoses:

1. 300.3 (F42), Obsessive-compulsive disorder (OCD): This disorder is characterized by compulsions and/or obsessions that cause significant distress and interfere with daily life. Individuals experience recurrent thoughts or urges and attempts to neutralize them with different thoughts or action (American Psychiatric Association, 2019).  (Comprehensive Psychiatric Evaluation Soap Note On Obsessive-compulsive disorder-Nursing Essay Example)
2. 300.02 (F41.1), Generalized anxiety disorder (GAD): GAD is characterized by excessive worry and anxiety about various events or activities. Individuals experience difficulty controlling worry, restlessness, fatigue, muscle tension, sleep disturbances, and difficulty concentrating (APA, 2019).
3. 300.7 (F45.22), Body dysmorphic disorder (BDD): BDD is characterized by a preoccupation with perceived flaws or defects in one’s appearance that are not noticeable to others or only appear slight (APA, 2019). Individuals present symptoms such as repetitive behaviors and preoccupation with body flaws.(Comprehensive Psychiatric Evaluation Soap Note On Obsessive-compulsive disorder-Nursing Essay Example)

Reflection.

The patient’s symptoms of intrusive thoughts and repetitive behaviors are consistent with the diagnostic criteria for OCD. The patient reports being preoccupied with the thoughts of germs and the possibility of transmitting them to others. As a result, she constantly cleans her room and clothes and takes a bath. She gets anxious and anxious and fearful about getting sick. Therefore, OCD is the primary diagnosis. The case patient’s symptoms of feeling tense, worried, and preoccupied with thoughts on cleanliness, germs, and getting sick are consistent with GAD symptoms. However, the client does not meet the full criteria for GAD diagnosis. Moreover, the client’s symptoms of preoccupation with dirty skin and repeated baths and reassurances indicate BDD.(Comprehensive Psychiatric Evaluation Soap Note On Obsessive-compulsive disorder-Nursing Essay Example)

Lessons learned from this case is the importance of comprehensive evaluation and assessment of mental health patients. A thorough evaluation is crucial in gathering information about a patient and her symptoms to make a definitive diagnosis and develop appropriate treatment plans (Boland & Verduin, 2021). Moreover, it is crucial to consider comorbid conditions when making diagnoses. Comorbidities contribute to substantial disparities in mortality, morbidity, and mental health care costs (Rosenfield et al., 2022). The case patient presented conditions that could have been attributed to different disorders, and it was ideal to consider all possibilities before making a final diagnosis. Lastly, it is crucial to involve clients in their care. Involving adolescents in their care is essential in gathering their views, experiences, and perspective to assess their capacity (Viksveen et al., 2022).(Comprehensive Psychiatric Evaluation Soap Note On Obsessive-compulsive disorder-Nursing Essay Example)

The legal/ethical considerations, in this case, include the client’s confidentiality, informed consent, and capacity. Confidentiality and consent are vital in ensuring the client’s autonomy and promoting informed decision-making, preventing conflicts of interest, maintaining the therapeutic alliance, and upholding professional codes of conduct and standards of care (Boland & Verduin, 2021). In this case, it is crucial to evaluate the client’s capacity to make an informed decision and involve the parent where necessary. Therefore, the practitioner should obtain informed consent from the parents considering the client’s age and capacity, and the parents ensure that the client’s confidentiality is respected. Lastly, the therapist would consider the potential cultural or religious factors that might impact the client’s treatment and ensure their beliefs and values are appreciated.(Comprehensive Psychiatric Evaluation Soap Note On Obsessive-compulsive disorder-Nursing Essay Example)

Social health determinants, including socioeconomic status, may impact the client’s ability to seek medication and therapy, while cultural factors may influence their willingness to seek treatment. These factors should be considered when planning for treatment. The therapist should work with the client and the parents to identify and address any social health determinant that may impact treatment and connect them to available community resources or adjust their treatment plan to fit present needs and circumstances. Health promotion may include regular therapy sessions, medication management, and helping the client develop coping skills and stress management techniques. The therapist should also work with the client and the parents to address co-occurring mental illnesses, including providing patient education on mental health care’s importance.  Top of Form(Comprehensive Psychiatric Evaluation Soap Note On Obsessive-compulsive disorder-Nursing Essay Example)

Case Formulation and Treatment Plan.  

1. Pharmacology – Start Fluoxetine 20mg PO PRN. Fluoxetine is well-tolerated and effective in managing OCD in children (Maneeton et al., 2020).
2. Physiotherapy – Continue with cognitive behavioral therapy. CBT is effective as an adjunct therapy for children with OCD (Van Noppen et al., 2021). CBT is crucial in identifying stimuli and learning coping mechanisms.(Comprehensive Psychiatric Evaluation Soap Note On Obsessive-compulsive disorder-Nursing Essay Example)
3. Education – Discuss with the client the side effects of medication. Inform the client and the parents of the benefits and side effects of fluoxetine. Discuss the adverse effects and when to contact the emergency services whose number is given.

RTC: 4 weeks.

References

American Psychiatric Association. (2019). Diagnostic and statistical manual of mental disorders (7^th ed.). American Psychiatric Publishing, Inc.   (Comprehensive Psychiatric Evaluation Soap Note On Obsessive-compulsive disorder-Nursing Essay Example)

Boland, R., & Verduin, M. (2021). Kaplan & Sadock’s Concise Textbook of Clinical Psychiatry. Lippincott Williams & Wilkins.

Maneeton, N., Maneeton, B., Karawekpanyawong, N., Woottiluk, P., Putthisri, S., & Srisurapanon, M. (2020). Fluoxetine in acutely treating children and adolescents with obsessive–compulsive disorder: a systematic review and meta-analysis. Nordic Journal of Psychiatry, 74(7), 461-469.(Comprehensive Psychiatric Evaluation Soap Note On Obsessive-compulsive disorder-Nursing Essay Example)

Rosenfeld, L. C., Wang, P., Holland, J., Ruble, M., Parsons III, T., & Huang, H. (2022). Care Management of Comorbid Medical and Psychiatric Illness: A Conceptual Framework for Improving Equity of Care. Population Health Management, 25(2), 148-156. https://doi.org/10.1089%2Fpop.2021.0366

Storch, E. A., McGuire, J. F., Wu, M. S., Hamblin, R., McIngvale, E., Cepeda, S. L., … & Goodman, W. K. (2019). Development and psychometric evaluation of the children’s Yale-Brown obsessive-compulsive scale second edition. Journal of the American Academy of Child & Adolescent Psychiatry, 58(1), 92-98. (Comprehensive Psychiatric Evaluation Soap Note On Obsessive-compulsive disorder-Nursing Essay Example)https://doi.org/10.1016/j.jaac.2018.05.029

Van Noppen, B., Sassano-Higgins, S., Appasani, R., & Sapp, F. (2021). Cognitive-Behavioral Therapy for Obsessive-Compulsive Disorder: 2021 Update. Focus, 19(4), 430-443. https://doi.org/10.1176/appi.focus.20210015

Viksveen, P., Bjønness, S. E., Cardenas, N. E., Game, J. R., Berg, S. H., Salamonsen, A., … & Aase, K. (2022). User involvement in adolescents’ mental healthcare: a systematic review. European Child & Adolescent Psychiatry, 31(11), 1765-1788. https://doi.org/10.1007/s00787-021-01818-2