Comprehensive Focused Soap Note for Anxiety PTSD and OCD-Nursing Paper Example

Comprehensive Focused Soap Note for Anxiety PTSD and OCD-Nursing Paper Example

Patient Information

Patient Initials: DC

Age: 7 years

Gender: Male

Subjective Assessment

Chief Complains: “He just seems so anxious and worried all the time.”

History of Presenting Illness:

DC is a 7-year-old male accompanied by his mother to the healthcare facility, who reported that his son always seems anxious and worried. Upon inquiry, the DC reports that he has never sought professional help for his problem. He reports that he is worried that his mother may not pick him up from school and may not return home like his father. The patient encounters problems with falling asleep, gets up frequently and always wants the lights and doors open. DC has bad dreams where he gets lost and cannot find his brother and mother.(Comprehensive Focused Soap Note for Anxiety PTSD and OCD-Nursing Paper Example)

Comprehensive Focused Soap Note for Anxiety PTSD and OCD-Nursing Paper Example
Comprehensive Focused Soap Note for Anxiety PTSD and OCD-Nursing Paper Example 1

            DC gets into trouble at school and home for throwing things. The patient also gets into trouble at school for not concentrating. His teacher was forced to move the patient’s chair next to her to monitor his movements. The patient always wants to come from school complaining of headaches and stomach pain. The patient does not like school since one of his classmates calls him ‘Mr. Smelly’. The patient wets his bed and does not take births afterwards. The patient reports not having stopped wetting his bed after taking DDVAP. The patient has lost his appetite, contributing to three pounds loss in the past three weeks. DC wonders why his father does not come home, although he was killed when the patient was five years old. However, the patient denied any self-harm or suicidal idealizations.(Comprehensive Focused Soap Note for Anxiety PTSD and OCD-Nursing Paper Example)

Past Psychiatric History: The patient has not suffered any mental health condition before. He has sought psychiatric help before(Comprehensive Focused Soap Note for Anxiety PTSD and OCD-Nursing Paper Example)

Past Medical History: DC has no history of chronic illness

Surgery: None

Hospitalization: None

Immunization: All the patient’s immunizations are up to date 

Allergies: The patient has no known food or drug allergies

Current Medications: None

Blood Transfusion: None

Developmental Milestones: The patient did not have birth complications or febrile convulsions as a child. The patient has not had any developmental delays.(Comprehensive Focused Soap Note for Anxiety PTSD and OCD-Nursing Paper Example)

Substance Use: DC does not have any history of substance or drug abuse

Family Psychiatric History: There is no history of mental health conditions in the family

Psychosocial History: DC lives with his mother, young brother, and dog. He enjoys playing with his dog. The patient reported that he did not help his mother with his brother and claimed that he smells milk and cries all the time. The patient also reported that his mother spends more time with his brother. The patient’s father died when he was five years old, and he keeps wondering why he will not come home.(Comprehensive Focused Soap Note for Anxiety PTSD and OCD-Nursing Paper Example)

ROS

General: DC’s mother reported that he had lost three pounds. However, the patient has no fever, night sweats, chills, or weakness.(Comprehensive Focused Soap Note for Anxiety PTSD and OCD-Nursing Paper Example)

HEENT: The patient has not experienced blurred vision, double vision or vision loss. He has not had loss of smell, nasal congestion, running nose, hearing loss, sore throat or dysphagia.(Comprehensive Focused Soap Note for Anxiety PTSD and OCD-Nursing Paper Example)

Skin: The patient has no skin rashes, swollen lymph nodes or rashes

Cardiovascular: The patient has no chest pain, swollen extremities

Respiratory: The patient denies wheezing, breathlessness, or cough

Gastrointestinal: The patient denies loss of appetite, abdominal pain, heartburns, difficulty in swallowing or change in bowel habits(Comprehensive Focused Soap Note for Anxiety PTSD and OCD-Nursing Paper Example)

Genitourinary: The denies pain when passing urine, urethra discharge, or swelling

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Neurological: The patient denies headache, loss of sensation, poor coordination, seizures or incontinence

Musculoskeletal: The patient denies weakness, pain or joint weakness

Hematologic: The patient does not have any infections, bleeding gums, or bruising

Lymphatics: The patient has no swollen lymph nodes or splenectomy(Comprehensive Focused Soap Note for Anxiety PTSD and OCD-Nursing Paper Example)

Endocrine: The patient denies heat or cold intolerance, increased thirst or urine output

Objective Assessment

Physical Examination

General Examination: The patient has good nutritional, no fatigue or distress symptoms

Vital Signs: Blood pressure of 120/79mmHg, pulse rate 66 bpm, temperature 98.6 F, weight 65 pounds, respiratory rate 17 breaths per minute, height 4’0(Comprehensive Focused Soap Note for Anxiety PTSD and OCD-Nursing Paper Example)

HEENT: Patient has normal pupillary response, sclerae moist and white bilaterally, No frontal or maxillary swelling, No mucosal changes on the nasopharynx and oropharynx

Neck: The patient has no neck stiffness, swelling or carotid bruit

Chest: The patient has normal breathing, no chest deformity, no tenderness on palpation, and chest resonant on percussion. Vesicular sounds heard on auscultation(Comprehensive Focused Soap Note for Anxiety PTSD and OCD-Nursing Paper Example)

Cardiovascular: Peripheral pulses heard. The pulses were regular. There were no murmurs after pericardial auscultation. No oedema or clubbing

Abdomen: The patient has no abdominal swelling, bowel sounds present, visible peristalsis, no masses on palpation,

Musculoskeletal: All muscles have 5/5 power, no swelling or pain

Neurological: Cranial nerves were intact, Sensation intact for all dermatomes, Normal deep tendon reflex, regular coordination(Comprehensive Focused Soap Note for Anxiety PTSD and OCD-Nursing Paper Example)

Lymph node/Skin: No oedema, cyanosis, clubbing, no palpable nodes

Diagnostic Testing: Complete blood count, magnetic resonance and blood biochemistry conducted were normal(Comprehensive Focused Soap Note for Anxiety PTSD and OCD-Nursing Paper Example)

Assessment

Mental Health Examination

            On mental health examination, the patient is a 7-year-old male who looks fit for his age. The patient was cooperative and calm. He was well-groomed and appeared to be hygienic. The patient sat comfortably and upright. He had a normal gait and did not show any signs of distress. He has appropriate behaviour and maintained eye contact throughout the interview without distraction. He showed appropriate facial expressions and had a good mood that corresponded well with affect. His speech was clear and coherent. He had no hallucinations or suicidal thoughts. He was alert and had adequate judgment, memory and attention. However, the patient was not oriented to the place since he thought he was in school when asked by the practitioner. DC is aware of his current illness. He reported that “she thought you were going to help me get better”. The patient also appreciated when he said that the session would make him feel better.(Comprehensive Focused Soap Note for Anxiety PTSD and OCD-Nursing Paper Example)

Diagnoses

Generalized Anxiety Disorder- Primary Diagnosis

            DC’s primary diagnosis is GAD. In the DSM-5-TR, an individual is diagnosed with GAD if they experience excessive anxiety symptoms and worrying symptoms for more days than not for at least six months (First et al., 2021). Anxiety and worrying symptoms dominated the patient’s interview, where he was reported to be constantly worried and anxious. The DSM-5-TR criterion also adds that people with GAD encounter symptoms such as easy fatigability, restlessness, problems with concentration, irritability and sleeping problems (American Psychiatric Association, 2022). DC also portrayed problems with concentration in school and sleeping disturbances. The patient’s teacher is constantly reminding DC to sit down and concentrate. The patient has difficulty falling asleep, wakes up frequently and experiences nightmares. The DSM-5-TR states that the symptoms must cause clinically significant impairment to be confirmed. The patient presents with altered functional levels at school and home. The patient likes school since one of his colleagues calls him Mr. Smelly. He complains of stomach pain and headaches when he goes home from school. The teacher must monitor the patient by sitting closer to him at school. The problem also affects the patient’s sleeping patterns, and he has sought psychiatric help to improve his condition.(Comprehensive Focused Soap Note for Anxiety PTSD and OCD-Nursing Paper Example)

Differential Diagnoses

Posttraumatic Stress Disorder

            The patient’s clinical manifestations also suggest a PTSD diagnosis. The DSM-5-TR Criterion A asserts that individuals will likely develop PTSD after learning about traumatic events that affected their loved ones or family members (American Psychiatric Association, 2022). The patient always worries about his mother’s and young brother’s safety. He worries that his mother may not return home to his father. DC’s mother did not inform him about his father’s death since he was too young. DC experiences recurrent distressing nightmares mainly related to traumatic events among PTSD patients. For instance, the patient dreams of losing his mother and young brother. However, the patient does not meet the PTSD criterion since he has no apparent intrusive symptoms, mood thought alterations or high arousal. PTSD Criterion A also has not been fully met as the patient does not know what happened to his father. (Comprehensive Focused Soap Note for Anxiety PTSD and OCD-Nursing Paper Example)

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Obsessive Compulsive Disorder

            Obsessive-compulsive disorder is another differential diagnosis that may be causing the patient problems. The DSM-5-TR claims that patients with OCD have obsessions and compulsions (American Psychiatric Association, 2022). In this case, obsessions are persistent thoughts encountered during disturbance as unwanted or intrusive, leading to anxiety and distress. DC experiences unwanted thoughts about the safety of his mother and young brother. He also worries that his mother may disappear and not return like his father. The patient also encounters compulsions to deal with anxiety and distress by throwing things at school at home. The patient also wants the door open and lights on, feeling that his mother is close to him to cope with anxiety. However, the patient’s symptoms do not fulfil the criteria for OCD. Thus, symptoms of other mental health disorders, such as GAD, better explain the patient’s disturbance. For instance, the DC’s worries and anxiety are better explained by GAD, making it the most suitable diagnosis.

Case Formulation and Treatment Plan

            This treatment plan is for the presumptive GAD diagnosis. The treatment plan entails pharmacotherapy, psychotherapy and supportive treatment. Selective Serotonin Reuptake Inhibitors (SSRIs) are the first-line pharmacotherapy treatment for GAD and are preferred due to their safety, efficacy and tolerability for most patients. The patient can receive fluoxetine   10 mg/day administered orally (Garakani et al., 2021). The dosage should be administered for four weeks regardless of whether the patient is responsive to treatment. The treatment should take about 12 months if the patient is responsive to the medication. Sleep disturbance was a significant problem for the patient. Sleeping aids such as zolpidem 5-10mg administered at bedtime for one week to prevent dependency will be effective in the short term (Edinoff et al., 2021).(Comprehensive Focused Soap Note for Anxiety PTSD and OCD-Nursing Paper Example)

Subsequently, cognitive behavioural therapy is the most effective psychotherapy for GAD. The intervention will be vital to eliminate the patient’s potential negative thoughts and behaviours and to recognize and restructure them. CBT has also been proven to reduce anxiety symptoms effectively while improving the patient’s functional levels (Hirsch et al., 2019). Notably, comparative alternative therapy will also be effective for the patient. Acupuncture therapy effectively reduces anxiety in GAD patients (Yang et al., 2021). Yoga (breathing regulation, body postures, relaxation, mindfulness and meditation) has beneficial effects.(Comprehensive Focused Soap Note for Anxiety PTSD and OCD-Nursing Paper Example)

Health Promotion/Education

            The practitioner should inform the patient’s mother about the diagnosis, treatment plan and strategies to promote treatment compliance. She should be educated and trained on patient coping skills. For instance, the mother should assist the patient in taking a bath to prevent smelling that causes him problems at school. The mother should also inform DC’s teacher about his condition. However, the teacher noted the patients noted the patient’s problem and sat close to help him. The mother should be educated about the significance of attending frequent check-ups and raising her concerns about DC to the healthcare professional. The follow-up clinics can be scheduled on weekends to prevent the patient from missing school. The patient and the mother should be given an emergency number that they can call to ask for help during emergencies.(Comprehensive Focused Soap Note for Anxiety PTSD and OCD-Nursing Paper Example)

Reflection

            The case study has broadened my comprehension of DSM-5-TR diagnostic criteria for GAD, PTSD, OCD and other mental health conditions. I acquired more knowledge on the management of GAD patients, especially children. I would enquire about the time the patient’s symptoms began, the duration and triggers to gain clarity about the diagnosis if I redo the case again. I would also use GAD screening tools for children to support my diagnosis. For example, the Multidimensional Anxiety Scale for children and the Paediatric Anxiety Rating Scale are suitable tools.(Comprehensive Focused Soap Note for Anxiety PTSD and OCD-Nursing Paper Example) 

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My subsequent intervention for the patient would be assessing the patient for prescribed drugs’ side effects. However, I will not change the GAD medications since changing the medication should occur after four weeks when their actions should have been experienced by then. By assessing for potential side effects, I will honour the ethical principles of beneficence and non-maleficence by ensuring that my treatment benefits the patient and does not cause harm. I will observe confidentiality during the assessment by interviewing the patient in a private room. While anxiety disorders are prevalent across the lifespan, early onset occurs by 11 years for most children, like in DC’s case (Solmi et al., 2022). However, the early onset of anxiety disorders can be prevented by community-based screening programs offered by qualified health personnel such as psychiatrists or mental health nurses. Preventive interventions are effective in curbing mental health disease onset across the lifespan.(Comprehensive Focused Soap Note for Anxiety PTSD and OCD-Nursing Paper Example)

Comprehensive Focused Soap Note for Anxiety PTSD and OCD-Nursing Paper Example
Comprehensive Focused Soap Note for Anxiety PTSD and OCD-Nursing Paper Example 2

References

American Psychiatric Association. (2022). Diagnostic And Statistical Manual of Mental Disorders, Text Revision Dsm-5-Tr. Amer Psychiatric.(Comprehensive Focused Soap Note for Anxiety PTSD and OCD-Nursing Paper Example)

Edinoff, A. N., Wu, N., Ghaffar, Y. T., Prejean, R., Gremillion, R., Cogburn, M., Chami, A. A., Kaye, A. M., & Kaye, A. D. (2021). Zolpidem: Efficacy and Side Effects for Insomnia. Health psychology research9(1), 24927. (Comprehensive Focused Soap Note for Anxiety PTSD and OCD-Nursing Paper Example)https://doi.org/10.52965/001c.24927

First, M. B., Gaebel, W., Maj, M., Stein, D. J., Kogan, C. S., Saunders, J. B., … & Reed, G. M. (2021). An organization-and category‐level comparison of diagnostic requirements for mental disorders in ICD‐11 and DSM‐5. World Psychiatry20(1), 34-51(Comprehensive Focused Soap Note for Anxiety PTSD and OCD-Nursing Paper Example). https://doi.org/10.1002/wps.20825

Garakani, A., Murrough, J. W., Freire, R. C., Thom, R. P., Larkin, K., Buono, F. D., & Iosifescu, D. V. (2020). Pharmacotherapy of anxiety disorders: current and emerging treatment options. Frontiers in psychiatry, 1412(Comprehensive Focused Soap Note for Anxiety PTSD and OCD-Nursing Paper Example). https://doi.org/10.3389/fpsyt.2020.595584

Hirsch, C. R., Beale, S., Grey, N., & Liness, S. (2019). Approaching Cognitive Behavior Therapy For Generalized Anxiety Disorder From A Cognitive Process Perspective. Frontiers in psychiatry10, 796. https://doi.org/10.3389/fpsyt.2019.00796

Solmi, M., Radua, J., Olivola, M., Croce, E., Soardo, L., Salazar de Pablo, G., Il Shin, J., Kirkbride, J. B., Jones, P., Kim, J. H., Kim, J. Y., Carvalho, A. F., Seeman, M. V., Correll, C. U., & Fusar-Poli, P. (2022). Age at onset of mental disorders worldwide: a large-scale meta-analysis of 192 epidemiological studies. Molecular psychiatry27(1), 281–295. https://doi.org/10.1038/s41380-021-01161-7

Yang, X. Y., Yang, N. B., Huang, F. F., Ren, S., & Li, Z. J. (2021). Effectiveness of acupuncture on anxiety disorder: a systematic review and meta-analysis of randomized controlled trials. Annals of general psychiatry20(1), 9. https://doi.org/10.1186/s12991-021-00327-5

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