Obsessive-compulsive disorder Comprehensive Clinical SOAP Note Nursing Paper Example

Obsessive-compulsive disorder Comprehensive Clinical SOAP Note Nursing Paper Example

Client ID: Initials: CH,AGE: 17, Demographic: African-American, Gender: F

Subjective.

Chief complaint: CH’s chief complaint is, “I am worried of being labeled a family black sheep because I am a lesbian and have a strong hatred towards men, including my father and brother.” Source of reliability: Self-referred and reliable. (Obsessive-compulsive disorder Comprehensive Clinical SOAP Note Nursing Paper Example)

Present Illness: CH checks in for anxiety treatment. She is worried about being labeled the “black sheep” due to her sexual orientation. CH notes that she had a solid Christian upbringing, and her parents are devout and strict Catholics who would not tolerate her attraction to women. Two years ago, her boyfriend held her incommunicado and sexually abused her for three days. She reported the matter to the police, and so far, the accused is still at large. She often experiences insomnia and anxiety. She feels worthless and finds solace in lesbian relationships. She has a strong hatred towards men and fears having conversations with them. At school, she cannot make presentations before other students because she is different. She admits to having sexual fantasies about her aunt, who is almost three times older, and the thoughts “cannot go away.” (Obsessive-compulsive disorder Comprehensive Clinical SOAP Note Nursing Paper Example)

Current psych meds:  Alprazolam 6mg PO QID for anxiety.

Past psychiatric history: None reported.

Past Medical Hx: None reported.

Allergies: NKFDA.

Substance use/abuse: Reports smoking and alcohol use. Denies ETOH.  

Past family, social history: Parents and siblings are alive and well.Obsessed with house parties.No legal trauma.

Family psych hx: None reported.

Education/Employment/Disability: First-year undergraduate student of Information technology. Never worked. No disability. (Obsessive-compulsive disorder Comprehensive Clinical SOAP Note Nursing Paper Example)

Primary support system: Parents.

Hobbies: Basketball.

Review of systems:

Constitutional: No weight loss, fever, or chills.

Eyes: Wear glasses for reading.

ENT: Reports no change in hearing and sense of smell. No sore throat.

Cardiac: No chest pains or discomfort.

Respiratory: Denies dyspnea. Reports no cough. 

GI: No abdominal pain.

Skin: Normal skin turgor and moisture.

Neurologic: Reports blackout when drunk.

Endocrine: Reports no polydipsia or polyuria.

Musculoskeletal: Reports no joint pain or swelling.

Objective:

Vitals: BP: 119/71 P: 71 Ht: 5”5” Wt: 135 BMI: 22.5 kg/m²

Appearance: Well-groomed. Eye contact avoidant.

Attitude/interaction: Interactive.

Activity level/behavior: Warm with comments and behavior.

Orientation: Alert and oriented × 4. (Obsessive-compulsive disorder Comprehensive Clinical SOAP Note Nursing Paper Example)

Speech: In-depth grammar and comprehension.

Thought content/process/perception: Past oriented and sombre. Negative perceptions about self were noted.

Mood/affect: Mood is normal.

Judgment/insight/cognitive/memory: Good judgement and insight.Normal ability to abstract.

Attention: Attentive.

Testing UDS positive for benzodiazepine.

Alcohol: Positive (Obsessive-compulsive disorder Comprehensive Clinical SOAP Note Nursing Paper Example)

Assessment:

1. Obsessive-compulsive disorder (OCD). ICD-10 code F42. CH presents symptoms that meet OCD diagnostic criteria, including persistent thoughts most times a day and are not attributed to psychological effects of substance abuse (American Psychiatric Association, 2013). This is the primary diagnosis. (Obsessive-compulsive disorder Comprehensive Clinical SOAP Note Nursing Paper Example)
2. Posttraumatic stress disorder (PSTD). ICD-10 code F43.10. CH presents symptoms associated with PSTD diagnosis, including exposure to sexual violence, recurrence of distressing memories, and avoidance of stimuli associated with the traumatic events (American Psychiatric Association, 2013). This diagnosis is refuted. (Obsessive-compulsive disorder Comprehensive Clinical SOAP Note Nursing Paper Example)
3. Acute stress disorder (ASD). ICD-10 code F43.0. CH presents symptoms of ASD, including exposure to sexual violence, recurrent distressing memories, and negative mood that impairs social functioning (American Psychiatric Association, 2013). This diagnosis is refuted.
4. Major depressive disorder (MDD). CH presents symptoms associated with moderate MDD, such as depressed mood, insomnia, and feelings of worthlessness (American Psychiatric Association, 2013). This diagnosis is refuted. (Obsessive-compulsive disorder Comprehensive Clinical SOAP Note Nursing Paper Example)
5. Selective mutism (SM). ICD-10 code F94.0. CH presents symptoms associated with SM, such as consistent failure to speak in specific social situations, and the disturbance interferes with academic and social functioning (American Psychiatric Association, 2013). This diagnosis is refuted.

Plan:

Discontinue Alprazolam 6mg PO QID for anxiety due to addictions. Start 20 mg PO QID for anxiety. May gradually increase 20 mg/day after four weeks, depending on response. Fluoxetine is effective and well-tolerated in treating social anxiety among children and adolescents between 7 and 17 years (Amray et al., 2019). According to Boaden et al. (2020), Fluoxetine is effective in treating OCD and MDD.  Start Zolpidem5 mg PRN for insomnia. Zolpidem is a short-term treatment of insomnia, helping patients to get sleep and stay asleep (Bouchette, Akhondi & Quick, 2021). Watch out for misuse and side effects, including changes in behavior, withdrawal, dependency, and next-day impairment (Moore & Mattison, 2018). (Obsessive-compulsive disorder Comprehensive Clinical SOAP Note Nursing Paper Example)

Referral: Counselor. To discuss the client’s case and perception. Help the client disclose her status to the parent and talk with the client’s parents about LGBTQ to dispel myths and misconceptions.  Teenagers can achieve better health outcomes when their sexual orientation is accepted and supported positively (CDC, 2019). (Obsessive-compulsive disorder Comprehensive Clinical SOAP Note Nursing Paper Example)

Next Visit: After four week