Patient with Anxiety SOAP Note-A Comprehensive Nursing Paper Sample

Patient with Anxiety SOAP Note-A Comprehensive Nursing Paper Sample

Name: D.C.

DOB: October 30th, 2016

Minor: Yes

Age: 7 Years

Gender: Male

Accompanied by: Mother

SUBJECTIVE:

CC: “You will make me better.”

HPI: D.C., a 7-year-old boy, is in the company of his mother at the clinic, stating his mother told him he would become better after seeing the practitioner. D.C. reports that he is worried most of the time about everything. According to the mother, D.C. has many bad dreams. D.C. also admits that he dreams a lot and gets so lost that he cannot find his mom and brother. The dreams happen nearly every night. D.C. sleeps with lights on and the door open to ensure the mom is close. While at school, D.C. also worries about his mum and brother with concerns about whether they are okay, and it is all he can think about. D.C. states he is unlikable at school by fellow students who call him Mr. Smelly. (Patient with Anxiety SOAP Note-A Comprehensive Nursing Paper Sample)The mom reports D.C. does not bath often and wets the bed/experiences night accidents. D.C. reports feeling sad and bad because his father has not returned home, and he fears that his mom will also not return one day. Per his teacher, D.C. struggles at school, indicating difficulties staying still or focusing. He often looks out the window, which puts him in trouble, forcing the teacher to move closer to where he sits to manage his behavior. D.C. reports that he is not violent but once threw a book at a fellow student. The mother states that D.C. is always anxious and worried about things like her dying or failing to pick him up at school. She also reports D.C. feels she loves his brother more than him. Additionally, the mother reports that D.C. Has sleeping difficulties and wakes up a lot. D.C. also pretends to have stomach aches and headaches almost every day to get away from school. Moreover, D.C. has unexplained weight loss, losing about three pounds over three weeks. D.C. is currently taking DDVAP, which is not working anymore.(Patient with Anxiety SOAP Note-A Comprehensive Nursing Paper Sample)

Social History: D.C. lives with his mother, a younger brother, and a pet dog called Sparky. D.C. reports her mother spends more time with the younger brother. D.C. likes playing and petting Sparky and building Lego.(Patient with Anxiety SOAP Note-A Comprehensive Nursing Paper Sample)

Family Psychiatric/Substance Use History: No psychiatric or substance abuse history. D.C.’s mother is alive and well, but the father died in a war as a military officer, although the patient knows he went on vacation and has never returned.  (Patient with Anxiety SOAP Note-A Comprehensive Nursing Paper Sample)

Past Psychiatric History:

            Hospitalization: None

Medication trials: None

Psychotherapy or Previous Psychiatric Diagnosis: Denies previous psychiatric history.

Medical History: None.   

• Current Medications: D.C. is currently on DDVAP for bed wetting.  
• Allergies: None.
• Reproductive Hx: None.

Development Milestones:

Development milestones met on time

Health Promotion:

Vaccination up to date

Sleeps 4-6 hours every night

D.C.’s nutrition is proper per PCP.

ROS:  

General: The mother reports that D.C. has experienced unexplained weight loss of 3 pounds in three weeks. Denies fever, chills, weakness, or fatigue.(Patient with Anxiety SOAP Note-A Comprehensive Nursing Paper Sample)

HEENT: Eyes: Denies visual loss, blurred vision, double vision, or yellow sclerae. Ears, Nose, Throat: No hearing loss, sneezing, congestion, runny nose, or sore throat.

Skin: No rash or itching.

Cardiovascular: Denies chest pain, chest pressure, or chest discomfort. No palpitations or edema.

Respiratory: Denies wheezes, shortness of breath, consistent coughs, and breathing difficulties while resting.

Gastrointestinal: No anorexia, nausea, vomiting, or diarrhea. No abdominal pain or blood.

Genitourinary: Denies burning on urination, urgency, hesitancy, odor, odd color(Patient with Anxiety SOAP Note-A Comprehensive Nursing Paper Sample)

Neurological: Denies headache, dizziness, syncope, paralysis, ataxia, numbness, or tingling in the extremities. No change in bowel or bladder control. Reports struggling to concentrate, pay attention, or stay still.

Musculoskeletal: Denies muscle, back pain, joint pain, or stiffness.

Hematologic: Denies anemia, bleeding, or bruising.

Lymphatics: Denies enlarged nodes. No history of splenectomy.

Endocrinologic: Denies Sweating, cold, or heat intolerance. No polyuria or polydipsia.

Psychiatric: D.C. is worried all the time about everything and has an anxious mood. He has bad dreams that keep him awake. D.C. struggles to sleep and stay asleep. The patient reports no intention or act of self-harm.(Patient with Anxiety SOAP Note-A Comprehensive Nursing Paper Sample)

OBJECTIVE:

Vital signs: Stable

Temp: 98.5F

            BP: 120/60

            P: 57

             RR: 15

             O2: Room air

             Pain: 0/10

             Ht: 4’6 feet

             Wt: 67 lbs

             BMI: 16.4

             BMI Range: Healthy weight

Physical Exam:

General appearance: D.C. is alert and oriented to self, date, and place. D.C. appears healthy and well-fed. He converses and engages regularly with the interviewer and responds to interview questions well, with little to no intervention from the mother. The patient demonstrated full attention throughout the interview.(Patient with Anxiety SOAP Note-A Comprehensive Nursing Paper Sample)

HEENT: Normocephalic and atraumatic. Sclera anicteric, No conjunctival erythema, PERRLA, oropharynx red, moist mucous membranes.

Neck: Supple. No JVD. Trachea midline. No pain, swelling, or palpable nodules.

Heart/Peripheral Vascular: Regular heart rate and rhythm. No murmurs. No palpitation. No peripheral edema to palpation bilaterally.(Patient with Anxiety SOAP Note-A Comprehensive Nursing Paper Sample)

Cardiovascular: Noted murmurs and other sounds from D.C.’s chest. D.C.’s heart rate is constant, and capillaries refill in two and a half seconds.  (Patient with Anxiety SOAP Note-A Comprehensive Nursing Paper Sample)

Musculoskeletal: Regular motion range and muscle mass. Shows no signs of swelling or bone and joint deformities.

Respiratory: No wheezes, and respirations are easy and regular.

Neurological: D.C. has a stable balance, regular gait, erect posture, good tone, and regular speech. D.C. shows signs of impaired concentration and is struggling at school.

Psychiatric: D.C. indicates a worried, anxious, and sad mood. D.C. portrays aggressive behavior.

Neuropsychological testing: D.C reports struggling with schoolwork. 

ASSESSMENT:

Mental Status Examination:

D.C., a 7-year-old male patient, presents with a worried, anxious, and sad mood, with the mother and patient reporting that the patient worries all the time and about everything. D.C. does less at school as he is worried about his mother and brother and what they are doing at home. D.C. indicates sadness for his father leaving and never coming back and fears the mother will also leave one day. D.C. cooperated well throughout the interview and answered all questions appropriately. D.C. was alert and oriented to self, date, and place. D.C. has no intention to harm himself.     (Patient with Anxiety SOAP Note-A Comprehensive Nursing Paper Sample)

Differential Diagnosis:

1. F41.9. Anxiety Disorder
2. F90.9. Attention-Deficit Hyperactivity Disorder

• F43.23. Adjustment Disorder

Rationale

1. F41.9. Anxiety Disorder

D.C. shows signs of anxiety disorder. D.C. and his mother report about the patient being worried all the time and about everything. He struggles at school because he is always worried about his mother and brother at home and what they are doing. D.C. also worries that his mother will one day leave and not pick him up at school because his father left and has never returned.(Patient with Anxiety SOAP Note-A Comprehensive Nursing Paper Sample) He also worries about his mother dying. D.C. has difficulties at school and struggles with concentration, paying attention, staying still, and constantly looking outside the window. He also experiences difficulties sleeping or staying asleep, has bad dreams, and cannot sleep with lights off or the door closed to feel his mother’s presence. The patient feels unlikable at school and constantly gets bullied for being smelly. The mother reports D.C. not bathing and wetting his bed. According to Bhatia and Goyal (2019), individuals with anxiety disorder are always worried about everything and anticipate bad events or disasters, which makes them overly concerned with everything in life. Anxiety disorder is confirmed when an individual cannot manage or control their worrying, which is the case with D.C.   (Patient with Anxiety SOAP Note-A Comprehensive Nursing Paper Sample)

• F90.9. Attention-Deficit Hyperactivity Disorder 

D.C. shows signs of attention-deficit hyperactivity disorder. D.C. reports struggling to concentrate or pay attention. Also, he cannot stay still at school and constantly stares through the window. D.C. experiences difficulties at schools and bullying for being smelly. D.C. shows signs of impaired functioning because the mother reports that he rarely bathes. Per the DSM-5 criteria, children with ADHD present with a non-ending inattention and/or hyperactivity-impulsivity pattern, which interferes with their normal functioning and/or development as evidenced by inattention with six or more symptoms continuing for at least six weeks to a point it does not align with developmental stage, negatively affecting social and academic execution, including the inability to pay attention to detail, committing unnecessary and careless errors in school assignments and other engaging activities, not paying attention when playing or in tasks, seeming less attentive when talked to, failing to adhere to instructions, organize activities, avoiding or being reluctant to engage in tasks that need continued attention, losing things easily, easy distractibility by external stimuli, and forgetfulness (Magnus et al., 2022). D.C. has less than six of the indicated symptoms; hence the diagnosis was refuted.     (Patient with Anxiety SOAP Note-A Comprehensive Nursing Paper Sample)

• F43.23. Adjustment Disorder

Per the presented subjective and obtained objective data, D.C. might have an adjustment disorder (AD). D.C.’s father left and has never returned. The patient understands the father went on vacation and is unaware of his death. Most worries and anxiety D.C. experiences are attached to his father not returning, implying that he has struggled to adjust to his father’s absence, leading to him fearing that his mother will also leave one day and not pick him up at school. (Patient with Anxiety SOAP Note-A Comprehensive Nursing Paper Sample)This event was stressful, which aligns with the definition of adjustment disorder that occurs when people struggle to adjust to stressful occurrences or the effects of a stressful event or a psychosocial stressor. The patient’s responses to stress must be inconsistent with typical responses of a regular person to a similar event and considerably impair the patient’s daily functioning (O’Donnell et al., 2019). According to the DSM-5 criteria, AD is confirmed when a patient develops emotional or behavioral symptoms to respond to a stressor or stressors within the first three months of onset. Additionally, the symptoms must be clinically significant, as evidenced by severe stress that is atypical or disproportional to the stressor(s) intensity, considering cultural aspects and external stimuli that would influence symptom development and intensity. The patient must also indicate severe social, occupational, and other functional impairments due to the stressor or response to the stressor (O’Donnell et al., 2019). D.C. did not meet the DSM-5 criteria for AD; hence the diagnosis was refuted.(Patient with Anxiety SOAP Note-A Comprehensive Nursing Paper Sample)

PLAN:

Combining psychotherapy and pharmacotherapy is recommended for this patient.

Psychotherapy

D.C. is a minor, and psychotherapy should be considered as the first-line treatment of anxiety. D.C. would benefit from behavioral therapy to improve his executive function and anxiety symptoms. Additionally, short-term psychodynamic psychotherapy, applied relaxation interpersonal psychotherapy, and social skills training can help improve anxiety symptoms, help D.C. adjust to his father’s absence, and help D.C. learn social skills to improve engagement at school. D.C. will also benefit from cognitive-behavioral therapy, which, according to Lopez et al. (2019), can help manage restlessness arising from school work and enhance concentration and attention. (Patient with Anxiety SOAP Note-A Comprehensive Nursing Paper Sample)

Medication

Although rarely recommended for patients in this age group, medications can help address anxiety symptoms. D.C. would benefit from low doses of anti-depressants like Zoloft to improve anxiety symptoms.  (Patient with Anxiety SOAP Note-A Comprehensive Nursing Paper Sample)

Patient Education

• Educate the patient and parent about medication adherence, medication side effects, any interactions with other substances, and when to report side effects to the clinician.
• Talk to the patient and parent about the dangers of combining prescription pharmaceuticals with other substances.
• Educate the parent about establishing a routine of activities, including school work, to help D.C. improve organization and task completion.
• Educate the parent to plan and encourage D.C.’s participation in physical activities and social activities
• Encourage the mother to spend more time with D.C.(Patient with Anxiety SOAP Note-A Comprehensive Nursing Paper Sample)

Follow-up: Follow-up will be in two weeks.

Reflection

The patient encounter and assessment were successful. The interviewer collected pertinent data to help diagnose and develop a comprehensive treatment plan. The patient cooperated and answered the questions well and appropriately. The mother provided relevant details to inform the diagnosis and treatment plan. In another encounter with the patient, I would require more information from the teacher about how they help the patient cope and address bullying. (Patient with Anxiety SOAP Note-A Comprehensive Nursing Paper Sample) The stressor that has contributed to the significant worrying, anxiety, and sadness is the patient’s father leaving and not returning. The patient thinks the father went on vacation, yet he is dead. The next intervention would involve engaging the parent on an approach to inform the patient about his father’s death. The hope that his father might return will continue to be a stressor and derail treatment outcomes.  (Patient with Anxiety SOAP Note-A Comprehensive Nursing Paper Sample)   

D.C. is a minor, and any intervention or treatment must involve a surrogate or adult who can give consent and make decisions. The clinician must also avoid events that might cause the patient harm, including recommending medications with a severe impact on a child or psychotherapy not applicable to patients in that age group. It is vital to respect medical care limitations, avoid bias or paternalism, any conflict of interest, and respect of the truth when dealing with a pediatric patient. Regarding health promotion, Mental Health America (2022) recommends positive parenting strategies to ensure D.C. does not feel less loved and receives unconditional care from the mother, constant communication and reassurance to improve self-confidence and self-esteem, encouraging teachers to be supportive to ensure a safe and secure environment free from bullying, adopting appropriate guidance and discipline at home and school to address behavioral and conduct issues, and encouraging the parent to manage the hygiene of the patient, who is only seven years old to ensure he takes a bath regularly.   (Patient with Anxiety SOAP Note-A Comprehensive Nursing Paper Sample)

References

Bhatia, M. S., & Goyal, A. (2019). Anxiety disorders in children and adolescents: Need for early detection. Journal of postgraduate medicine, 64(2), 75–76. https://doi.org/10.4103/jpgm.JPGM_65_18(Patient with Anxiety SOAP Note-A Comprehensive Nursing Paper Sample)

Lopez, P. L., Torrente, F. M., Ciapponi, A., Lischinsky, A. G., Cetkovich-Bakmas, M., Rojas, J. I., Romano, M., & Manes, F. F. (2019). Cognitive-behavioral interventions for attention deficit hyperactivity disorder (ADHD) in adults. The Cochrane database of systematic reviews, 3(3), CD010840. https://doi.org/10.1002/14651858.CD010840.pub2(Patient with Anxiety SOAP Note-A Comprehensive Nursing Paper Sample)

Magnus, W., Nazir, S., Anilkumar, A. C., & Shaban, K. (2022). Attention deficit hyperactivity disorder (ADHD).

Mental Health America. (2022). What every child needs for good mental health. https://www.mhanational.org/what-every-child-needs-good-mental-health(Patient with Anxiety SOAP Note-A Comprehensive Nursing Paper Sample)

O’Donnell, M. L., Agathos, J. A., Metcalf, O., Gibson, K., & Lau, W. (2019). Adjustment Disorder: Current Developments and Future Directions. International journal of environmental research and public health, 16(14), 2537. https://doi.org/10.3390/ijerph16142537(Patient with Anxiety SOAP Note-A Comprehensive Nursing Paper Sample)

https://www.ncbi.nlm.nih.gov/