Focused SOAP Note for Anxiety, PTSD, and OCD
CC (chief complaint): Anxious and worried all the time”
HPI: A 7-year-old child and his mother came in for a mental examination at the inpatient psychiatric facility. The patient’s mother says her son has suffered from anxiety and constant worry his mother would die or will inevitably forget to get him from school since he was a little child. There is no identifiable precipitating factor for the patient’s increased concern. His mother states her son often has the impression that she prefers his younger sibling over him. He is often defiant and often causes harm to himself or others by tossing things about the home or even at school. Because of his recurring dreams, he has trouble falling asleep. He often fakes stomachaches and headaches at school to get a pass home. His mother says he hasn’t eaten in days and has dropped roughly three pounds as a result. Even though his physician has prescribed DDVAP, the patient continues to wet the bed on occasion.
Substance Use History:There is no history of mental illness or drug abuse in the family.
Current Medications: For bedwetting, he uses 100 micrograms of DDVAP.
Allergies: No known dietary, environmental, or medication allergies
Surgeries: Denies having ever had surgery.
Chronic Diseases: No established chronic disease
Major traumas: No prior tragic experiences
Hospitalization: No previous hospitalizations
PMH: The pediatrician diagnosed the patient with nocturnal enuresis, and he was given the medication DDVAP 100mg.
Family History: The patient has a close relationship with his mother and younger sibling. His dad was killed in the war. The patient was just five years old when his father was sent overseas with the military.
Social History:The patient enjoys playing with pets. When he is at home, he plays a policeman in his room with his dog. He also likes using his LEGOs to construct things.
· GENERAL:There are no night sweats, chills, weariness, or fever. Verifies recent weight decrease of roughly 3 pounds.
HEENT: Head: Headache complaints. There were no head injuries, hair changes, vertigo, or unconsciousness. Eyes: no double vision, blurriness, or alterations in vision. denies wearing glasses or having any unusual vision. Sclera is clean and free of any abnormalities. No indications of discomfort, discharge, dizziness, or ringing in the ears. denies nasal hemorrhage, sinus pressure, post-nasal drip, or congestion are present. Denies having gum disease, a hoarse voice, a sore throat, a toothache, trouble swallowing, bleeding gums, or ulcers.
SKIN: Intact, showing no hives, rashes, itching, or indications of skin problems.
CARDIOVASCULAR: Denies orthopnea, irregular heartbeat, palpitations, rapid or slow heartbeats, edema, or chest discomfort.
RESPIRATORY: Denies persistent coughing, sputum, discomfort, or loud breathing.
GASTROINTESTINAL: Denies experiencing diarrhea, diarrhea, or constipation. confirms lack of appetite and stomach discomfort.
GENITOURINARY: denies painful urination, unusual urine color, hesitation, or urgency.
NEUROLOGICAL: denies fainting, weakness, temporary paralysis, unconsciousness, or the absence of spells. Significant alterations in bowel or bladder control. Reports headache.
MUSCULOSKELETAL: denies discomfort in the joints, muscles, or back. Full ranges of motion are present in both extremities without any stiffness.
HEMATOLOGIC: denies having ever had bleeding issues or injuries.
LYMPHATICS: denies having had an enlarged node or a splenectomy.
ENDOCRINOLOGIC: Denies having polyuria, polydipsia, or a heat or cold sensitivity.
Lab Tests: Thyroid issues may cause mood changes, thus a thyroid test should be conducted. Routine Hb and WBC tests. LFTs for liver function and basic metabolic panels are essential to assess hepatic and renal status for dosage titration, particularly with psychotropic drugs (Ayano et al., 2020). Drug and cortisol testing is also done. CT scans and head X-rays for anatomical abnormalities. The optimal psychotropic agent requires echocardiography and ECG.
Pediatric Assessment tools: Record his body temperature, BMI, BP, and RR. Assess the patient’s age-appropriate dental development. Assess the patient’s diet to ensure it contains vitamins, carbs, fibers, and proteins. Examine the patient’s growth and the child’s vaccinations.
Mental Status Examination:The 7-year-old patient entered the examination room dressed appropriately for his age. His orientation in person, place, and time remains intact. He is cooperative and capable of answering all inquiries while easily keeping eye contact. He speaks with fluency and a distinct tone. His mood is melancholy. He is preoccupied, always checking to see whether his mother is around. His cognitive process is logically structured. Both short- and long-term memory are unimpaired. He believes he is about to die. Denies hallucinations, suicidal thoughts, or delirium.
Separation Anxiety Disorder (SAD): Children who have lost a parent or sibling often develop this psychological condition. The case study patient was split from his father at 5 years old. According to DSM-5, SAD patients must show significant concern relative to their developmental stage or age (Krause et al., 2021). In addition, the patient must have at least three of the following symptoms: regular night terrors, a persistent aversion to sleeping alone in the dark, frequent extreme anguish away from family, and bodily symptoms like headache or stomach pain while separated. The patient qualifies for SAD diagnosis.
Generalized Anxiety Disorder (GAD):GAD patients usually worry excessively, unrealistically, and persistently about nothing in particular (Plaisted et al., 2021). DSM-5 diagnostic criteria require patients to have severe, uncontrollable concern and anxiety for at least six months (Ayano et al., 2020). Sleep troubles, muscular tension, concentration issues, irritability, restlessness, and excessive exhaustion must persist for at least six months. The case study patient had most of these symptoms. His fear of being apart from his mother disqualifies this diagnosis.
Oppositional Defiant Disorder (ODD):ODD in children is characterized by repeated anger, irritation, vindictiveness, and defiance for more than six months. Similar to the case study, this condition is frequent among kids who have lost a loved one or have been split apart from them (Impey, Gordon, & Baldwin, 2020). Argumentativeness, irritability, decreased energy, lack of interest in routine chores, withdrawal, and depressed mood are among the DSM-5’s diagnostic criteria for OOD (Plaisted et al., 2021). The majority of the above-mentioned symptoms were present in the case study patient, but SAD was already present, making this diagnosis incorrect.
Reflections:The patient’s mental examination is age-appropriate and extremely outstanding since it has all the data needed to reach a diagnosis. The mother of the patient was very helpful in discussing the symptoms the patient had at home. It may also be helpful to speak with the patient’s instructors and peers to get a feel for how they behave in the classroom. The patient is a minor, thus the mother has a legal and ethical obligation to be involved in decisions about his care (Impey et al., 2020). Therefore, the PMHNP is required to tell the mother about the diagnosis and the potential treatments to be taken into account while caring for the patient.
Case Formulation and Treatment Plan:
Primary Diagnosis: Separation Anxiety Disorder (SAD).
Psychotherapy: Psychotherapy is advised as the first-line treatment for SAD in young people (Elmore & Crouch, 2020). Cognitive behavioral therapy is the psychotherapeutic approach that works best for kids (CBT).
Pharmacotherapy: Selected serotonin reuptake inhibitors, including Zoloft, might be taken into consideration for further therapy of the patient’s symptoms. However, this medication is linked to a rise in children’s suicide thoughts (Elmore & Crouch, 2020). As a result, it’s important to adjust the dosage carefully and keep an eye on the patient’s progress.
Health Promotion:The patient’s mother devises a regular eating and sleeping schedule to encourage his sleep cycle (Impey et al., 2020).
Patient Education: The patient’s mother has to be made aware of the importance of her role in supporting her son to take the recommended actions, such as engaging in psychotherapy.
Follow-up: The patient should follow up with the clinic after four weeks to evaluate the efficacy of the therapy and make any necessary adjustments.
Ayano, G., Betts, K., Maravilla, J. C., & Alati, R. (2020). The risk of anxiety disorders in children of parents with severe psychiatric disorders: a systematic review and meta-analysis. Journal of Affective Disorders.
Elmore, A. L., & Crouch, E. (2020). The Association of Adverse Childhood Experiences with Anxiety and Depression for Children and Youth, 8 to 17 Years of Age. Academic Pediatrics, 20(5). https://doi.org/10.1016/j.acap.2020.02.012
Impey, B., Gordon, R. P., & Baldwin, D. S. (2020). Anxiety disorders, post-traumatic stress disorder, and obsessive-compulsive disorder. Medicine.
Krause, K. R., Chung, S., Adewuya, A. O., Albano, A. M., Babins-Wagner, R., Birkinshaw, L., … & Wolpert, M. (2021). International consensus on a standard set of outcome measures for child and youth anxiety, depression, obsessive-compulsive disorder, and post-traumatic stress disorder. The Lancet Psychiatry, 8(1), 76-86.
Plaisted, H., Waite, P., Gordon, K., & Creswell, C. (2021). Optimizing exposure for children and adolescents with anxiety, OCD and PTSD: a systematic review. Clinical Child and Family Psychology Review, 1-22.