Choose a case or disorder and Create a Focused SOAP Note/case presentation of a child or Adolescent. Use the attached template.
Week (enter week #): (Enter assignment title)
Student Name
College of Nursing-PMHNP, Walden University
PRAC 6665: PMHNP Care Across the Lifespan I
Faculty Name
Assignment Due Date
Subjective:
CC (chief complaint):
HPI:
Substance Current Use:
Medical History:
· Current Medications:
· Allergies:
Reproductive Hx:
ROS:
· GENERAL:
· HEENT:
· SKIN:
· CARDIOVASCULAR:
· RESPIRATORY:
· GASTROINTESTINAL:
· GENITOURINARY:
· NEUROLOGICAL:
· MUSCULOSKELETAL:
· HEMATOLOGIC:
· LYMPHATICS:
· ENDOCRINOLOGIC:
Objective:
Diagnostic results:
Assessment:
Mental Status Examination:
Diagnostic Impression:
PRIMARY DIAGNOSIS
3 DIFFERENTIAL DIAGNOSIS
Reflections:
Case Formulation and Treatment Plan: NRNP/PRAC 6665 & 6675 Comprehensive Focused SOAP Psychiatric Assessment Template
Week (enter week #): (Enter assignment title)
Student Name
College of Nursing-PMHNP, Walden University
PRAC 6665: PMHNP Care Across the Lifespan I
Faculty Name
Assignment Due Date
Subjective:
CC (chief complaint):
HPI:
Substance Current Use:
Medical History:
· Current Medications:
· Allergies:
· Reproductive Hx:
ROS:
· GENERAL:
· HEENT:
· SKIN:
· CARDIOVASCULAR:
· RESPIRATORY:
· GASTROINTESTINAL:
· GENITOURINARY:
· NEUROLOGICAL:
· MUSCULOSKELETAL:
· HEMATOLOGIC:
· LYMPHATICS:
· ENDOCRINOLOGIC:
Objective:
Diagnostic results:
Assessment:
Mental Status Examination:
Diagnostic Impression:
Reflections:
Case Formulation and Treatment Plan:
PRECEPTOR VERFICIATION:
I confirm the patient used for this assignment is a patient that was seen and managed by the student at their Meditrek approved clinical site during this quarter course of learning.
Preceptor signature: ________________________________________________________
Date: ________________________
References
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Week 6: Case Presentation of an Adolescent with Anxiety Disorder
Student Name: [Your Name]
College of Nursing-PMHNP, Walden University
PRAC 6665: PMHNP Care Across the Lifespan I
Faculty Name: [Faculty Name]
Assignment Due Date: [Assignment Due Date]
Subjective:
CC (chief complaint):
The patient, a 16-year-old male, presents with complaints of excessive worry and fearfulness, which has been interfering with his daily activities and school performance.
HPI:
The patient’s parents report that the adolescent has been increasingly anxious over the past six months. He frequently complains of stomach aches and headaches, especially before school or social events. His parents note that he avoids social gatherings and extracurricular activities that he once enjoyed. The patient denies any suicidal or self-harming thoughts.
Substance Current Use:
The patient denies any current or past substance use.
Medical History:
The patient has a past medical history of asthma, for which he uses an albuterol inhaler as needed.
Current Medications:
Albuterol inhaler PRN for asthma symptoms.
Allergies:
No known drug allergies.
Reproductive Hx:
N/A (not applicable) for this age group.
ROS:
· GENERAL: The patient’s general health is fair, with no recent weight changes.
· HEENT: No visual or auditory disturbances reported.
· SKIN: No rashes, lesions, or changes in skin appearance.
· CARDIOVASCULAR: No chest pain or palpitations reported.
· RESPIRATORY: Occasional asthma symptoms relieved with albuterol inhaler.
· GASTROINTESTINAL: Frequent complaints of stomach aches and occasional nausea.
· GENITOURINARY: No genitourinary symptoms reported.
· NEUROLOGICAL: No history of seizures or neurological deficits.
· MUSCULOSKELETAL: No recent injuries or musculoskeletal complaints.
· HEMATOLOGIC: No history of bleeding disorders or easy bruising.
· LYMPHATICS: No lymphadenopathy reported.
· ENDOCRINOLOGIC: No endocrine-related issues reported.
Objective:
Diagnostic results:
General physical examination: Within normal limits for age and developmental stage.
Mental Status Examination: The patient appears anxious, with increased psychomotor agitation during the assessment. Affect is tense and anxious, and he expresses feelings of fear and worry. Speech is rapid, with occasional difficulties in finding words. Thought process is goal-directed, but the patient demonstrates some obsessive and intrusive thoughts. No perceptual disturbances noted.
Assessment:
Mental Status Examination:
The patient presents with symptoms consistent with an anxiety disorder. He exhibits excessive worry, physical complaints, and avoidance behaviors, which are impacting his daily functioning and social life.
Diagnostic Impression:
Generalized Anxiety Disorder (GAD) is the primary diagnosis based on the patient’s persistent and excessive worry and fearfulness about various aspects of life, along with physical symptoms and avoidance behaviors.
3 Differential Diagnoses:
Social Anxiety Disorder: This was considered due to the patient’s avoidance of social gatherings and extracurricular activities he once enjoyed.
Panic Disorder: Although panic attacks were not reported, the patient’s physical symptoms and excessive worry could be associated with panic episodes.
Obsessive-Compulsive Disorder (OCD): The presence of intrusive thoughts and anxiety-related compulsions warranted consideration of OCD.
Reflections:
This case highlights the importance of recognizing anxiety disorders in adolescents. It is crucial to differentiate between various anxiety disorders as they may present with overlapping symptoms. A comprehensive assessment is essential to provide an accurate diagnosis and appropriate treatment.
Case Formulation and Treatment Plan:
Case Formulation:
The patient’s symptoms, including excessive worry, physical complaints, and avoidance behaviors, are consistent with a diagnosis of Generalized Anxiety Disorder (GAD). The patient’s history of asthma should be considered as a potential contributing factor to anxiety symptoms.
Treatment Plan:
Psychoeducation: Provide psychoeducation to the patient and his parents about GAD, its symptoms, and the role of anxiety in daily life.
Cognitive-Behavioral Therapy (CBT): Initiate CBT to help the patient identify and challenge maladaptive thought patterns and develop coping strategies for anxiety.
Relaxation Techniques: Teach relaxation exercises such as deep breathing and progressive muscle relaxation to manage physical symptoms of anxiety.
Medication: Considering the severity of symptoms and impairment in daily functioning, a low-dose selective serotonin reuptake inhibitor (SSRI) may be prescribed to alleviate anxiety symptoms.
Follow-up: Schedule regular follow-up appointments to monitor treatment progress and adjust the treatment plan as needed.
PRECEPTOR VERIFICATION:
I confirm the patient used for this assignment is a patient that was seen and managed by the student at their Meditrek approved clinical site during this quarter course of learning.
Preceptor signature: ________________________________________________________
Date: ________________________
References:
