Assignment: Focused SOAP Note for Anxiety, PTSD, and OCD
In assessing patients with anxiety, obsessive-compulsive, and trauma and stressor-related disorders, you will continue the practice of looking to understand chief symptomology in order to develop a diagnosis. With a differential diagnosis in mind, you can then move to a treatment and follow-up plan that may involve both psychopharmacologic and psychotherapeutic approaches.
In this Assignment, you use a case study to develop a focused SOAP note based on evidence-based approaches.
To Prepare
Review this week’s Learning Resources. Consider the insights they provide about assessing and diagnosing anxiety, obsessive compulsive, and trauma-related disorders.
Review the Focused SOAP Note template, which you will use to complete this Assignment. There is also a Focused SOAP Note Exemplar provided as a guide for Assignment expectations.
Review the video, Case Study: Dev Cordoba. You will use this case as the basis of this Assignment. In this video, a Walden faculty member is assessing a mock patient. The patient will be represented onscreen as an avatar.
Consider what history would be necessary to collect from this patient.
Consider what interview questions you would need to ask this patient.
The Assignment
Develop a Focused SOAP Note, including your differential diagnosis and critical-thinking process to formulate a primary diagnosis. Incorporate the following into your responses in the template:
Subjective: What details did the patient provide regarding their chief complaint and symptomology to derive your differential diagnosis? What is the duration and severity of their symptoms? How are their symptoms impacting their functioning in life?
Objective: What observations did you make during the psychiatric assessment?
Assessment: Discuss the patient’s mental status examination results. What were your differential diagnoses? Provide a minimum of three possible diagnoses with supporting evidence, listed in order from highest priority to lowest priority. Compare the DSM-5-TR diagnostic criteria for each differential diagnosis and explain what DSM-5-TRcriteria rules out the differential diagnosis to find an accurate diagnosis. Explain the critical-thinking process that led you to the primary diagnosis you selected. Include pertinent positives and pertinent negatives for the specific patient case.
Plan: What is your plan for psychotherapy? What is your plan for treatment and management, including alternative therapies? Include pharmacologic and nonpharmacologic treatments, alternative therapies, and follow-up parameters, as well as a rationale for this treatment and management plan. Also incorporate one health promotion activity and one patient education strategy.
Reflection notes: What would you do differently with this patient if you could conduct the session again? Discuss what your next intervention would be if you could follow up with this patient. Also include in your reflection a discussion related to legal/ethical considerations (demonstrate critical thinking beyond confidentiality and consent for treatment!), health promotion, and disease prevention, taking into consideration patient factors (such as age, ethnic group, etc.), PMH, and other risk factors (e.g., socioeconomic, cultural background, etc.).
Provide at least three evidence-based, peer-reviewed journal articles or evidenced-based guidelines that relate to this case to support your diagnostics and differential diagnoses. Be sure they are current (no more than 5 years old).
Expert Answer and Explanation
Subjective:
CC (chief complaint): The patient feels worried.
HPI: The patient has a history of bad dreams, and he states that he has the tendency of dreaming that he is lost, and that he is unable to find his younger sibling, and his mother. The patient states that he has had this experience almost every night. He also mentions that he don’t like being in a dark place, and that he only gets to sleep when his mom puts him in a night light while the door is open. He feels worried about the wellbeing of his mom and brother while he is at school. The sypmtoms seem to affect the student’s concentration in class (Goergen et al., 2016).
Substance Current Use:
Medical History:
Current Medications: The patient is not on any medications.
Allergies: No history of allergy.
Reproductive Hx: No information is given about the patient’s reproductive health.
ROS:
GENERAL: He does not eat and he has lost three pounds.
HEENT: No problem detected.
SKIN: No skin problem indicated.
CARDIOVASCULAR: No caridc problem.
RESPIRATORY: No history of breathing problems.
GASTROINTESTINAL: Stomach ache
GENITOURINARY: He wets the bed at night.
NEUROLOGICAL: No symptoms mentioned.
MUSCULOSKELETAL: Headaches.
HEMATOLOGIC: no history of hematologic disorder.
LYMPHATICS: No lymphatic disorder.
ENDOCRINOLOGIC: No hormonal disorder detected.
Objective:
Diagnostic results:
Assessment:
Mental Status Examination:
Diagnostic Impression:
Reflections:
Case Formulation and Treatment Plan:
Reflection Notes:
References
Briars, L., & Todd, T. (2016). A Review of Pharmacological Management of Attention-Deficit/Hyperactivity Disorder. The journal of pediatric pharmacology and therapeutics : JPPT : the official journal of PPAG, 21(3), 192–206. Doi: https://doi.org/10.5863/1551-6776-21.3.192.
Goergen, A. F., Ashida, S., Skapinsky, K., de Heer, H. D., Wilkinson, A. V., & Koehly, L. M. (2016). What You Don’t Know: Improving Family Health History Knowledge among Multigenerational Families of Mexican Origin. Public health genomics, 19(2), 93–101. Doi:https://doi.org/10.1159/000443473.
Khatiban, M., Tohidi, S., & Shahdoust, M. (2019). The effects of applying an assessment form based on the health functional patterns on nursing student’s attitude and skills in developing the nursing process. International journal of nursing sciences, 6(3), 329–333. Doi:https://doi.org/10.1016/j.ijnss.2019.06.004.
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Sample Answer Guide:
Objective:
During the psychiatric assessment, the patient appeared anxious and had trouble making eye contact. He had a hard time staying focused during the interview and reported difficulty sleeping at night. He also reported feeling irritable and having difficulty concentrating during the day. He had no evidence of hallucinations or delusions.
Assessment:
Differential diagnoses include:
Posttraumatic Stress Disorder (PTSD) – the patient’s history of bad dreams and fear of dark places are consistent with symptoms of PTSD. Additionally, his history of experiencing traumatic events (not explicitly stated in the case study) would support a diagnosis of PTSD.
Generalized Anxiety Disorder (GAD) – the patient’s persistent and excessive worry about his family’s well-being and difficulty sleeping could be indicative of GAD.
Obsessive-Compulsive Disorder (OCD) – the patient’s recurring dreams about being lost and not finding his family could be indicative of OCD. Additionally, his need for a night light and the door to be open to sleep could be a manifestation of OCD-related rituals.
Based on the patient’s symptoms and history, the primary diagnosis is PTSD. The patient’s history of traumatic events, along with his recurring bad dreams, fear of dark places, and difficulty sleeping all align with the diagnostic criteria for PTSD in the DSM-5. GAD and OCD are also possible diagnoses, but the symptoms of PTSD appear to be more prominent and significant in this case. Pertinent positives for PTSD include the patient’s history of bad dreams and fear of dark places. Pertinent negatives include the absence of any reported symptoms of hallucinations or delusions.
Plan:
The plan for psychotherapy will include cognitive-behavioral therapy (CBT) and Eye Movement Desensitization and Reprocessing (EMDR). These therapies have been shown to be effective in treating PTSD. The patient will also be prescribed an SSRI (Selective Serotonin Reuptake Inhibitor) to help with symptoms of anxiety and sleep disturbance. Nonpharmacologic treatments will include relaxation techniques such as deep breathing and progressive muscle relaxation. A follow-up appointment will be scheduled in 2 weeks to assess the patient’s progress and adjust the treatment plan as needed.
Health promotion activity: Encouraging the patient to engage in regular physical activity, such as walking or jogging, to help improve symptoms of anxiety and promote overall well-being.
Patient education strategy: Providing the patient with information about PTSD, including symptoms, causes, and treatment options, so that he can have a better understanding of his condition and be an active participant in his own treatment.
Reflection notes:
If given the opportunity to conduct the session again, I would gather more information about the patient’s history of traumatic events to better understand the origins of his symptoms. Additionally, I would explore the patient’s coping mechanisms and support systems to identify any potential barriers to treatment. My next intervention would be to provide the patient with education and resources on self-care strategies, such as stress management techniques and relaxation exercises, to help him manage his symptoms between therapy sessions.
Legal/ethical considerations: Ensuring that the patient’s informed consent is obtained before beginning any treatment and maintaining confidentiality in accordance with HIPAA regulations. Additionally, considering cultural and socioeconomic factors that may impact the patient’s access to care and treatment options.
Supporting sources:
“Cognitive-behavioral therapy for posttraumatic stress disorder: A review of the treatment literature.” Journal of Traumatic Stress, 2010
“Eye movement desensitization and reprocessing for posttraumatic stress disorder: A review.” Journal of Anxiety Disorders, 2013
