NRNP 6675 Week 3 Assignment : Focused SOAP Note for Anxiety, PTSD, and OCD Essay

 NRNP 6675 Week 3 Assignment : Focused SOAP Note for Anxiety, PTSD, and OCD Essay

 NRNP 6675 Week 3 Assignment : Focused SOAP Note for Anxiety, PTSD, and OCD Essay

Subjective:

CC (chief complaint): The patient’s mother states: “Dev is always anxious and worried about silly things like I’m going to die, or I won’t pick him up from school.”

HPI:

Dev Cordoba is a 7-year-old male patient referred for counseling by his pediatrician. Dev is accompanied by his mother to the counseling clinic. She states that Dev is always anxious and worried about silly things like the mother will die or not pick him up from school. Dev states that he is worried most of the time about everything. He also reports having bad dreams, mostly that he is lost and cannot find his mother or younger brother.  Dev also states that he loses concentration in class and gets into trouble for looking out the window.

The mother reports that Dev claims she loves his brother more than him. He throws things around the house and has gotten in trouble at school for throwing things. Dev’s mother further states that He has a difficult time going to sleep since he wants his lights on, doors open, and gets up frequently. In addition, Dev usually wants to leave school and go home almost daily, claiming he has stomach aches and headaches. He fails to eat and has lost three pounds in the past three weeks. Furthermore, Dev wets the bed at night, which has persisted despite being prescribed DDVAP.

Substance Current Use: No history of substance use.

Medical History: No history of chronic illnesses. Immunizations are up to date.

• Current Medications: No current medications
• Allergies: No known food or drug allergies.

• Reproductive Hx: Not applicable

ROS:

• GENERAL: Positive for weight loss (3 pounds in 3 weeks). Negative for fever, chills
• HEENT: Denies visual loss, ear pain/discharge, nasal discharge/blockage, or sore throat.
• SKIN: Denies rashes, itching, or bruising.
• CARDIOVASCULAR: Negative for edema, chest pain, dyspnea, or palpitations.
• RESPIRATORY: Negative for cough, sputum production, chest pain, or SOB.
• GASTROINTESTINAL: Reports loss of appetite and stomach aches.
• GENITOURINARY: Denies urinary symptoms or penile discharge.
• NEUROLOGICAL: Positive for headaches.
• MUSCULOSKELETAL: Denies muscle pain or joint stiffness/pain.
• HEMATOLOGIC: Denies easy bruising or hx of anemia.
• LYMPHATICS: Denies lymph node swelling.
• ENDOCRINOLOGIC: Denies acute thirst, excessive hunger, or cold-heat intolerance.

Objective:

Diagnostic results: No diagnostic tests were ordered.

Assessment:

Mental Status Examination:

The client is neat and appropriately dressed. He is alert and oriented to person, place, and time. His speech is clear, and he demonstrates a coherent and logical thought process. The client exhibits worries about his mother and younger brother being in danger. The client has a fear of darkness. No delusions or hallucinations were noted.

Diagnostic Impression:

Pediatric Generalized Anxiety Disorder (GAD)

Pediatric GAD manifests with excessive and uncontrollable worry or anxiety about various things and events. The worry occurs alongside symptoms such as muscle tension, headaches, gastrointestinal distress, concentration difficulties, restlessness, sleep disturbances, and heart palpitations. The symptoms cause marked distress and interfere with a child’s educational, social, and emotional functioning (Panganiban et al., 2019). Pediatric GAD is the most likely diagnosis based on the patient’s history of having excessive but unwarranted worry about his mother and younger brother being in danger or the mother failing to pick him up from school. In addition, the patient present with GAD symptoms such as constant GI distress (stomach aches), headaches, poor concentration in class, and sleeping difficulties. The symptoms have interfered with Dev’s school performance.

Separation Anxiety Disorder

Separation anxiety disorder is characterized by persistent and excessive anxiety that surpasses the expected anxiety for a child’s developmental level. The anxiety is related to separation or imminent separation from an attachment figure, such as the primary caretaker or a close family member (Patel & Bryant, 2021). Children with Separation anxiety disorder exhibit persistent excessive distress when expecting or being separated from home or attachment figures. They also have recurrent and excessive worry about losing their major attachment figures or about potential harm happening to them. In addition, they have recurrent and excessive worry about experiencing an unpleasant event that results in separation from an attachment figure (Patel & Bryant, 2021). As a result, they are reluctant to be away from home, to school, or elsewhere due to the fear of separation. Furthermore, they have constant nightmares about separation and physical symptoms, such as headaches, nausea, vomiting, and stomachaches, when separation from an attachment figure occurs or is expected.

Separation anxiety disorder is a differential diagnosis based on Dev’s excessive worry about being separated from his mother and brother. He experiences anxiety about losing his mother through death or the mother failing to show up in school. Dev also experiences nightmares about being separated from his mother and brother and has physical symptoms such as headaches and stomachache. The anxiety about being separated from his mother and brother makes Dev constantly want to go back home.

Pediatric Obsessive-Compulsive Disorder (OCD)

Pediatric OCD presents with recurring obsessions, that is, persistent unwanted thoughts urges, or images, and compulsions, which are recurrent unwarranted actions that interfere with an individual’s life (Nazeer et al., 2020). OCD is a differential diagnosis based on Dev’s recurring obsessions about losing his mother and brother. The obsessions lead to compulsions such as sleeping with the lights on and doors open and wanting to go back home to be with the mother.

Reflections:

If I were to conduct the session again, I would assess for factors that may have caused the excess anxiety in the client, such as stressful life events, parental emotional problems, disrupted attachment, and history of traumatic experiences. Besides, I would inquire more to identify if the patient is being bullied, which places the child at risk of having excessive anxiety. If I were to follow up with the patient, I would use the GAD-7 to assess the severity of the client’s anxiety symptoms, which will measure the improvement in symptoms (Mossman et al., 2018). Ethical principles should be observed in this patient by seeking consent, maintaining confidentiality, and using treatment interventions associated with the best outcomes and no harm to the patient (Bipeta, 2019).

Case Formulation and Treatment Plan:

Dev is a 7-year-old male client who presented with excessive anxiety and worry, which pointed to a diagnosis of pediatric GAD. The treatment plan will include psychotherapy approaches. Psychotherapy will include weekly cognitive-behavioral therapy (CBT) for a total of 12 sessions. The CBT will include individual sessions with family involvement to foster the therapy process. The family component in the psychotherapy sessions will focus on communication, contingency management, and problem-solving, which are associated with favorable long-term therapy benefits (Panganiban et al., 2019).

References

Bipeta, R. (2019). Legal and Ethical Aspects of Mental Health Care. Indian journal of psychological medicine, 41(2), 108–112. https://doi.org/10.4103/IJPSYM.IJPSYM_59_19

Mossman, S. A., Luft, M. J., Schroeder, H. K., Varney, S. T., Fleck, D. E., Barzman, D. H., Gilman, R., DelBello, M. P., & Strawn, J. R. (2018). The Generalized Anxiety Disorder 7-item scale in adolescents with generalized anxiety disorder: Signal detection and validation. Annals of clinical psychiatry: official journal of the American Academy of Clinical Psychiatrists, 29(4), 227–234A.

Nazeer, A., Latif, F., Mondal, A., Azeem, M. W., & Greydanus, D. E. (2020). Obsessive-compulsive disorder in children and adolescents: epidemiology, diagnosis, and management. Translational pediatrics, 9(Suppl 1), S76–S93. https://doi.org/10.21037/tp.2019.10.02

Panganiban, M., Yeow, M., Zugibe, K., & Geisler, S. L. (2019). Recognizing, diagnosing, and treating pediatric generalized anxiety disorder. JAAPA: official journal of the American Academy of Physician Assistants, 32(2), 17–21. https://doi.org/10.1097/01.JAA.0000552719.98489.75

Patel, A. K., & Bryant, B. (2021). Separation Anxiety Disorder. JAMA, 326(18), 1880-1880. doi:10.1001/jama.2021.17269

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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.

Photo Credit: Photographee.eu / Adobe Stock

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 diagnostic criteria for each differential diagnosis and explain what DSM-5 criteria 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).

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Rubric Detail

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Name: NRNP_6675_Week3_Assignment_Rubric

• Grid View
• List View

		Excellent 90%–100%	Good 80%–89%	Fair 70%–79%	Poor 0%–69%
Create documentation in the Focused SOAP Note Template about your assigned patient. In the Subjective section, provide: • Chief complaint • History of present illness (HPI) • Past psychiatric history • Medication trials and current medications • Psychotherapy or previous psychiatric diagnosis • Pertinent substance use, family psychiatric/substance use, social, and medical history • Allergies • ROS		14 (14%) – 15 (15%) The response throughly and accurately describes the patient’s subjective complaint, history of present illness, past psychiatric history, medication trials and current medications, psychotherapy or previous psychiatric diagnosis, pertinent histories, allergies, and review of all systems that would inform a differential diagnosis.	12 (12%) – 13 (13%) The response accurately describes the patient’s subjective complaint, history of present illness, past psychiatric history, medication trials and current medications, psychotherapy or previous psychiatric diagnosis, pertinent histories, allergies, and review of all systems that would inform a differential diagnosis.	11 (11%) – 11 (11%) The response describes the patient’s subjective complaint, history of present illness, past psychiatric history, medication trials and current medications, psychotherapy or previous psychiatric diagnosis, pertinent histories, allergies, and review of all systems that would inform a differential diagnosis but is somewhat vague or contains minor innacuracies.	0 (0%) – 10 (10%) The response provides an incomplete or inaccurate description of the patient’s subjective complaint, history of present illness, past psychiatric history, medication trials and current medications, psychotherapy or previous psychiatric diagnosis, pertinent histories, allergies, and review of all systems that would inform a differential diagnosis. Or the subjective documentation is missing.
In the Objective section, provide: • Physical exam documentation of systems pertinent to the chief complaint, HPI, and history • Diagnostic results, including any labs, imaging, or other assessments needed to develop the differential diagnoses		14 (14%) – 15 (15%) The response thoroughly and accurately documents the patient’s physical exam for pertinent systems. Diagnostic tests and their results are thoroughly and accurately documented.	12 (12%) – 13 (13%) The response accurately documents the patient’s physical exam for pertinent systems. Diagnostic tests and their results are accurately documented.	11 (11%) – 11 (11%) Documentation of the patient’s physical exam is somewhat vague or contains minor innacuracies. Diagnostic tests and their results are documented but contain minor innacuracies.	0 (0%) – 10 (10%) The response provides incomplete or inaccurate documentation of the patient’s physical exam. Systems may have been unnecessarily reviewed. Or the objective documentation is missing.
In the Assessment section, provide: • Results of the mental status examination, presented in paragraph form • At least three differentials with supporting evidence. List them from top priority to least priority. Compare the DSM-5 diagnostic criteria for each differential diagnosis and explain what DSM-5 criteria 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.		18 (18%) – 20 (20%) The response thoroughly and accurately documents the results of the mental status exam. Response lists at least three distinctly different and detailed possible disorders in order of priority for a differential diagnosis of the patient in the assigned case study, and it provides a thorough, accurate, and detailed justification for each of the disorders selected.	16 (16%) – 17 (17%) The response accurately documents the results of the mental status exam. Response lists at least three distinctly different and detailed possible disorders in order of priority for a differential diagnosis of the patient in the assigned case study, and it provides an accurate justification for each of the disorders selected.	14 (14%) – 15 (15%) The response documents the results of the mental status exam with some vagueness or innacuracy. Response lists at least three different possible disorders for a differential diagnosis of the patient and provides a justification for each, but may contain some vagueness or innacuracy.	0 (0%) – 13 (13%) The response provides an incomplete or inaccurate description of the results of the mental status exam and explanation of the differential diagnoses. Or the assessment documentation is missing.
In the Plan section, provide: • Your plan for psychotherapy • 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. • Incorporate one health promotion activity and one patient education strategy.		23 (23%) – 25 (25%) The response provides an evidence-based, detailed, and appropriate plan for psychotherapy for the patient. The response provides an evidence-based, detailed, and appropriate plan for treatment and management, including pharmacologic and nonpharmacologic treatments, alternative therapies, and follow-up parameters. A strong rationale for the plan is provided that demonstrates critical thinking and content understanding. The response includes at least one evidence-based health promotion activity and one evidence-based patient education strategy.	20 (20%) – 22 (22%) The response provides an evidence-based and appropriate plan for psychotherapy for the patient. The response provides an evidence-based and appropriate plan for treatment and management, including pharmacologic and nonpharmacologic treatments, alternative therapies, and follow-up parameters. An adequate rationale for the plan is provided. The response includes at least one health promotion activity and one patient education strategy.	18 (18%) – 19 (19%) The response provides a somewhat vague or inaccurate plan for psychotherapy for the patient. The response provides a somewhat vague or inaccurate plan for treatment and management, including pharmacologic and nonpharmacologic treatments, alternative therapies, and follow-up parameters. The rationale for the plan is weak or general. The response includes one health promotion activity and one patient education strategy, but it may contain some vagueness or innacuracy.	0 (0%) – 17 (17%) The response provides an incomplete or inaccurate plan for psychotherapy for the patient. The response provides an incomplete or inaccurate plan for treatment and management, including pharmacologic and nonpharmacologic treatments, alternative therapies, and follow-up parameters. The rationale for the plan is inaccurate or missing. The health promotion and patient education strategies are incomplete or missing.
• Reflect on this case. Discuss what you learned and what you might do differently. 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 that takes into consideration patient factors (such as age, ethnic group, etc.), PMH, and other risk factors (e.g., socioeconomic, cultural background, etc.).		5 (5%) – 5 (5%) Reflections are thorough, thoughtful, and demonstrate critical thinking.	4 (4%) – 4 (4%) Reflections demonstrate critical thinking.	3.5 (3.5%) – 3.5 (3.5%) Reflections are somewhat general or do not demonstrate critical thinking.	0 (0%) – 3 (3%) Reflections are incomplete, inaccurate, or missing.
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).		9 (9%) – 10 (10%) The response provides at least three current, evidence-based resources from the literature to support the assessment and diagnosis of the patient in the assigned case study. The resources reflect the latest clinical guidelines and provide strong justification for decision making.	8 (8%) – 8 (8%) The response provides at least three current, evidence-based resources from the literature that appropriately support the assessment and diagnosis of the patient in the assigned case study.	7 (7%) – 7 (7%) Three evidence-based resources are provided to support the assessment and diagnosis of the patient in the assigned case study, but they may only provide vague or weak justification.	0 (0%) – 6 (6%) Two or fewer resources are provided to support the assessment and diagnosis decisions. The resources may not be current or evidence based.
Written Expression and Formatting – The paper follows correct APA format for parenthetical/in-text citations and reference list.		5 (5%) – 5 (5%) Uses correct APA format with no errors	4 (4%) – 4 (4%) Contains 1-2 grammar, spelling, and punctuation errors	3.5 (3.5%) – 3.5 (3.5%) Contains 3-4 grammar, spelling, and punctuation errors	0 (0%) – 3 (3%) Contains five or more grammar, spelling, and punctuation errors that interfere with the reader’s understanding
Written Expression and Formatting – English Writing Standards: Correct grammar, mechanics, and punctuation		5 (5%) – 5 (5%) Uses correct grammar, spelling, and punctuation with no errors	4 (4%) – 4 (4%) Contains 1-2 APA format errors	3.5 (3.5%) – 3.5 (3.5%) Contains 3-4 APA format errors	0 (0%) – 3 (3%) Contains five or more APA format errors
Total Points: 100

Name: NRNP_6675_Week3_Assignment_Rubric