Focused SOAP Note on Patients with Anxiety Assignment

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Focused SOAP Note on Patients with Anxiety Assignment

Subjective:

CC (chief complaint): When the child is brought forward, he laments, “I am not sleeping well and I’m afraid to be by myself in the dark with my door shut.” “My little brother is cherished more than me, and I am constantly anxious and worried,” he further grumbles. The young person gets furious and frustrated and throws things around the house and at school. As a result of his inadequate nutrition, he is now losing weight. He also claims to have stomach problems and migraines on a regular basis. But after examining him, the PCP was unable to identify any clear physical or medical issues that would have been consistent with these physical symptoms. Focused SOAP Note on Patients with Anxiety Assignment

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HPI: The client is a 7-year-old Caucasian male presenting as above. The boy’s mother disputes any prior history of mental health problems. The symptoms began around a year ago, but they have become increasingly apparent over the past few months. Since the physician has ruled out a physical disease that could be the origin of the worries, it is evident that they are mental in nature. They keep going without ever stopping, day or night. They are also notorious for being persistent and difficult to get rid of. Whenever he is far from home and not with his mother, as he is when at school, these problems get exacerbated. When he wakes up at home with his mother, there is a small sense of relief. The symptoms begin over the course of the day and are severe at nighttime when he is alone himself in his bedroom, away from his mother. His mother gives his grievances a six out of ten for severity.

Substance Current Use: Substance abuse is not a family history. Being a minor, he does not consume alcohol or any other drugs. Focused SOAP Note on Patients with Anxiety Assignment

Medical History: He has no history of physical disease.

  • Current Medications: OTC Melatonex 1.5 mg PO at night (for sleeplessness).
  • Allergies: NKDA.
  • Reproductive Hx: Client is a boy yet to reach puberty.

ROS:

  • GENERAL: Denies having chills, fatigue, or fever; but admits to weight loss.
  • HEENT: Denies light sensitivity, double vision, ear discharge, rhinorrhea, or dysphagia.
  • SKIN: Negative for rashes, itching, or eczema.
  • CARDIOVASCULAR: Negative for chest tightness or pain and palpitations.
  • RESPIRATORY: Denies SOB, wheezing, or coughing.
  • GASTROINTESTINAL: Denies N/D/V.
  • GENITOURINARY: Denies nocturnal enuresis.
  • NEUROLOGICAL: Denies dizziness, fainting, or loss of bladder/ bowel control.
  • MUSCULOSKELETAL: Denies muscle, joint, or back pains.
  • HEMATOLOGIC: Denies blood or clotting problems.
  • LYMPHATICS: Denies lymphadenopathy or splenectomy.
  • ENDOCRINOLOGIC: Denies excessive sweating, thirst, eating, urination. Also denies heat/ cold intolerance as well as hormone treatment (Ball et al., 2019). Focused SOAP Note on Patients with Anxiety Assignment

Objective:

Diagnostic results:

  • The laboratory results: CRP = 0.2 mg/L; WBC 6.9 x 109/L; Hb 13.6 g/dL.
  • Investigations: MRI indicates no brain changes.

Assessment:

Mental Status Examination: The patient is a 7-year-old Caucasian male child conforming to his chronological age in appearance. Speech is clear and goal-directed, and his grooming is suitable. He is oriented all round, with no clear mannerisms, tics, or idiosyncrasies. His self-reported mood is “anxious,” and his affect is dysphoric hence congruent. He denies illusions, hearing voices, or having weird beliefs. He denies HI but admits to SI. His insight and judgment are affected. Focused SOAP Note on Patients with Anxiety Assignment

Diagnosis: Separation Anxiety Disorder (SAD): 309.21 (F93.0)

Severe anguish over being separated from a loved one, concern that is out of proportion to age, fear spending the night alone in a space, an exaggerated fear of losing anyone important, recurrent grievances about somatic symptoms like headaches and abdominal pain that signal imminent detachment, and persistent bad dreams are all signs of separation anxiety disorder (APA, 2022; Boland et al., 2021). The boy meets all these DSM-5-TR diagnostic criteria for SAD.

Differential Diagnoses

  1.  Post-traumatic Stress Disorder (PTSD): 309.81 (F43.10)

The most important diagnostic standard for PTSD is that the disorder must have been brought on by a traumatic event that happened in the past (APA, 2022; Boland et al., 2021). It is hard to verify the allegations of trauma this youngster has undergone because his mother kept him in the dark about the death of his father. Focused SOAP Note on Patients with Anxiety Assignment

  1. Generalized Anxiety Disorder (GAD): 300.02 (F41.1)

According to the DSM-5-TR, the main difference in symptoms is that SAD patients’ anxiety is primarily caused by their upcoming severance from a loved one (APA, 2022; Boland et al., 2021). The diagnostic criteria for GAD include the inability to control worry and anxiety, the presence of indicators associated with a clinically significant impairment in functioning, and the persistence of worry and anxiety for at least a six-month period in the person.

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Case Formulation and Treatment Plan:

The boy will require off-label SSRI as well as cognitive restructuring (therapy).

  • Sertraline (Zoloft) 25 mg PO daily (Stahl, 2020).
  • One-on-one cognitive behavioral therapy or CBT (Corey, 2023).  Focused SOAP Note on Patients with Anxiety Assignment

Reflection

            I would change nothing if I were to repeat this assessment (Carlat, 2023; Zakhari, 2021). Ethical and legal parameters were met, including confidentiality, privacy, and autonomy in the form of informed consent (Haswell, 2019). Age and socioeconomic determinants of health, or SDOH, were among the patient characteristics that shaped this client’s health education (Artiga & Hinton, 2018). Being a minor, the mother was the primary recipient of instruction. In health education and promotion, the three key themes were understanding, coping, and support. Socioeconomic status, academic performance, living circumstances, and healthcare access were among the SDOH. Focused SOAP Note on Patients with Anxiety Assignment

 

References

American Psychiatric Association [APA] (2022). Diagnostic and Statistical Manual of Mental Disorders-Text Revision (DSM-5-TR), 5th ed. Author.

Ball, J., Dains, J.E., Flynn, J.A., Solomon, B.S., & Stewart, R.W. (2019). Seidel’s guide to physical examination: An interprofessional approach, 9th ed. Elsevier.

Boland, R., Verdiun, M., & Ruiz, P. (Eds) (2021). Kaplan and Sadock’s synopsis of psychiatry, 12th ed. Wolters Kluwer.

Carlat, D.J. (2023). The psychiatric interview, 5th ed. Wolters Kluwer.

Corey, G. (2023). Theory and practice of counselling and psychotherapy, 11th ed. Cengage Learning.

Haswell, N. (2019). The four ethical principles and their application in aesthetic practice. Journal of Aesthetic Nursing, 8(4), 177-179. https://doi.org/10.12968/joan.2019.8.4.177 

Stahl, S.M. (2020). Stahl’s essential psychopharmacology: Prescriber’s guide, 7th ed. Cambridge University Press.

Zakhari, R. (2021). The psychiatric-mental health nurse practitioner certification review manual. Springer Publishing Company. Focused SOAP Note on Patients with Anxiety Assignment