Focus soap note

Focused Soap Note for Anxiety, PTSD, AND OCD

Comprehensive SOAP Note for Anxiety PTSD and OCD Essay

Subjective:

CC: “She thought you would help me get better.”

HPI: DC is a 7-year-old male present for mental health assessment in the mother’s company. DC denies previous psychiatric evaluation and resorts to persistent worry about everything. The client reports dreaming that he is lost every night. During such dreams, he cannot find his mother and little brother. He despises darkness and sleeps with the door open and the night light on. He does not like school, and fellow pupils call him Mr Smelly as he does not like taking a bath. He reported feeling sad and bad, partly because of his father’s absence, and worried his mother would never return. While at school, he keeps looking out the window and has difficulty sitting and focusing. The mother reports that DC worries about her death and not coming to pick him up from school. The mother further says that DC complains about the more love the brother gets from her. He throws things while at the house and in school. He has difficulty going to sleep and wakes up frequently. He always wants to go home, complaining of headache and stomach ache almost daily. He does not eat and lost 3 lbs over the last three weeks.(Comprehensive SOAP Note for Anxiety PTSD and OCD Essay)

Comprehensive SOAP Note for Anxiety PTSD and OCD Essay

Past Psychiatric History:

General Statement: This is the first time the client has entered treatment for mood problems.

Caregivers: Mother.

Hospitalizations: No history of hospitalization, detox, or self-harm.

Medication trials: DDVAP to help with bed wetting.(Comprehensive SOAP Note for Anxiety PTSD and OCD Essay)

Psychotherapy or Previous Psychiatric Diagnosis: No previous mental health diagnosis.

Substance Use History: No history of substance abuse was reported.(Comprehensive SOAP Note for Anxiety PTSD and OCD Essay)

Family Psychiatric/Substance Use History:  No blood relative with a mental health history. No substance use history was reported. 

Social History: He lives with her mother and younger brother. Father was killed in service when he was five. He likes playing with her dog and LEGOs. No safety issues on record.(Comprehensive SOAP Note for Anxiety PTSD and OCD Essay)

Medical History:

Current Medications: No current medications.

Allergies:NKFDA

Reproductive Hx:NA.

ROS:

GENERAL: 3-pound weight loss. No fatigue, fever, or chill.(Comprehensive SOAP Note for Anxiety PTSD and OCD Essay)

HEENT: Eyes: No visual problems. Ears, Nose, Throat: No hearing or nasal concerns. No difficulty swallowing.

SKIN: No skin rashes.

CARDIOVASCULAR: No chest pain or discomfort.

RESPIRATORY: No breathing complications.

GASTROINTESTINAL: No nausea, vomiting, or diarrhea.

GENITOURINARY: No Urinary hesitancy, dysuria, or hematuria.(Comprehensive SOAP Note for Anxiety PTSD and OCD Essay)

NEUROLOGICAL: No tingling in the extremities. No headache or numbness.

MUSCULOSKELETAL: No back pain, muscle stiffness, or joint pain.

HEMATOLOGIC: No anemia, bleeding, or bruising.

LYMPHATICS: No enlarged nodes. No history of splenectomy.

ENDOCRINOLOGIC: No heat or sweat hypersensitivity or Hyperhidrosis. No polyuria or polydipsia.(Comprehensive SOAP Note for Anxiety PTSD and OCD Essay)

Physical Exam: NA

Diagnostic results: Providing a Child Behavior Checklist (CBC) and requesting Teacher Report Form (TRF) would provide supplementary information for a definitive diagnosis. Both tools rate a child’s behavioral and emotional problems at home and school and are effective for children between 6 and 18 years (Thapar et al., 2015).(Comprehensive SOAP Note for Anxiety PTSD and OCD Essay)

Assessment

Mental Health Examination: The client is appropriately dressed and oriented to person, time, space, and event. He is conversant and interactive. He reports feeling worried, and the effect s congruent with the mood. He is attentive, but eye contact is avoidant. No visual or auditory hallucinations were noted during the exam. Memory and cognition are intact. Judgment and insights are normal. He denies self-harming behaviors toward himself or others. No suicide ideation was noted to the am, and the client is not at risk of self-harm or harming others.(Comprehensive SOAP Note for Anxiety PTSD and OCD Essay)

Differential Diagnosis

  1. 300.02 (F41.1), Generalized Anxiety Disorder: The diagnostic criteria include persistent worry/anxiety about many things lasting at least six months and challenging to control (American Psychiatric Association [APA], 2019). Affected people experience at least three or more symptoms, such as restlessness, muscle rigidity, difficulty concentrating, fatigue, or sleeplessness. These symptoms are clinically significant, affect important areas of functioning, and are not attributed to other medical conditions or effects of substance abuse.(Comprehensive SOAP Note for Anxiety PTSD and OCD Essay)
  2. 309.28 (F43.23), Adjustment Disorders, with mixed anxiety and depressed mood: Adjustment disorder is marked by behavioral or emotional symptoms against a stressor presenting within three months (APA, 2019). Affected individuals experience marked distress and impaired important areas of functioning. Moreover, the symptoms are not attributed to normal bereavement, other mental health disorders, or medical conditions.(Comprehensive SOAP Note for Anxiety PTSD and OCD Essay)
  3. 309.81 (F43.10), Posttraumatic Stress Disorder: Posttraumatic stress disorder (PTSD) is characterized by threatened or real experience with injury, death, or sexual violence either directly, witnessing, learning about the event, or repeated exposure (APA, 2019). Individuals experience one or more symptoms, such as intrusive and recurrent distressing dreams/memories, flashbacks, prolonged or intense psychological distress, and marked physiological reactions to similar stimuli. Individuals also experience altered cognition and mood and develop altered reactivity and arousal associated with traumatic events. These symptoms are experiences following the traumatic experience, and individuals develop persistent avoidance of stimuli related to such events.(Comprehensive SOAP Note for Anxiety PTSD and OCD Essay)

Reflection

In a similar case, I would interview the child alone and in a safe room to promote a sense of confidentiality and acquire more information the client would not have provided in the mother’s presence. In this case, GAD is the primary diagnosis since the client presents symptoms that meet its diagnostic criteria, such as persistent sadness and worry, irritability, difficulty concentrating, nightmares, and weight loss. DC increasingly worries about everything, including his mother and brothers (Walden University, 2021). Particularly, he worries that his mother will one day leave and never return like his father. GAD is characteristically associated with worry about many things and is difficult to control (Sadock et al., 2015). The worry affects his concentration in school and causes irritability, as the mother reports him throwing things around the house.(Comprehensive SOAP Note for Anxiety PTSD and OCD Essay)

However, the client has a combined presentation of depression and anxiety. People with AD respond emotionally to stressful events (Sadock et al., 2015). In this case, the client’s mood issues are related to two perceived stressful events. One, the client is concerned that the brother is receiving more attention from the brother than he is. Two, the client is affected by the fact that the father left and never returned. As a result, he experiences emotional outbursts and relationship problems with his brother and other pupils at school. However, this diagnosis is refuted as GAD better explains the symptoms.(Comprehensive SOAP Note for Anxiety PTSD and OCD Essay)

Moreover, the client’s symptoms suggest PSTD. While most traumatic events are associated with traumatic experiences, individuals, particularly children, can act uncharacteristically against the loss of a parent and consequently as part of grief and consequently develop emotional and behavioral responses to such absence such as irritability, engaging in risky behavior, lose interest in things, and worry about the surviving parent. Although children are vulnerable to psychosocial adversity (Centers for Disease Control and Prevention, 2020; Thapar et al., 2015), the client’s symptoms do not meet the diagnostic criterion for PTSD.(Comprehensive SOAP Note for Anxiety PTSD and OCD Essay)

The ethical aspects in this case scenario are informed consent and confidentiality. The client’s capacity for an informed decision is limited, and the practitioner must provide the parent with consent and use language that the parent and the client can understand to promote informed decisions. Moreover, the practitioner should ensure the client’s clinical information is not disclosed to any third party except the parents and other personnel as guided by legislation and circumstances.(Comprehensive SOAP Note for Anxiety PTSD and OCD Essay)

Treatment Plan

  1. Pharmacotherapy – Initiate Buspirone 7.5 mg PO QID for GAD. Buspirone is effective for GAD and well tolerated in pediatric patients (Strawn et al., 2018). The dosage can be increased depending on the client’s response.
  2. Psychotherapy – Initiate parent-child cognitive behavioral therapy (CBT). Parent-child CBT is recommended as an effective intervention for anxiety disorders in children ages four and seven (Alvarez et al., 2018). At least six sessions in which the parent and the child are. Sadock et al. (2015) acknowledge parental involvement in pediatric therapy and the effectiveness of interactive parent-child therapy in mitigating behavioral and emotional issues for children below nine years.(Comprehensive SOAP Note for Anxiety PTSD and OCD Essay)
  3. Education: Educate the parent on the anxiety symptoms, available treatment, benefits, and risks. Discuss with the client’s parents the importance of an appropriate diet to gain weight.(Comprehensive SOAP Note for Anxiety PTSD and OCD Essay)

RTC: After two weeks.

Comprehensive SOAP Note for Anxiety PTSD and OCD Essay

References

Alvarez, E., Puliafico, A., Leonte, K. G., & Albano, A. M. (2018). Psychotherapy for anxiety disorders in children and adolescents. Available at: http://www.uptodate.com/  (Retrieved 5 March 2023)

American Psychiatric Association (APA). (2019). Diagnostic and statistical manual of mental disorders (DSM-5®). American Psychiatric Publishing

Centers for Disease Control and Prevention. (2020, 3 April). Adverse childhood experiences (ACEs) Links to an external site. [Video]. https://www.cdc.gov/violenceprevention/aces/index.html

Sadock, B. J., Sadock, V. A., & Ruiz, P. (2015). Kaplan & Sadock’s synopsis of psychiatry (11th ed.). Wolters Kluwer. 

Strawn, J. R., Mills, J. A., Cornwall, G. J., Mossman, S. A., Varney, S. T., Keeshin, B. R., & Croarkin, P. E. (2018). Buspirone in children and adolescents with anxiety: a review and Bayesian analysis of abandoned randomized controlled trials. Journal of child and adolescent psychopharmacology28(1), 2-9. https://doi.org/10.1089/cap.2017.0060

Thapar, A., Pine, D. S., Leckman, J. F., Scott, S., Snowling, M. J., & Taylor, E. A. (Eds.). (2015). Rutter’s child and adolescent psychiatry (6th ed.). Wiley Blackwell. 

Walden University. (2021). Case study: Dev Cordoba. Walden University Canvas. https://waldenu.instructure.com

Frequently Asked Questions

Is OCD and PTSD an anxiety disorder?

Yes, both Obsessive-Compulsive Disorder (OCD) and Post-Traumatic Stress Disorder (PTSD) are anxiety disorders. OCD involves persistent intrusive thoughts (obsessions) and repetitive behaviors (compulsions) that are driven by anxiety. PTSD, on the other hand, develops after experiencing or witnessing a traumatic event and involves symptoms such as intrusive memories, avoidance, and heightened arousal, all rooted in the anxiety response to the trauma.(Comprehensive SOAP Note for Anxiety PTSD and OCD Essay)

What is the difference between PTSD and OCD?

PTSD (Post-Traumatic Stress Disorder) is a mental health condition that arises after experiencing a traumatic event, leading to symptoms such as flashbacks, nightmares, hypervigilance, and avoidance of triggers associated with the trauma. OCD (Obsessive-Compulsive Disorder), on the other hand, involves persistent and unwanted thoughts (obsessions) that lead to ritualistic behaviors or mental acts (compulsions) aimed at reducing anxiety. While both disorders can cause distress and impairment, they stem from different underlying mechanisms and have distinct symptom profiles.(Comprehensive SOAP Note for Anxiety PTSD and OCD Essay)

How does OCD affect PTSD?

OCD (Obsessive-Compulsive Disorder) and PTSD (Post-Traumatic Stress Disorder) are distinct mental health conditions, but they can sometimes coexist or interact. In cases of comorbidity, individuals with PTSD might develop OCD-like symptoms as a way to cope with their distressing memories or trauma-related triggers. These symptoms can involve compulsive rituals or obsessions aimed at reducing anxiety linked to the traumatic event.(Comprehensive SOAP Note for Anxiety PTSD and OCD Essay)

What is the difference of OCD and anxiety?

Obsessive-Compulsive Disorder (OCD) is a specific anxiety disorder characterized by intrusive, unwanted thoughts (obsessions) and repetitive behaviors or mental acts (compulsions) aimed at reducing anxiety caused by these obsessions. While anxiety is a broader emotional response to a perceived threat or stressor, OCD is a subtype of anxiety disorder that involves distinct patterns of intrusive thoughts and ritualistic behaviors aimed at managing the distress caused by those thoughts.(Comprehensive SOAP Note for Anxiety PTSD and OCD Essay)

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