Focused SOAP Note for Generalized anxiety disorder, Panic disorder, Social anxiety Disorder and Dysthymia
Assignment
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
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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).
Solution
Week (enter week #): (Enter assignment title)
Student Name
College of Nursing-PMHNP, Walden University
NRNP 6675: PMHNP Care Across the Lifespan II
Faculty Name
Assignment Due Date
Subjective:
CC (chief complaint): Patient D is brought to the clinic for excessive worrying and anxiety about different issues in his life
HPI: The 7-year-old is accompanied by the mother to the hospital. He asserts that he worries about his mother and sibling which has been affecting his concentration in class. He now sits next to the teacher for easy monitoring and supervision. He is restless and has trouble concentrating.
Substance Current Use: None
Medical History:
- Current Medications: The patient has been on vitamin D supplements
- Allergies: No reported allergies
- Reproductive Hx: Not sexually active
ROS:
- GENERAL: No weight loss/gain, no fatigue, no chills
- HEENT: No eye pain, redness or significant vision changes, no sneezing, no nasal congestion, no runny nose
- SKIN: no itching, redness, or eczema
- CARDIOVASCULAR: no palpations, no chest pressure or pain no edema
- RESPIRATORY: no shortness of breath, denies cough or sputum, no wheezing
- GASTROINTESTINAL: no diarrhea , no constipation, no anorexia, no abdominal pain
- GENITOURINARY: no changes in the urinary pattern, no urgency, no burning sensation, no incontinence
- NEUROLOGICAL: no dizziness, no headache, no paralysis, denies tingling, no confusion
- MUSCULOSKELETAL: no muscle weakness or pain, no stiffness
- HEMATOLOGIC: no history of anemia, no bruising or bleeding
- LYMPHATICS: no swollen lymph nodes, has no history of splenectomy
- ENDOCRINOLOGIC: no heat or cold intolerance
Objective:
Vitals: Temp 96.4, Pulse rate of 76, Respiration rate 18 non labored, B/P 100/65
Diagnostic results: The patient scored 30 on the Screening for Child Anxiety Related Disorders Inventory which indicates that the patient has generalized anxiety disorder (Mossman et al., 2017).
Assessment:
Mental Status Examination: The patient is a 7-year-old Caucasian male who appears his age. He is cooperative during the session though appears restless and fidgety. He also has trouble concentrating. He has no signs of hallucinations or troubling speech.
Diagnostic Impression: The diagnostic impression is a generalized anxiety disorder. The differential diagnoses are social anxiety disorder, panic disorder, and dysthymia
Generalized anxiety disorder (GAD)
The DSM-5 diagnostic criteria for GAD entails the presence of excessive anxiety and worry about various events or topics, the worry experienced is challenging to control (Gale & Millichamp, 2016). The anxiety and worry symptoms must be accompanied by at least three of the following symptoms, edginess or restlessness, impaired concentration, tiring easily, irritability, difficulty sleeping, and increased muscle aches or soreness. The case study shows that D keeps worrying about his mom and his brother. The case study also shows that in school the teacher keeps on telling him to sit down and to focus since he keeps looking outside the window. It is therefore evident that he has issues with concentration and excessive worrying which needs to be managed.
Panic disorder
Panic disorder is abrupt surges of fear and discomfort which peak within a short time. Individuals must present with at least four of the symptoms. The disorder is associated with recurring panic attacks, fear of losing control, feeling of derealization and depersonalization, accelerated heart rate and breath, chest pain, trembling and shaking, and excessive worry about a future attack (Kim, 2019).
Social anxiety Disorder
Social anxiety disorder is also known as social phobia. Individuals diagnosed with the condition experience various symptoms like the excessive worry of being embarrassed, excessive fear, fear of being humiliated and judged. Social interactions tend to cause irrational anxiety, embarrassment, fear, and self-consciousness. Since individuals fear being humiliated and being rejected, the condition is often associated with avoidance behavior which tends to impair a person’s social interactions (Chadelaine et al., 2018). The conditions result in impaired educational attainment, occupational performance, quality of life, and relationships.
Dysthymia
Dysthymia is a condition that is characterized by hopelessness, low self-esteem, poor concentration, low energy levels. Sleep changes and loss of interest in pleasurable activities. Schramm et al. (2020) claim that the condition is usually difficult to diagnose until it manifests later as major depressive disorder. The healthcare practitioners, therefore, need to diagnose the condition early to initiate early treatment and management for the achievement of positive healthcare outcomes.
Reflections:
Initially, the patient was put on medication only. What I would do differently with this patient would be to modify the treatment plan. If I were to revise the plan I would combine both therapy and pharmacological agents. I would also recommend the use of relaxation techniques such as breathing exercises and other mindful practices like yoga to help manage anxiety levels.The patient was prescribed Escitalopram 5 mg daily which is a selective serotonin reuptake inhibitor. The medication is recommended as a first-line treatment for anxiety disorders (Jiang et al., 2017). Nursing literature indicates that the combination of therapy and pharmacological agents is effective in the management and treatment and management of generalized anxiety disorder symptoms.
The history that would be important to collect from the patient
- History of anxiety disorders in the family
Interview Questions
- How would you want your mother to treat you differently?
- How do you interact with your other classmates?
- Do you think if your father was around your worries would lessen?
Legal and ethical considerations
The patient’s issue attracts ethical issues based on the fact that he is a minor. The patient, therefore, lacks the knowledge and capacity to make health-related decisions. Similarly, he requires parental guidance and supervision to ensure compliance with medication and therapy. The parent must therefore be fully incorporated in every aspect of care such as health promotion, disease promotion, and the designing of the patient’s treatment plan since she is the patient’s immediate support system.
Case Formulation and Treatment Plan:
After the patient’s diagnosis with generalized anxiety disorder, the treatment plan was a combination of pharmacological agents and psychotherapy. The patient was prescribed selective serotonin reuptake inhibitors (SSRIs) Escitalopram. The medication works by increasing the serotonin levels in the brain which results in the reduction of worrying and anxiety among the patients.
The medication however has some side effects which could be tolerated if the medication is taken on a minimal dosage based on the patient’s profile. Some of the side effects include feeling shaky, yawning, loss of appetite, sweating, dizziness, weakness, drowsiness, and dry mouth among others.
The plan for psychotherapy is cognitive behavioral therapy. Cognitive behavioral therapy entails learning how to recognize how maldaptive thinking could result in distorted thoughts, perceptions and attitudes. The therapy aims helping the person take control of his/her own percpetions and circumstances. An alternative therapy that would help to alleviate anxiety would relaxation techniques such as breathing exercises and yoga which would help in the management of anxiety.
One health promotion activity would be patient education about anxiety, causes and ways of managing anxiety. One patient education strategy would be use of printed materials written in a language that would be easily understood by the patient.
The patient’s mother was advised on the importance of medication compliance to minimize cases of symptoms relapse of adverse events especially when the medication is stopped abruptly.
The patient and the mother seemed to understand the discussion and at the same time agreed to follow the laid-out guidelines as advised throughout the session.
In case of an emergency, the patient should call 911. Similarly, if the patient experiences allergic reactions or hives, the patient should contact a healthcare practitioner to minimize the possibility of disease.
The patient should return to the clinic after four weeks for follow-up. If I follow up with the patient the next intervention would be the recommendation to use breathing exercises to regulate worrying and anxiety. During the session, the physician will discuss any notable event on the patient’s health. The follow-up is supposed to ensure that the patient is coping well with the medication and therapy and that the required outcomes are being achieved as desired. The follow-up is also supposed to improve patient’s functioning and reduce chronic symptoms which would increase the burden of disease and costs of care while at the same time requiring high-level management.
References
Chapelaine, A., Carrier, J. D., Fournier, L., Duhoux, A., & Roberge, P. (2018). Treatment adequacy for social anxiety disorder in primary care patients. PloS one, 13(11), e0206357.
Gale, C. K., & Millichamp, J. (2016). Generalised anxiety disorder in children and adolescents. BMJ clinical evidence, 2016, 1002.
Jiang, K., Li, L., Wang, X., Fang, M., Shi, J., Cao, Q., He, J., Wang, J., Tan, W., & Hu, C. (2017). Efficacy and tolerability of escitalopram in treatment of major depressive disorder with anxiety symptoms: a 24-week, open-label, prospective study in Chinese population. Neuropsychiatric disease and treatment, 13, 515–526. https://doi.org/10.2147/NDT.S120190
Kim Y. K. (2019). Panic Disorder: Current Research and Management Approaches. Psychiatry investigation, 16(1), 1–3. https://doi.org/10.30773/pi.2019.01.08
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. (2017). 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.
Schramm, E., Klein, D. N., Elsaesser, M., Furukawa, T. A., & Domschke, K. (2020). Review of dysthymia and persistent depressive disorder: history, correlates, and clinical implications. The Lancet Psychiatry, 7(9), 801-812.