Focused SOAP Note for Anxiety, PTSD, and OCD

Subjective:

CC (chief complaint): “My mom says I’m worried all the time and don’t sleep good.”

HPI: Dev Cordoba is a seven-year-old boy presenting with persistent anxiety, sleep disturbances, somatic complaints, and social withdrawal. His symptoms include daily worry about his mother’s safety, frequent nightmares about being lost, difficulty sleeping alone, enuresis, irritability, and poor focus at school. His symptoms have persisted for several months and appear to have intensified since his father’s death, though he remains unaware that his father has passed. Dev’s functional impairments are evident academically and socially; he reports bullying at school, concentration issues, and daily stomachaches: Focused SOAP Note for Anxiety, PTSD, and OCD.

Substance Current Use: No substance use.

Medical History: History of nocturnal enuresis; prescribed DDAVP with minimal effectiveness. No known physical conditions per pediatrician’s evaluation.

• Current Medications: DDAVP for enuresis.
• Allergies: No known drug or food allergies.

• Reproductive Hx: Not applicable.

ROS:

• GENERAL: Notable weight loss (3 lbs in 3 weeks), reduced appetite, fatigue.
• HEENT: No visual or auditory deficits were reported.
• SKIN: No rashes or lesions.
• CARDIOVASCULAR: No palpitations or chest pain.
• RESPIRATORY: No cough or breathing difficulties.
• GASTROINTESTINAL: Complaints of daily stomachaches; no nausea or vomiting.
• GENITOURINARY: Nighttime enuresis persists.
• NEUROLOGICAL: No seizures, tremors, or dizziness were reported.
• MUSCULOSKELETAL: No joint or muscle pain.
• HEMATOLOGIC: No bruising or bleeding issues.
• LYMPHATICS: No noted lymphadenopathy.
• ENDOCRINOLOGIC: No polyuria or polydipsia was reported.

Objective:

Diagnostic results:

No laboratory or imaging studies were indicated or performed at this time, as the presentation is psychiatric and well-supported by clinical interviews and behavioral observations. The pediatric workup ruled out medical causes for sleep disturbances, appetite loss, and somatic complaints such as stomachaches and headaches, with no physical pathology identified. The use of DSM-5-TR criteria during the interview process supports a diagnosis of Separation Anxiety Disorder, with differential consideration for PTSD and Generalized Anxiety Disorder.

Further standardized tools such as the Screen for Child Anxiety-Related Emotional Disorders or the Child Behavior Checklist may be administered during follow-up to quantify symptom severity and track response to treatment. At present, no neuroimaging or lab work is warranted unless symptoms evolve to suggest neurological or metabolic concerns.

Assessment:

Mental Status Examination:

Dev is a well-groomed 7-year-old male who appears his stated age. He is cooperative and shows appropriate behavior. He answers questions spontaneously and appropriately. His speech is clear, and his thought processes are logical and age-appropriate.

The mood is anxious, and the affect is congruent with the situation. He denies suicidal ideation or self-harm. There are no delusions or hallucinations. He shows good orientation and fair insight for his age.

Diagnostic Impression:

The primary diagnosis for Dev Cordoba is Separation Anxiety Disorder (F93.0). His presentation includes excessive distress about being apart from his mother, refusal to attend school, frequent somatic complaints such as headaches and stomachaches, and persistent fear that his mother may not return (Feriante et al., 2023). These symptoms have been ongoing for more than four weeks, meet DSM-5-TR diagnostic criteria, and significantly impair his academic and social functioning.

Differential Diagnoses:

• Post-Traumatic Stress Disorder, Preschool Subtype (F43.10)

One differential diagnosis is Post-Traumatic Stress Disorder, Preschool Subtype (F43.10), given Dev’s recurring nightmares, fear of darkness, hypervigilance, and emotional dysregulation following the absence of his father (Mann et al., 2024). However, Dev has not been told that his father died in combat, and there is no clear evidence of direct trauma exposure or flashbacks that meet the DSM-5-TR definition of PTSD in children under age six. Due to the lack of known trauma awareness or re-experiencing symptoms beyond dreams, PTSD remains a lower priority in the differential list.

• Obsessive-Compulsive Disorder (F42.9):

Another possible diagnosis is Obsessive-Compulsive Disorder (F42.9), as Dev exhibits repetitive thoughts of harm coming to his mother and behaviors like checking and needing the nightlight and opening the door to feel safe. However, these behaviors are better explained by his attachment anxiety rather than true compulsions intended to reduce the distress caused by intrusive obsessions, as required in DSM-5-TR criteria for OCD (Brock et al., 2024). Thus, OCD is ruled out as a primary diagnosis due to the symptom context being rooted in separation distress rather than ritualistic patterns.

• Adjustment Disorder with Anxiety (F43.22):

Another possible diagnosis is Adjustment Disorder with Anxiety (F43.22), as Dev is clearly experiencing psychological distress in response to a significant life change, the unexplained absence of his father. While his symptoms could reflect this diagnosis, the duration and intensity, along with specific separation-related fears, exceed the expected response and persist beyond the typical time frame for Adjustment Disorder (Geer, 2023). Therefore, Adjustment Disorder is ruled out in favor of Separation Anxiety Disorder, which better fits the clinical picture and chronic nature of Dev’s presentation.

Reflections:

If I could re-conduct the session, I would gently explore Dev’s understanding of his father’s absence to assess unresolved grief more explicitly. A follow-up intervention would include involving a child grief counselor and family therapy to provide clarity and support in a developmentally appropriate way.

Legal/Ethical Considerations:

Ethically, the mother must be guided in disclosing the truth about Dev’s father in a therapeutic setting to avoid prolonged confusion and grief. Clinicians must balance respecting the family’s beliefs with the child’s psychological needs. Additionally, informed consent for therapy must address limits of confidentiality, for instance, harm to self or others, and incorporate the child’s assent where possible.

Health Promotion and Prevention:

Given Dev’s age, Latino background, single-parent household, and socioeconomic stress, it is critical to consider cultural sensitivity, trauma-informed care, and social determinants of health, for example, access to mental health services and school environment. Preventing chronic anxiety and academic failure involves integrated care, psychoeducation, and school collaboration.

Case Formulation and Treatment Plan:

The treatment plan for Dev includes initiating play therapy integrated with trauma-informed cognitive behavioral therapy (CBT) to address his anxiety and grief while also incorporating parent-child interaction therapy (PCIT) to support maternal bonding and behavioral regulation (Chand et al., 2023). Given his age and symptom profile, no psychotropic medications are recommended at this stage, though SSRIs like fluoxetine may be considered if psychotherapy alone is insufficient. Complementary strategies such as calming bedtime routines, therapeutic storybooks, and comfort items will help improve sleep and reduce nighttime anxiety.

Weekly therapy sessions are advised for eight weeks, with follow-up assessments every four weeks to monitor weight, mood, behavior, and school functioning. Educating Dev’s mother on establishing consistent routines and open communication is vital, along with providing psychoeducation on identifying anxiety triggers and managing school-related stress (Morgado et al., 2022). Culturally sensitive approaches are essential, given Dev’s Latino background and single-parent household; these must account for socioeconomic barriers and promote access to mental health care. In future sessions, a deeper exploration of Dev’s understanding of his father’s absence and the ethical guidance around truth-telling should be prioritized, ensuring developmentally appropriate grief support and emotional safety.

References

Brock, H., Hany, M., & Rizvi, A. (2024, February 24). Obsessive-compulsive disorder (OCD). PubMed; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK553162/

Chand, S. P., Kuckel, D. P., & Huecker, M. R. (2023, May 23). Cognitive behavior therapy (CBT). National Library of Medicine; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK470241/

Feriante, J., Bernstein, B., & Torrico, T. (2023). Separation anxiety disorder. PubMed; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK560793/

Geer, K. (2023). Adjustment disorder. Primary Care: Clinics in Office Practice, 50(1), 83–88. https://doi.org/10.1016/j.pop.2022.10.006

Mann, S. K., Marwaha, R., & Torrico, T. J. (2024). Post-traumatic stress disorder (PTSD). PubMed; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK559129/

Morgado, T., Lopes, V., Carvalho, D., & Santos, E. (2022). The effectiveness of psychoeducational interventions in adolescents’ anxiety: A systematic review protocol. Nursing Reports, 12(1), 217–225. https://doi.org/10.3390/nursrep12010022

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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.

Resources
Be sure to review the Learning Resources before completing this activity.
Click the weekly resources link to access the resources.

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.
  

  Focused SOAP Note for Anxiety, PTSD, and OCD

• Consider what history would be necessary to collect from this patient.
• Consider what interview questions you would need to ask this patient.