Comprehensive Focused SOAP Psychiatric Evaluation
Subjective:
ID: Dev Age: 7 years
CC (chief complaint): “I worry about everything.”
HPI: A 7-year-old male was referred to the clinic by his pediatrician for the management of anxiety and worry. He has been worrying about losing his brother and mother while in school. He also has difficulty falling and maintaining sleep and often wants to sleep with the lights on: Comprehensive Focused SOAP Psychiatric Evaluation.
While in school, he gets into a lot of trouble and reports complaints of headaches and stomach aches. He has not been eating properly for the past three weeks and has lost three pounds.
Substance Current Use: Negative
Medical History:
- Current Medications: None.
- Allergies:No known food or drug allergies.
- Reproductive Hx: Denies any abnormalities in his reproductive health. The patient also has a negative history of maternal use of substances of abuse.
ROS:
- GENERAL: The client recently lost three pounds.
- HEENT: Denies head injuries, visual or hearing loss, nasal congestion, or difficulty swallowing.
- CARDIOVASCULAR: Denies chest pains or palpitations.
- RESPIRATORY: Denies wheezing or shortness of breath.
- GASTROINTESTINAL: The patient reported occasional stomach aches.
- NEUROLOGICAL: The client reported occasional headaches.
- MUSCULOSKELETAL: Denies joint or muscular pain or restrictions in the range of motion.
- ENDOCRINOLOGIC: Denies heat or cold intolerance
Objective:
Diagnostic results: The manifestations of extreme worry and anxiety point toward an anxiety disorder. Diagnostic assessment tools, such as the generalized anxiety disorder-7 (GAD-7), maintain effectiveness in screening for anxiety disorder. They can also be used to distinguish generalized anxiety disorder from other anxiety disorders (Sapra et al., 2020).
Assessment:
Mental Status Examination: The patient is alert. He’s also responsive. He is also aware of place, time, and event, and he can articulate the rationale for his healthcare seeking in an age-appropriate manner.
His speech is coherent and goal-directed. His judgment, thought process, and thought content are also intact. No signs of delusions. There are also no reports of suicidal tendencies or hallucinations.
Diagnostic Impression:
Differentials
Generalized anxiety disorder (GAD): GAD is a psychiatric illness. It is defined by persistent worry about things that others would not worry about. Other symptoms include sleeplessness, restlessness, fatigue, irritability, gastrointestinal disorders, and muscle tension (DSM-V, n.d.). The existence of worry, sleeplessness, and trouble concentrating at school made the diagnosis likely.
Panic disorder: The presence of worry and sustained anxiety in the presented patient case led to the inclusion of this diagnosis. However, the differential is less probable as the patient’s manifestations were not spontaneous. Additionally, somatic symptoms, such as palpitations, which are usually present in panic attacks, were absent (Kim, 2019).
Bipolar disorder: The manic or hypomanic phase of bipolar disorder may sometimes preset with sustained anxiety. Irritability, insomnia, and GI disturbances may also be present. This makes bipolar a probable diagnosis. However, the clinical history of the client was negative of depressive episodes making the diagnosis less probable (McIntyre et al., 2020).
Diagnosis: The presumptive diagnosis is GAD. The symptoms of anxiety, insomnia, difficulty concentrating, and GI disturbances point toward the diagnosis.
Case Formulation and Treatment Plan:
The client will referred to a psychotherapist. He will be initiated on cognitive behavioral therapy (CBT) to manage his anxiety. CBT is the first line in managing mild to moderate anxiety disorders.
If the patient fails to benefit from CBT, he will be started on anti-anxiety medications. Selective serotonin reuptake inhibitors, such as fluoxetine, are used as first-line in managing GAD (Melo-Carrillo et al., 2023).
Reflections: The case is of a 7-year-old male patient with GAD. One thing I would do differently when managing the patient is to apply diagnostic screening tools, such as GAD-7. During follow-up, I would be keen to assess the symptom severity, noting the frequency of the symptoms to ascertain the patient’s response to therapy.
An ethical obligation during care borders on autonomy; since the patient is a minor, caregivers should be keen on involving the client’s parents in the therapy process. As a point of health promotion, the client and his family should be educated on the disease process and how to identify the symptoms. This will facilitate the care process for the patient.
References
DSM-V. (n.d.). DSM. Psychiatry.org – DSM. https://www.psychiatry.org/psychiatrists/practice/dsm
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
McIntyre, R. S., Berk, M., Brietzke, E., Goldstein, B. I., López-Jaramillo, C., Kessing, L. V., Malhi, G. S., Nierenberg, A. A., Rosenblat, J. D., Majeed, A., Vieta, E., Vinberg, M.,Young, A. H., & Mansur, R. B. (2020). Bipolar disorders. The Lancet, 396(10265), 1841–1856. https://doi.org/10.1016/s0140-6736(20)31544-0
Melo-Carrillo, A., Rodriguez, R., Ashina, S., Lipinski, B., Hart, P., & Burstein, R. (2023). Psychotherapy treatment of generalized anxiety disorder improves when conducted under a narrow band of Green Light. Psychology Research and Behavior Management, Volume 16, 241–250. https://doi.org/10.2147/prbm.s388042
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Question 
WK 3 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.
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
Comprehensive Focused SOAP Psychiatric Evaluation
THE ASSIGNMENT
In 2 pages 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-TR diagnostic criteria for each differential diagnosis and explain what DSM-5-TR 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).
Video link below
Walden University. (2021). Case study: Dev Cordoba. Walden University Canvas. https://waldenu.instructure.com
Resources: