Comprehensive SOAP Note Analysis-Differential Diagnosis and Critical Thinking in Primary Diagnosis Formulation

Comprehensive SOAP Note Analysis-Differential Diagnosis and Critical Thinking in Primary Diagnosis Formulation

Subjective

CC (chief complaint): “I feel worried. I worry about just everything”.

HPI: DC is a 7-year-old male brought to the clinic by his mother after a referral from his pediatrician. He presents with complaints of extreme worry. He has been worrying about everything. He worries about his mother and brother while at school and even dreams frequently about losing them. His worries affect his sleep and schooling. He also worries about his dad not returning and his mother not reporting. He also reports feeling sad because of wetting his bed. The client’s mother reported that he is anxious and worried all the time about her dying and being unable to pick him up from school. Additionally, he has trouble going to and staying in school. He claims his brother is loved more than him and sometimes gets into trouble at school for throwing things around. While at school, he wants to return home because of complaints of headache and stomach ache. He also does not eat properly and has lost three pounds in the past three weeks.

Substance Current Use: The client has no history of substance use.

Medical History: The client denied having been hospitalized before or having been involved in any accidents or head injuries.

Current Medications: The patient is not on any medications. He denies having used any psychotropic agents.

Allergies: The patient has no known allergies.

Reproductive Hx: No reports of any reproductive health anomalies, including maternal use of alcohol or other substances of abuse.

ROS:

GENERAL: The client is a 7-year-old child. He has recently lost three pounds. No reports of fever or chills.

HEENT: No reports of head injuries, swelling, or hair loss. There were also no reports of visual changes, use of hearing aids, or hearing loss. He also has no ear, nose, or eye discharge, nasal congestion, nasal discharge, or nasal swelling and tenderness. There were also no reports of sneezing, difficulty swallowing, or sore throat.

SKIN: No reports of skill lesions, scars, or swelling. There were also no reports of colour changes in the skin.

CARDIOVASCULAR: No reports of chest pain or discomfort, palpitations, or edema.

RESPIRATORY: No reports of wheezing, shortness of breath, cough, or sputum production.

GASTROINTESTINAL: There were reports of abdominal pain that prompted the client to want out of school. No reports of inconsistent bowel movements or melena stool.

GENITOURINARY: No reports of dysuria, urinary hesitance, frequency, or urgency. There were also no reports of malodorous urine or urinary color change. There were, however, reports of bed-wetting.

NEUROLOGICAL: No reports of syncope, dizziness, or tremors. There were also no reports of bladder inconsistency or ataxia.

MUSCULOSKELETAL: No reports of joint stiffness, swelling, limited range of motion, or pain.

HEMATOLOGIC: No reports of anemia, clotting issues, or bruising. There were also no reports of using blood thinners.

LYMPHATICS: No reports of splenectomy or lymph glandular swelling.

ENDOCRINOLOGIC: No reports of intolerance to cold or excessive sweating.

Objective:

Diagnostic results: Psychiatric assessment of the patients revealed symptoms consistent with those of generalized anxiety disorders (GAD). GAD is a mental health illness characterized by extreme worry, difficulty in controlling worries, and irritability, among others. GAD-7 is a seven-item tool used to assess the presence and severity of GAD. Findings from the tool can help distinguish GAD from other anxiety disorders and also help inform the need and choice for therapy. While these findings are suggestive of the disease, they cannot be used alone to make a GAD diagnosis. Clinical investigations are necessary to confirm the disorder.

Assessment:

Mental Status Examination: The client is alert and responsive to the interview questions. He is well-oriented to place, event, and time. His speech is coherent, normative in volume and intonation, and goal-directed, while his effect is euthymic. He demonstrates intact and logical judgment. No reports of hallucinations, delusions, or suicidal thoughts and tendencies.

Differentials: Generalized anxiety disorder (GAD). GAD is a common mental health illness among children and adolescents. It is characterized by anxiety, restlessness, fatiguability, insomnia, irritability, and muscle tension. The fifth manual of the diagnostic and statistical manual for mental health disorders (DSM-V) criteria includes the presence of extreme worry with difficulties in controlling the worry for the last six months (Mishra & Varma, 2023). Other accompanying symptoms include fatigue, restlessness, distractibility, muscle tension, irritability, sleep disturbances, and muscle tension. The worry in GAD must be multi-focal, appearing in diverse settings such as at school and home. It should also be causing significant impairment in schooling areas and other social and occupational functions. The diagnosis should also rule out anxiety from physical causes. The client in the case presented had symptoms consistent with those of GAD. To begin with, he presented with extreme worry. The worry manifested in diverse settings and caused impairment in his schooling functions. The worry was also accompanied by symptoms suggestive of GAD, such as sleep disturbances, difficulty concentrating at school, irritability, and GI disturbances. This points to the high likelihood of GAD.

Panic disorder is another differential in the case. Panic disorders are anxiety disorders that are characterized by frequent and sudden panic attacks. These attacks are intermittent and short-lasting, often an hour or less. The hallmark feature of panic disorders is the spontaneity of the panic attacks and the absence of a trigger factor for these attacks (Kim, 2019). This differential was eliminated because of the lack of spontaneity in the case presented.

The manic or hypomanic phase of bipolar disorder is another likely differential in the case. The manic and hypomanic phases of bipolar disorders are characterized by a decreased need for sleep, distractibility, and irritable mood, among others (McIntyre et al., 2020). The patient in the case presented with similar manifestations warning the inclusion of this differential. It was, however, eliminated because of the absence of other features of the disorders, such as depressive episodes, grandiosity, and compulsivity, among others.

Diagnostic impression: GAD. The symptoms of the clients are consistent with those of GAD as defined in DSM-V. The case is thus likely to be GAD.

Case Formulation and Treatment Plan:

The client in the case presented had GAD. Comprehensive management of GAD utilizes psychotherapeutic modalities and pharmacotherapy to alleviate anxiety symptoms and help the client lead a normative life. Cognitive behavioral therapy is the first line in the management of mild to moderate anxiety. It is effective in alleviating anxiety manifestations (Melo-Carrillo et al., 2023). The client, in this case, will be started on a CBT program. If CBT fails, the client will be started on pharmacotherapy. Selective serotonin reuptake inhibitors (SSRIs) are the most preferred agent in the management of GAD due to their tolerability and safety profile. Other agents that can be used in this respect include buspirone, antipsychotic medications, and benzodiazepines (Mishra & Varma, 2023). As part of health promotion and preservation for the client, he will be scheduled for a follow-up after two weeks to ascertain the effectiveness of the applied therapy. One educational strategy that will be used is verbal education at the point of care.

Reflections:

Subjective and objective findings from the case revealed manifestations consistent with those of GAD. GAD is a clinical diagnosis made in the presence of GAD symptoms per the DSM-V criteria for GAD. Treatment aims to alleviate anxiety symptoms. I concur with the assessment of the patient as it is indicative of the symptoms suggestive of GAD. On follow-up of the patient, I would be keen on the presence and severity of the symptoms as this will help ascertain the effectiveness of the chosen modalities. When managing the client, several considerations of the ethical and legal obligations become apparent. The legal obligations of competency and informed consent come into play. As a legal obligation for caregivers, maintaining competent care for diverse patients is paramount. This includes being tolerant of clients’ emotions while not allowing themselves to be consumed by their client’s emotions. In this respect, the caregiver must be tolerant of the client’s emotions during therapy. The principle of beneficence is an ethical consideration in this case. It implores caregivers to promote the welfare of their patients. In this respect, caregivers should opt for therapeutic modalities that are more likely to optimize their clinical outcomes.

In the resolve to promote and preserve the health of communities and the client, the client and his family members should be educated on the disease process and its impact on health. This is likely to lessen potential stigmatization and subsequent discrimination. Understanding the disease process will also help the client and the community to be better accountable for preventing the disease. Caregivers, in this regard, have a role in educating communities on the risk factors of the disease. The communication process should maintain cultural awareness, sensitivity, and simple language to ensure that diverse communities are engaged in the messaging.

References

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

Mishra, A. K., & Varma, A. R. (2023). A comprehensive review of the Generalized Anxiety Disorder. Cureus. https://doi.org/10.7759/

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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?

Comprehensive SOAP Note Analysis-Differential Diagnosis and Critical Thinking in Primary Diagnosis Formulation

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 rule 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. Als,o 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).