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Carefully read and answer each bullet point of the assignment (answer briefly).
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To Prepare
• 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 Case Study: Dev Cordoba. You will use this case as the basis of this Assignment
• Consider what history would be necessary to collect from this patient.
• Consider what interview questions you would need to ask this patient.
Comprehensive Psychiatric Focused SOAP notes
Student’s name
Institution Affiliation
Faculty Name
Assignment Due Date
Comprehensive Psychiatric Focused SOAP notes
Patient information
Patients initial :D.C age: 7 Gender: Male
Subjective:
CC (chief complaint): excess anxiety and worry
HPI:
The 7-year-old Dev is brought in by his mother who reports that he has recently developed anxiety on most occasions, she says that the child has poor concentration in studies, depressed and anxious. The patients claims that he is worried about the safety of his family members. He is aggressive both at school and at home. Generally, the patients report poor sleep patterns, injurious behaviors, poor appetite anhedonia, Repetitive compulsive behaviors, distressing memories of trauma, sleep disturbance, detached feelings and estrangement from others. The mum is concerned about his weight loss she reports that the patient has lost 3 pounds in the past 3 weeks the mother claims that she had initially sought medical advice from a pediatrician, whereby the child was been put under medication following the observation of the symptoms. However, the symptoms persisted and were referred. to pediatrician.
Past psychiatric history– the patient has no past psychiatric history; the patient has seen a pediatrician relating to general anxiety.
Family psychiatric disorder. the mother claims there are no history of mental disorder in the family.
Social History- the patient lives with his mother and brother. He lost his dad that was deployed on the military but he currents knows that he is on vacation. The mother does not how to break the news of the passing of his dad to the patient for fear it might worsen the already existing symptoms.
Substance Current Use: Patient denies any substance use
Medical History: no history of medical trials for psychotic conditions
• Current Medications: the patient is currently on DDVAP
• Allergies: no known allergies
• Reproductive Hx: No known reproductive related issues
ROS:
• GENERAL: drastic weight loss over the past weeks, No fever, occasional weakness, and fatigue.
• HEENT: Eyes: no blurred vison, double vison, yellow sclerae or visual loss no hearing loss congestion or sore throat.
• SKIN: no itching or rash
• CARDIOVASCULAR: Denies chest pains or discomfort, palpitation, fast or slow heart rates, orthopnea or edema.
• RESPIRATORY: denies dyspnea, stubborn coughs, Denies noisy breathing or sputum.
• GASTROINTESTINAL: reports abdominal pain, and anorexia.
• GENITOURINARY: frequent urination, no odor or odd color
• NEUROLOGICAL: reports headaches change in bladder control, dizziness, no black out spells or syncope
• MUSCULOSKELETAL: no joint pain, back pain or stiffness
• HEMATOLOGIC: reports change in weight, occasional bruising, no asemia
• LYMPHATICS: No history of splenectomy or enlarged nodes
• ENDOCRINOLOGIC: no polyuria or polydipsia, no report of colds or sweating
Objective
The patients present at least three of the six clinical criteria for GAD thus supports an adequate diagnosis.
ECG: normal stimulus rhythm
Thyroid function tests: normal thyroid stimulating hormone.
Diagnostic results:
Differential diagnosis
Social phobia- notably the patient suffers social phobia which is associated with anxiety whereby he fears social scrutiny, being judged, bullied, and negative evaluations especially from his friends at school who call him names. Through this the patient reactivated by throwing things. This is often portrayed from irrational fear an embarrassment during social interactions especially at school.
Panic phobia-The patient presented symptoms of anxiety, entailing fear of the death of his family members, sleep disorders, bad dreams. Among the many symptoms of panic phobia being the fear of dying that the patient attributes.
Obsessive compulsive disorder – furthermore, the patients suffer from obsessive compulsive disorder characterized by poor concentrations in school, excess worry and restlessness
Primary diagnosis
The primary diagnosis of the patient was characterized by anxiety and worry while undergoing his day-to-day activities, this was pronounced through the excessive worry of his family members safety, irritability, sleep inconsistencies. His mother said that the patients’ symptoms have persisted over the past few months due to the absence of his dad, thus, the primary diagnosis being genialized anxiety disorder.
Assessment:
Mental Status Examination:
He is a 7-year-old who looks his stated age, and was quite cooperative during the session. His speech his clear, with normal volume and tone and particular very coherent, he loses his concentration to the slightest form of distraction. However, there is no evidence of looses of flight of ideas as there is no abnormal motor activity.
Diagnostic Impression:
The overall diagnosis being the generalized anxiety disorder
Reflections:
Case Formulation and Treatment Plan:
The treatment plan for generalized anxiety disorder is dependent of the extent it affects the day-to-day function of a patient. The main treatment option plans include medication and psychotherapy can be used separately in combination to achieve better results.
For Dev Cordoba’s case, the first line of treatment recommended for his anxiety is putting him under cognitive behavioral theory, anxiety management. the therapies are initiated before any for of medication is introduced. The cognitive behavioral therapy is a short-term treatment plan that works to focuses technique the patient the appropriate skills that help to manage his worried and ease the anxiety. During this particular visit, there was no vaccination administered nor prescription of medication. The ECG and thyroid function tests were order. No lab test order, the main recommendation be psychoeducation education, anxiety management training and cognitive behavioral therapy to be used.
Other recommendations that the patient’s mother should adopt is lifestyle changes. They include prioritizing sleep, adopting relation techniques such as yoga and meditation to ensure the patient is relation. Notably, by introducing healthy eating to boost the patient’s appetite. Additionally, the patient’s mother was advised to adhere to non-drug therapies and make follow up visits. It is also important for the patient’s mother to inform him of the passing of his father so he can learn to familiarize with the situation. Notably, he will overcome the shock and depression through the sessions and therapies. Continued treatments will ensure that the symptoms are address and prevent the need for higher level of care.
References
Jordan, P., Shedden-Mora, M. C., & Löwe, B. (2017). Psychometric analysis of the Generalized Anxiety Disorder scale (GAD-7) in primary care using modern item response theory. PloS one, 12(8), e0182162.
