Focused SOAP Note for Anxiety, Obsessive-Compulsive and Related, and Trauma and Stressor-Related Disorders

Focused SOAP Note for Anxiety, Obsessive-Compulsive and Related, and Trauma and Stressor-Related Disorders

Focused SOAP Note for Anxiety Disorder

Subjective:

CC: “Sometimes I’m extremely worried, and other times I’m very sad. My feelings are difficult to put into words.”

HPI: K.B is a 36-year old female who presents to the clinic with complaints of constant worry about everything that started 8 months ago. She reveals that her husband is a cancer patient, and that she lives in continuous fear that he may pass away at any moment, to the point that she has nightmares about it. She also reports having difficulty falling asleep at night. She claims that she has dropped four pounds in the last month due to her lack of appetite and that this has occurred over the course of the last month. She also complains that she is exhausted almost every day and that she suffers from headaches and stomachaches on a frequent basis. She claims that she has not been having hallucinations, delusions or thoughts of suicide Focused SOAP Note for Anxiety, Obsessive-Compulsive and Related, and Trauma and Stressor-Related Disorders.

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Medical History: Asthma

Current Medications: Ibuprofen 500mg for headaches

Allergies: Penicillin- rash. Denies food or seasonal allergies

Reproductive History: Denies current sexual activity. Denies miscarriages or abortions.

Substance Current Use and History: Denies alcohol drinking, tobacco or illicit drug use. Family Psychiatric/Substance Use History: Her paternal grandmother had depression. Denies family history of substance use disorders or suicides.

Social History: K.B is married and lives with her husband, her son, and her nephew. She works at a local bakery but has not gone to work in two weeks. Her highest level of education is college level. She is an active church participant and loves volunteering and bible study sessions. Denies history of abuse. Her support system comprises her family and church.

ROS:

GENERAL: Reports 4-pound weight loss, fatigue and occasional headaches.

HEENT: Reports frequent headaches. Denies head injury. Denies eye/vision problems. Denies loss hearing, ear pain, or discharge. Denies runny nose, nasal congestion or sinus problems. Denies sore throat or swallowing problems.

SKIN: Denies rash, lesions or discoloration.

CARDIOVASCULAR: Denies chest pain, palpitations, or swelling.

RESPIRATORY: Denies cough, shortness of breath, or wheezing.

GASTROINTESTINAL: Reports occasional stomach aches. Denies nausea, vomiting, constipation or diarrhea.

GENITOURINARY: Denies increased urination, burning on urination, or history of UTIs.

NEUROLOGICAL: Denies dizziness, vertigo, seizures or loss of coordination. MUSCULOSKELETAL: Denies back pain, muscle pain, joint pain, or injury.

HEMALOGICAL: Denies history of anemia or excessive bleeding.

LYMPHATICS : Denies enlarged nodes

ENDOCRINOLOGIC: denies cold or heat intolerance. Denies excessive sweating.

 

Objective:

Diagnostic Results: No diagnostic test was required during this assessment session

Assessment:

Mental Status Examination

K.B is a 36-year-old African American who looks like her stated age. Patient is alert and oriented x4, stays attentive, obeys all instructions, and provides accurate responses to all questions. Patient is well-dressed, well-groomed and well-nourished but appears fidgety and uneasy. The patient appears excessively worried and restless, and had a sad mood. Displays no psychotic symptoms. Denies suicidal or homicidal ideation. Denies delusions, hallucinations or intrusive thoughts. Her speech is clear and coherent. All of memories are intact. Good judgment and insight Focused SOAP Note for Anxiety, Obsessive-Compulsive and Related, and Trauma and Stressor-Related Disorders.

Diagnostic Impression

Generalized Anxiety Disorder (F41. 1): This is a mental condition characterized by a constant and disproportionate level of worry over a variety of different things, especially when compared to the actual impact of those things (Iani et al., 2019). It is defined by overwhelming and uncontrolled feelings of worry and stress, restlessness, difficulties focusing, difficulty sleeping, and physical symptoms that have been persistent for more than six months, which affect with an individual’s day-to-day activities (APA, 2013). K.B has been experiencing persistent feelings of worry, restlessness, sleeping problems and physical symptoms for eight months.

Depressive Disorder (F32.9): Depression is a mental illness that is characterized by an overwhelming sense of sadness and a lack of interest in daily activities. It has an impact on a person’s feelings, thoughts, and behaviors, and it may result in a wide range of psychological and physical issues (Bains & Abdijadid, 2021).   A person suffering from depression may experience feelings of despair or dread, agitation or irritability, lack of interest in most or all usual activities sleep difficulties, weariness, decreased appetite and weight loss or increased appetites for food and weight gain. There is a correlation between some of these symptoms and the symptoms that the patient K.B. presents.

Panic Disorder (F41.0): Panic disorder is a form of anxiety disorder that may induce panic attacks, which are abrupt emotions of dread even when there is no actual risk (Kim, 2019).  Patients with the disease could have the impression that they are spiraling out of control, and they might also have physical symptoms like, a rapid rate of heartbeat, chest or stomach pain, breathing problems, weakness or sweating. Panic attacks may strike at any moment, in any place, and with no warning.

Treatment Plan

The patient will be prescribed an antidepressant medication like escitalopram 10mg once daily. Cognitive behavioral therapy (CBT) weekly sessions a week are also recommended for this patient in order to assist in breaking negative cycles and breaking down the things that cause her to feel sad, worried, or apprehensive (Carpenter et al., 2018). Patient education to be provided to this patient would involve teaching her on the importance of being physically active, developing a sleep routine, and eating healthy. She would also be educated on the importance of adhering to the treatment plan to facilitate a fast recovery.

Reflection

In this particular patient encounter, one thing I could have done differently would have been to begin by greeting the patient and asking more questions that are unconnected to the planned appointment. This would have helped to establish an environment that was more friendly and inviting. During the course of an interview, it is essential for a PHMNP to cultivate a setting that is receptive of each and every patient. This will make it easier for the patient to comprehend that this is a setting dedicated to assisting them in their recovery and that they are welcomed regardless any flaws or faults. I must also keep my impartiality in my role as a PMHNP. Because of my commitment to ethics, I feel compelled to highlight the need of providing patients with assistance instead of criticizing them or treating them unjustly on the basis of the beliefs or inclinations.

Week 3: Anxiety, Obsessive-Compulsive and Related, and Trauma and Stressor-Related Disorders Anxiety disorders provide a good opportunity to take a close look at the nature/nurture debate as well as the gene/environment interactions that influence the nervous system and neurochemistry. A significant part of most of Sigmund Freud’s theories, the concept of anxiety has been debated and discussed over many years in the psychiatric literature. While Freud’s theories focused on the “mind” and the unconscious, another way to look at anxiety is with Hans Selye’s concept of “fight or flight” in which the sympathetic nervous system activates a response to stress. As you explore anxiety disorders, you will notice that no two cases of anxiety are the same. Obsessive-compulsive disorder is characterized by the presence of obsessive thoughts, which manifest as persistent thoughts, images, or even “urges.” The only way that the individual can disperse the anxiety of these persistent thoughts/images and urges is to perform a behavior (the compulsion). The compulsion could be checking things, counting, reciting a silent prayer, or repeating a number of phrases Focused SOAP Note for Anxiety, Obsessive-Compulsive and Related, and Trauma and Stressor-Related Disorders.

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The disorder becomes so pervasive that the person can spend a significant amount of time each day attending to the compulsion in order to relieve the anxiety caused by the obsession. Although trauma and stressor-related disorders stem from exposure to a traumatic or stressful event, not all exposures to trauma or stress will result in a disorder. However, following these types of events, patients may report symptoms that interfere with their ability to function well in one or more areas of their life, such as flashbacks, nightmares, or intense psychological or physiological distress. This week, you will explore evidence-based treatment methods for patients with anxiety, obsessive-compulsive, as well as trauma and stressor-related disorders. Learning Objectives Students will: Assess patients with anxiety, obsessive-compulsive, and trauma and stressor-related disorders Develop differential diagnoses for patients with anxiety, obsessive-compulsive, and trauma and stressor-related disorders Develop appropriate treatment plans for patients with anxiety, obsessive-compulsive, and trauma and stressor-related disorders Advocate health promotion and patient education strategies for patients with anxiety, obsessive-compulsive, and trauma and stressor-related disorders Learning Resources Required Readings (click to expand/reduce) Required Media (click to expand/reduce) Medication Review Review the FDA-approved use of the following medicines related to treating anxiety disorders, OCD, PTSD, and related disorders: Anxiety Generalized anxiety disorder Panic disorder alprazolam amitriptyline amoxapine buspirone chlordiazepoxide citalopram clomipramine clonazepam clonidine clorazepate cyamemazine desipramine diazepam dothiepin doxepin duloxetine escitalopram fluoxetine fluvoxamine gabapentin (adjunct) hydroxyzine imipramine isocarboxazid lofepramine loflazepate lorazepam maprotiline mianserin mirtazapine moclobemide nefazodone nortriptyline oxazepam paroxetine phenelzine pregabalin reboxetine sertraline tiagabine tianeptine tranylcypromine trazodone trifluoperazine trimipramine venlafaxine vilazodone alprazolam citalopram desvenlafaxine duloxetine escitalopram fluoxetine fluvoxamine mirtazapine paroxetine pregabalin sertraline tiagabine (adjunct) venlafaxine alprazolam citalopram clonazepam desvenlafaxine escitalopram fluoxetine fluvoxamine isocarboxazid lorazepam mirtazapine nefazodone paroxetine phenelzine pregabalin reboxetine sertraline tranylcypromine venlafaxine Posttraumatic stress disorder Reversal of benzodiazepine effects Social anxiety disorder citalopram clonidine desvenlafaxine escitalopram fluoxetine fluvoxamine mirtazapine nefazodone paroxetine prazosin (nightmares) propranolol (prophylactic) sertraline venlafaxine flumazenil citalopram clonidine desvenlafaxine escitalopram fluoxetine fluvoxamine isocarboxazid moclobemide paroxetine phenelzine pregabalin sertraline tranylcypromine venlafaxine Obsessive-compulsive disorder citalopram clomipramine escitalopram fluoxetine fluvoxamine paroxetine sertraline venlafaxine vilazodone Assignment: 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. Photo Credit: Photographee.eu / Adobe Stock 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 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-TRcriteria 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).

References

 American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders, fifth edition DSM-5 American Psychiatric Association, 2013.

Bains, N., & Abdijadid, S. (2021). Major depressive disorder. In StatPearls [Internet]. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK559078/

Carpenter, J. K., Andrews, L. A., Witcraft, S. M., Powers, M. B., Smits, J. A., & Hofmann, S. G. (2018). Cognitive behavioral therapy for anxiety and related disorders: A meta‐analysis of randomized placebo‐controlled trials. Depression and Anxiety, 35(6), 502-514. https://doi.org/10.1002/da.22728

Iani, L., Quinto, R. M., Lauriola, M., Crosta, M. L., & Pozzi, G. (2019). Psychological well-being and distress in patients with generalized anxiety disorder: The roles of positive and negative functioning. PLOS ONE, 14(11), e0225646. https://doi.org/10.1371/journal.pone.0225646

Kim, Y. (2019). Panic disorder: Current research and management approaches. Psychiatry Investigation, 16(1), 1-3. https://doi.org/10.30773/pi.2019.01.08 Focused SOAP Note for Anxiety, Obsessive-Compulsive and Related, and Trauma and Stressor-Related Disorders