NRNP 6675 Focused SOAP Note for Anxiety, PTSD, and OCD Walden University
Subjective:
Chief Complaint (CC): “Anxious and worried all the time.”
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History of Present Illness (HPI): A 7-year-old child and his mother presented for a mental evaluation at the inpatient psychiatric facility. The mother reports that her son has experienced persistent anxiety and worry since early childhood, primarily centered around fears of her death or forgetting to pick him up from school. There is no specific triggering event for the heightened anxiety. The patient also believes that his mother favors his younger sibling over him, leading to defiance and self-harming behaviors, including throwing objects at home and school. He experiences recurring nightmares, making it difficult for him to fall asleep. The patient feigns stomachaches and headaches at school to be sent home and hasn’t eaten in days, resulting in a three-pound weight loss. Despite being prescribed DDVAP for bedwetting, he still wets the bed occasionally.
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Substance Use History: There is no family history of mental illness or substance abuse.
Medical History:
Current Medications: The patient uses 100 micrograms of DDVAP for bedwetting.
Allergies: No known allergies to food, environmental factors, or medications.
Surgeries: No history of surgical procedures.
Chronic Diseases: No documented chronic illnesses.
Major Traumas: No prior traumatic experiences.
Hospitalization: No previous hospitalizations.
Past Medical History: The pediatrician diagnosed the patient with nocturnal enuresis and prescribed DDVAP 100mg.
Family History: The patient has a close relationship with his mother and younger sibling. His father was killed in a military deployment when the patient was just five years old.
Social History: The patient enjoys playing with pets and takes on the role of a policeman in his room with his dog when at home. He also has an interest in building with LEGOs.
Review of Systems (ROS):
– GENERAL: No night sweats, chills, fatigue, or fever. Recent weight loss of approximately 3 pounds is noted.
– HEENT: The patient reports headaches but no head injuries, changes in hair, vertigo, or loss of consciousness. No double vision, blurriness, or vision changes. He denies wearing glasses or experiencing unusual vision. His eyes show no abnormalities, discomfort, discharge, dizziness, or ringing in the ears. He denies nosebleeds, sinus issues, post-nasal drip, or congestion. No gum disease, hoarse voice, sore throat, toothaches, swallowing difficulties, bleeding gums, or ulcers are reported.
– SKIN: The skin is intact with no hives, rashes, itching, or signs of skin problems.
– CARDIOVASCULAR: No orthopnea, irregular heartbeat, palpitations, rapid or slow heartbeats, edema, or chest discomfort.
– RESPIRATORY: Denies persistent cough, sputum, discomfort, or noisy breathing.
– GASTROINTESTINAL: No diarrhea, constipation, or vomiting. The patient has a reduced appetite and reports stomach discomfort.
– GENITOURINARY: Denies painful urination, unusual urine color, hesitancy, or urgency.
– NEUROLOGICAL: Denies fainting, weakness, temporary paralysis, loss of consciousness, or seizure-like episodes. The patient mentions experiencing headaches.
– MUSCULOSKELETAL: No joint pain, muscle soreness, or back pain. Full range of motion in all extremities without stiffness.
– HEMATOLOGIC: No history of bleeding issues or injuries.
– LYMPHATICS: No previous history of enlarged lymph nodes or splenectomy.
– ENDOCRINOLOGIC: Denies polyuria, polydipsia, or sensitivity to heat or cold.
Objective:
Diagnostic Results:
Lab Tests: Given the potential impact of thyroid issues on mood, a thyroid function test is recommended. Routine hemoglobin (Hb) and white blood cell (WBC) tests are performed. Liver function tests (LFTs) and basic metabolic panels are essential to evaluate hepatic and renal status for dosage adjustments, particularly with psychotropic medications (Ayano et al., 2020). Drug and cortisol testing is conducted, and CT scans and head X-rays are ordered to rule out anatomical abnormalities. Echocardiography and ECG are necessary to determine the optimal psychotropic agent.
Pediatric Assessment Tools: The patient’s body temperature, BMI, blood pressure (BP), and respiratory rate (RR) are recorded. Age-appropriate dental development is assessed, along with the patient’s dietary habits to ensure proper intake of vitamins, carbohydrates, fiber, and proteins. Growth and vaccination status are also examined.
Assessment:
Mental Status Examination: The 7-year-old patient presented well-dressed and age-appropriate in the examination room. He demonstrated intact orientation to person, place, and time, remaining cooperative and maintaining eye contact. He communicated fluently and clearly but appeared preoccupied, frequently checking for the presence of his mother. The patient’s cognitive processes were logically structured, and both short- and long-term memory appeared unimpaired. He expressed a melancholic mood and a belief that he is going to die. He denied experiencing hallucinations, suicidal thoughts, or delirium.
Diagnostic Impression:
1. Separation Anxiety Disorder (SAD): The patient exhibits symptoms consistent with SAD, which commonly develops in children who have experienced the loss of a parent or separation from loved ones. According to DSM-5 criteria, SAD patients must display excessive anxiety for their developmental stage, along with specific symptoms such as recurrent nightmares, avoidance of sleeping alone in the dark, extreme distress when separated from family, and physical complaints like headaches or stomach pain during separation (Krause et al., 2021). The patient meets the criteria for a diagnosis of SAD.
2. Generalized Anxiety Disorder (GAD): GAD typically involves excessive, unrealistic, and persistent worrying about various matters (Plaisted et al., 2021). DSM-5 diagnostic criteria require severe and uncontrollable anxiety for at least six months, accompanied by symptoms like sleep disturbances, muscle tension, concentration difficulties, irritability, restlessness, and excessive fatigue (Ayano et al., 2020). The patient in this case study exhibits several of these symptoms. However, his specific fear of separation from his mother excludes a diagnosis of GAD.
3. Oppositional Defiant Disorder (ODD): ODD in children is characterized by persistent anger, irritability, vindictiveness, and defiance lasting more than six months. This condition is often seen in children who have experienced loss or separation (Impey, Gordon, & Baldwin, 2020). Symptoms may include argumentativeness, irritability, decreased energy, disinterest in daily tasks, withdrawal, and a sad mood, as outlined in DSM-5 criteria (Plaisted et al., 2021). While most of these symptoms are present in the case study patient, the primary diagnosis of SAD takes precedence, making ODD an incorrect diagnosis.
Reflections: The patient’s mental examination is appropriate for his age and provides comprehensive information for reaching a diagnosis. Involving the patient’s mother in decision-making is essential, as the patient is a minor (Impey et al., 2020). Therefore, the PMHNP must inform the mother of the diagnosis and potential treatment options while considering the patient’s care.
Case Formulation and Treatment Plan:
Primary Diagnosis: Separation Anxiety Disorder (SAD).
Psychotherapy: Cognitive behavioral therapy (CBT) is recommended as the first-line treatment for SAD in children (Elmore & Crouch, 2020).
Pharmacotherapy: Consider selective serotonin reuptake inhibitors, such as Zoloft, for further management of the patient’s symptoms. However, careful dose adjustment and close monitoring are crucial due to the medication’s association with increased suicidal thoughts in children (Elmore & Crouch, 2020).
Health Promotion: The patient’s mother should establish a regular eating and sleeping schedule to support his sleep patterns (Impey et al., 2020).
Patient Education: The patient’s mother should be informed of her essential role in assisting her son with following the recommended interventions, including participation in psychotherapy.
Follow-up: The patient should return to the clinic after four weeks to assess treatment effectiveness and make any necessary adjustments.
References
Ayano, G., Betts, K., Maravilla, J. C., & Alati, R. (2020). The risk of anxiety disorders in children of parents with severe psychiatric disorders: a systematic review and meta-analysis. Journal of Affective Disorders.https://doi.org/10.1016/j.jad.2020.12.134
Elmore, A. L., & Crouch, E. (2020). The Association of Adverse Childhood Experiences with Anxiety and Depression for Children and Youth, 8 to 17 Years of Age. Academic Pediatrics, 20(5). https://doi.org/10.1016/j.acap.2020.02.012
Impey, B., Gordon, R. P., & Baldwin, D. S. (2020). Anxiety disorders, post-traumatic stress disorder, and obsessive-compulsive disorder. Medicine.https://doi.org/10.1016/j.mpmed.2020.08.005
Krause, K. R., Chung, S., Adewuya, A. O., Albano, A. M., Babins-Wagner, R., Birkinshaw, L., … & Wolpert, M. (2021). International consensus on a standard set of outcome measures for child and youth anxiety, depression, obsessive-compulsive disorder, and post-traumatic stress disorder. The Lancet Psychiatry, 8(1), 76-86.https://doi.org/10.1016/S2215-0366(20)30356-4
Plaisted, H., Waite, P., Gordon, K., & Creswell, C. (2021). Optimizing exposure for children and adolescents with anxiety, OCD and PTSD: a systematic review. Clinical Child and Family Psychology Review, 1-22.https://doi.org/10.1007/s10567-020-00335-z
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