Week 3 _ FOCUSED SOAP NOTE FOR ANXIETY, PTSD, AND OCD

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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 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. ( Attached documents)
  • Review the video, Case Study: Dev Cordoba. (See below the complete transcript.) 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.

THE ASSIGNMENT – INSTRUCTIONS

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-TRdiagnostic 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.
  • 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).

 

Case Study: Dev Cordoba.

 

Walden University. (2021). Case study: Dev Cordoba. Walden University Canvas. https://waldenu.instructure.com

 

Transcript:

  1. JENNY: Hi there. My name is Dr. Jenny. Can you tell me yourname and how old you are?

DEV CORDOBA: My name is Dev,and I am seven years old.

  1. JENNY: Wonderful. Dev, can you tell me whatthe month and the date is? And where are we right now?

DEV CORDOBA: Todayis St. Patrick’s Day. It’s March 17th.

  1. JENNY: Do youknow where we are?

DEV CORDOBA: We’reat the school.

  1. JENNY: Good. Did your mom tell you whyyou’re here today to see me?

DEV CORDOBA: She thought you were going to help me be better.

  1. JENNY: Yes, Iam here to help you. Have you ever come to seesomeone like me before, or talked to someone likeme before to help you with your mood?

DEV CORDOBA: No, never.

  1. JENNY: OK. Well, I would liketo start with getting to know you a little bitbetter, if that’s OK. What do you like to do forfun when you’re at home?

DEV CORDOBA: Oh, I have a dog. His name is Sparky. We play policeman in my room. And I have LEGOs, and I couldbuild something if you want.

  1. JENNY: I would love to seewhat you build with your LEGOs. Maybe you can bring thatin for me next appointment. Who lives in your home?

DEV CORDOBA: My mom and mybaby brother and Sparky.

  1. JENNY: Do you helpyour mom with your brother?

DEV CORDOBA: No. His breath smells likebad milk all the time. [CHUCKLES] And hecries a lot, and my mom spends more time with him.

  1. JENNY: So how do youfeel most of the time? Do you feel sad orworried or mad or happy?

DEV CORDOBA: Worried.

  1. JENNY: What types ofthings do you worry about?

DEV CORDOBA: I don’tknow, just everything. I don’t know.

  1. JENNY: OK. So your mom tells me you alsohave a lot of bad dreams. Can you tell me a littlemore about your bad dreams, like maybe what they’reabout, how many nights you might have them?

DEV CORDOBA: I dreama lot that I’m lost, that I can’t find my momor my little brother. They seem like they happenalmost every night, but maybe not some nights.

  1. JENNY: Now thatmust feel horrible. Have you ever been lost beforewhen maybe you weren’t asleep?

DEV CORDOBA: Oh, no. No. And I don’t like the dark. My mom puts me in a nightlight with the door open, so I know she’s really there.

  1. JENNY: That seems likethat probably would help. Do you like to go to school? Or would you rather not go?

DEV CORDOBA: I worryabout by mom and brother when I’m at school. All I can think aboutis what they’re doing, and if they’re OK. And besides, nobodylikes me there. They call me Mr. Smelly.

  1. JENNY: Well. That’s not nice at all. Why do you feelthey call you names?

DEV CORDOBA: I don’t know. But my mom says it’s becauseI won’t take my baths. [SIGHS] She tells

me to, and it– and I have night accidents.

  1. JENNY: Oh, how doesthat make you feel?

DEV CORDOBA: Sad and really bad. They don’t know how it feels fortheir daddy to never come home. What if my momdoesn’t come home too?

  1. JENNY: Yes, you seemto worry about that a lot. Does this worry stop you frombeing able to learn in school?

DEV CORDOBA: Well, [SIGHS]my teacher is, all the time, telling me to sitdown and focus. And I get in trouble for[SIGHS] looking out the window. And she moved mychair beside her desk, but I don’t mind becauseBilly leaves me alone now.

  1. JENNY: Billy. Have you ever hitBilly or anyone else?

DEV CORDOBA: No, but Idid throw my book at him.

  1. JENNY: Hmm.

DEV CORDOBA: [CHUCKLES]

  1. JENNY: What about yourself? Have you ever hit yourself orthought about doing something to hurt yourself?

DEV CORDOBA: No.

  1. JENNY: OK. Well, Dev, I would liketo talk to your mom now. We’re going to worktogether, and we’re going to help you feelhappier, less worried, and be able toenjoy school more. Is that OK?

DEV CORDOBA: Yes. Thank you.

MISS CORDOBA: Hi.

  1. JENNY: Thank you, MissCordoba, for bringing in Dev. I feel we can help him. So tell me, what is your

main concerns for Dev?

MISS CORDOBA: [SIGHS] Well,he just seems so anxious and worried all the time, sillythings like I’m going to die, or I won’t pickhim up from school. He says I love hisbrother more than him. He’ll throw thingsaround the house, and gets in trouble atschool for throwing things. He has a difficulttime going to sleep. He wants his lights on, doorsopen, gets up frequently. And he’s all the timewanting to come home from school, claims stomachaches, and headaches almost daily. He won’t eat. He’s lost three poundsin the past three weeks. Our pediatrician sent us toyou because he doesn’t believe anything is physically wrong. Oh, and I almost forgot. He still wets the bed at night. [SIGHS] We’ve tried everything. His pediatriciandid give him DDVAP, but it doesn’t seem to help.

  1. JENNY: Hmm. OK. Can you tell me,any blood relatives have any mental healthor substance use issues?

MISS CORDOBA: No, not really.

  1. JENNY: Whatabout his father? He said that he never came home?

MISS CORDOBA: Oh, yes. His father was deployed withthe military when Dev was five. I told Dev he was on vacation. I didn’t know what to tell him. I thought he was tooyoung to know about war. And his father waskilled, so Dev still doesn’t understand that hisfather didn’t just leave him. [SIGHS] I just feel so guiltythat all of this is my fault.

  1. JENNY: Miss Cordoba,you did the right thing by bringing in Dev. We can help you with him.

MISS CORDOBA: Oh, thank you.