FOCUSED SOAP NOTE FOR ANXIETY, PTSD, AND OCD
A patient complains, “I worry about my mum and brother,” and virtually every night, he has a dream in which he is lost. The patient is still bedwetting.
HPI: The patient, a 7-year-old White boy with a volatile mood, visited the doctor’s office with his mother. The patient claims that he is really concerned about his mother and younger brother. The mother claimed that the patient would find any justification to return home from school. The patient fears losing his mother and sibling and losing his father when he was five years old. The patient struggles with a concentration in class and experiences bullying there. The mother has addressed the patient’s hygiene, although the patient has occasionally refused to take a bath.
The patient still wets the bed, and virtually every night, they have nightmares. Nowadays, the patient denies any self-harming thoughts. The patient has never harmed himself.
No Current Usage of Substance
Family and social Hx: Patient has few friends at school and no FHX of mental illness. It is abused and referred to as “Mr. Smelly.”
Current prescriptions: For bedwetting, the patient is now taking DDVAP. Allergies Unknown allergies
The patient is an unmarried child with no reproductive issues.
General: The patient shed 3 pounds in the last 3 weeks without experiencing any medical problems. The patient disputes any temperature or fatigue.
HEENT: The patient denies experiencing a headache, itchy or uncomfortable eyes, ear trouble, or nosebleeds. The patient disputes any oral discomfort, chewing or swallowing issues.
Cardiovascular: The patient disputes having heart palpitations or chest pain. Respiratory: The patient disputes having a cough or trouble breathing.
Musculoskeletal: The patient disputes anybody or muscle pain. Neurological: Consistent gait; patient disputes headache and vertigo. Skin: The patient disputes any itching or rashes.
In order to rule out any medical conditions connected to the patient’s enuresis, a urinalysis would be prescribed as the diagnosis.
Assessment of the patient’s mental state reveals that he is a White boy aged 7 who appears to be that age. The patient is awake and aware of the name, month, and day. The patient may make direct eye contact with the doctor and is dressed appropriately for the season. The patient is helpful and able to respond to inquiries quickly. Normal loudness and clear, comprehensible speech are used. The patient’s recent and distant memories remain unharmed. While speaking about his mother and brother, the patient appeared depressed and anxious. The patient disputes hearing and seeing things, as well as having suicidal or murderous ideas.
PTSD is a mental illness that can affect people who have been through traumatic, startling, or hazardous events. (2015) Kammer, Seedat, and Stein. After encountering a frightening incident, it is normal to feel fearful, but experiencing recurring nightmares, terrifying thoughts, and other symptoms that interfere with a child’s regular activities leads to the diagnosis of PTSD. The patient’s father passed away two years ago, and he has not really processed it. The patient feels like his father has abandoned him. The patient worries greatly about losing his mother and has dreams about getting lost.
ADHD is a type of mental disease characterized by difficulties focusing and paying attention. ( NIH, 2021). My patient struggles to concentrate in class; he frequently finds his eyes straying out the window. The teacher had to encourage the patient to keep focused while at school repeatedly.
Many kids have a separation anxiety disorder (SAD), which causes them to feel anxious when they are not with their parents. Those who have gone through painful experiences like the death of a family member may become too attached to their live parents and fear losing them as well. (2021; Boston Children’s Hospital). SAD patients have trouble concentrating in class and may experience feelings of impending doom. In order to be brought home near his mother, my patient frequently pretended to be ill at school.
I discovered throughout our conversation that the patient’s mother feels somewhat responsible for her son’s current predicament. When his father died, the patient believed he was being abandoned by his father, according to the patient’s mother. Did the patient’s mother have an opportunity to explain the situation to her son? The mother is reckless around the patient and overburdened with the infant. The mother informed the patient that she knew he was referred to as Mr. Smelly at school and that, occasionally, the patient did not want to take a shower. As the patient is 7 years old, his mother ought to correct him when he behaves incorrectly. Beneficience-based ethical concepts would be used. Family counseling with her son would be extremely beneficial for the mother, who appears to be in desperate need of assistance.
Case Development and Treatment Strategy
The patient’s treatment strategy would take into account his SAD, ADHD, and PTSD diagnostics. The patient will begin counseling right away, and cognitive behavioral therapy (CBT) is the most effective option at this time because it has been shown effective in treating anxiety disorders in children and adolescents. Randomized clinical trials have shown that at the end of treatment, almost two-thirds of children who received CBT were free of their primary disease. (Ollendick, Seligman, 2017). Treatment will involve a family session with the patient’s mother; strengthening the patient’s relationship with her mother is essential. To strengthen the patient’s sense of security and enhance the quality of their connection, CDI, a type of cognitive behavioral therapy, will be employed. CDI would involve the parent showing warmth, attention, and praise. For a period of eight weeks, the patient would be scheduled for at least one family session and one individual session each. The next treatment plan would then be developed after evaluating the patient’s conduct. Normally, I would not start a patient on PTSD or SAD medication, but if necessary, I would give them Prozac 10 mg once daily for PTSD and SAD. When the next visit was set up, the patient’s medication would be evaluated.
Boston children Hospital. (2021). Separation Anxiety Disorder Symptoms & Causes. Retrieved from https://www.childrenshospital.org/conditions-and- treatments/conditions/s/separation-anxiety- Kaminer, D., Seedat, S., & Stein, D. J. (2015). Post-traumatic stress disorder in children. World psychiatry : official journal of the World Psychiatric Association (WPA), 4(2), 121–125.
National Institute of mental Health. (2021). Attention-Deficit/Hyperactivity Disorder. Retrieved from https://www.nimh.nih.gov/health/topics/attention-deficit-hyperactivity-disorder- adhd
Seligman, L. D., & Ollendick, T. H. (2017). Cognitive-behavioral therapy for anxiety disorders in youth. Child and adolescent psychiatric clinics of North America, 20(2), 217–238. https://doi.org/10.1016/j.chc.2017.01.003 disorder/symptoms-and-causes
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- 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.
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