FOCUSED SOAP NOTE FOR ANXIETY, PTSD, AND OCD

Subjective

CC: Patient states ” I worry about my mom and brother” patient has nightmare almost every night where he feels lost. patient still wet the bed

HPI: Patient is a a 7 year old Caucasian male that came to the Dr office with mother for unstable mood. Patient states he worries a lot about his mother and little brother. Mother said patient will come up with any excuses to go back home from school. Patient lost father at age 5 and is scare of loosing his mother and brother. Patient has hard time focusing at school, is bullied at school. Patient hygiene has been addressed by mother but patient sometimes refused to take a bath.

Patient still wet the bed, and has nightmare almost every night. Currently, patient denies thought of hurting others of self. Patient has never engaged in self harm behavior.

Substance Current Use: None

Family and social Hx: There is no FHX of mental illness; patient does not have many friends at school. it is bullied and called ” Mr Smelly”

Current medication: Currently, patient is taking DDVAP for bedwetting Allergies: No known Allergy

Reproductive Hx: Patient is a child with no children

ROS

General: Patient lost 3 lbs in the past 3 weeks without any medical issue. Patient denies fever or fatigue

HEENT: Patient denies headache, painful or itchy eyes, denies ear pain, running nose or nose bleed. patient denies mouth pain, difficulty chewing or swallowing food.

Cardiovascular: Patient denies chest pain, irregular heartbeat. Respiratory: Patient denies cough, or difficulty breathing.

Musculoskeletal: Patient denies muscle or body pain. Neurological: Steady gait, Patient denies headache, dizziness. Skin: Patient denies itching and the presence of any rashes.

Objective

Diagnostic Result: urinalysis would be ordered to r/o any medical condition related to patient with enuresis

Assessment

Mental Status Examination: Patient is a 7 year old Caucasian male, looking his stated age. Patient is alert and oriented to name, month and date. Patient is appropriately dressed for the season, able to make direct eye contact when talking to the Dr. Patient is cooperative and is able to answer questions in a timely manner. Speech is coherent and clear with normal volume. patient recent and remote memory are intact. Patient appeared sad and worries while talking about his mother and brother. Patient denies auditory and visual hallucination, suicidal and homicidal thoughts.

Diagnostic Impression:

PTSD: is a mental disorder that can find in individualwho experiencienced traumatic, shocking or dangerous event. (Kaminer, Seedat, & Stein, 2015). It is normal to feel afraid after facing a scary situation, but having constant scary thoughts, nightmare, and symptoms that interferes with a children daily activities result in the diagnostic of PTSD. Patient lost his father 2 years ago and has not properly process it. Patient thinks his father abandoned him. Patient has nightmares of being lost and is excessively worried of losing his mother.

ADHD: is a mental illness caused by difficulty to stay focus and maintaining attention. ( NIH, 2021). My patient has a hard time paying attention to teacher at school, his sight kept wandering out of the windown during class. Patient had to be reminded many times at school by the teacher to stay focus

Separation Anxiety Disorder (SAD): Many children experience feeling of anxiety when away from parents. Others, having experiencing some traumatic event as death of a family member may became clingy to the living parents and scared of loosing them too. ( Boston Children Hospital, 2021). Children having SAD have hard time focusing at school and may have feeling of imprending doom. My patient tied manhy times to make excuse of sickness at school in order to be sent home close to his mother.

Reflections:

During my discussion with the patient i learned that patient’s mother feels somewhat guilty of her son current situation. Mother said patient thought his father was on vacation at the time of his death and now the patient believes he was abandoned by his father, did he mother has a chance to clarify that situation with her son? Mother appear to be overwhelmed with the baby and a little careless with the patient. Patient stated they called him Mr smelly at school and the mother is aware of that and stated patient does not want to take shower sometimes. Patient is a 7 years old and the mother should be the one correcting him when he does wrong. Ethical principles of beneficence would be used. Mother looks like she is in great needs of help would greatly benefit from family therapy with her son.

Case Formulation and Treatment Plan

Patient’s treatment plan would include his diagnostic which is SAD, ADHD, and PTSD. Patient will start immediately a therapy session and Cognitive Behavioral therapy (CBT) would be the best choice at this time because CBT have shown to be efficace for the treatment of anxiety disorders in children and adolescents. Randomized clinical trials indicate that approximately two-thirds of children treated with CBT will be free of their primary diagnosis at posttreatment. (Seligman, & Ollendick, 2017). Family session with patient’s mother would be included during terapy; improving patient’s retaionship with mother is crucial. Child directed interaction or CDI which is a form of CBT would be used to improve the quality of their relationship and will strength the patient’s feeling of safety. CDI would involve praise, attention and warm from the parent. Patient would be scheduled to have at least one family session and one individual session each for 8 weeks. After that, patient behavior would be assessed to form the next treatment plan. Usually I would not start patient on medication for PTSD or SAD but if needed, I will put patient on Prozac 10mg once daily for PTSD and SAD. Patient medication would be reviewed in 8 weeks when he next appointment would be scheduled.

References

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.
  

  FOCUSED SOAP NOTE FOR ANXIETY, PTSD, AND OCD

• 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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