Focused SOAP Note for Generalized anxiety disorder, Major depressive disorder, Dysthymia, Social anxiety disorder, and Panic disorder
For this Assignment, you will document information about a patient that you examined during the last 3 weeks, using the Focused SOAP Note Template provided. You will then use this note to develop and record a case presentation for this patient. Be sure to incorporate any feedback you received on your Week 3 and Week 7 case presentations into this final presentation for the course.
To Prepare
Review the Kaltura Media Uploader resource in the left-hand navigation of the classroom for help creating your self-recorded Kaltura video.
Select a child or adolescent patient that you examined during the last 3 weeks who presented with a disorder for which you have not already created a Focused SOAP Note in Weeks 3 or 7. (For instance, if you selected a patient with anorexia nervosa in Week 7, you must choose a patient with another type of disorder for this week.)
Create a Focused SOAP Note on this patient using the template provided in the Learning Resources. There is also a completed Focused SOAP Note Exemplar provided to serve as a guide to assignment expectations.
Please Note:
All SOAP notes must be signed, and each page must be initialed by your Preceptor. Note: Electronic signatures are not accepted.
When you submit your note, you should include the complete focused SOAP note as a Word document and PDF/images of each page that is initialed and signed by your Preceptor.
You must submit your SOAP note using SafeAssign. Note: If both files are not received by the due date, faculty will deduct points per the Walden Grading Policy.
Then, based on your SOAP note of this patient, develop a video case study presentation. Take time to practice your presentation before you record.
Include at least five scholarly resources to support your assessment, diagnosis, and treatment planning.
Ensure that you have the appropriate lighting and equipment to record the presentation.
The Assignment
Record yourself presenting the complex case study for your clinical patient. In your presentation:
- Dress professionally with a lab coat and present yourself in a professional manner.
- Display your photo ID at the start of the video when you introduce yourself.
Ensure that you do not include any information that violates the principles of HIPAA (i.e., do not use the patient’s name or any other identifying information).
Present the full complex case study. Include chief complaint; history of present illness; any pertinent past psychiatric, substance use, medical, social, family history; most recent mental status exam; current psychiatric diagnosis including differentials that were ruled out; and plan for treatment and management.
Report normal diagnostic results as the name of the test and “normal” (rather than specific value). Abnormal results should be reported as a specific value.
Be succinct in your presentation, and do not exceed 8 minutes. Specifically address the following for the patient, using your SOAP note as a guide:
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 their mental status examination results. What were your differential diagnoses? Provide a minimum of three possible diagnoses and why you chose them. List them from highest priority to lowest priority. What was your primary diagnosis, and why? Describe how your primary diagnosis aligns with DSM-5 diagnostic criteria and is supported by the patient’s symptoms.
Plan: What was your plan for psychotherapy (include one health promotion activity and patient education)? What was 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.
Reflection notes: What would you do differently with this patient if you could conduct the session over? If you can follow up with your patient, explain whether these interventions were successful and why or why not. If you were not able to conduct a follow-up, discuss what your next intervention would be.
Solution
Week (enter week #): (Enter assignment title)
Student Name
College of Nursing-PMHNP, Walden University
NRNP 6665: PMHNP Care Across the Lifespan I
Faculty Name
Assignment Due Date
Subjective:
CC (chief complaint): Patient C.T presents to the clinic with excessive worrying and anxiety
HPI: The 18-year-old Caucasian male presents to the office for worrying and excessive anxiety. He highlights the worrying increases when he expects something to happen and is uncertain about the effects. He experiences restlessness and has trouble concentrating.
Substance Current Use: None
Medical History:
Current Medications: The patient is on vitamin D supplements
Allergies: No reported allergies
Reproductive Hx: He is sexually active. No history of STIs
ROS:
- GENERAL: No significant increase or reduction of weight
- HEENT: No eye pain, redness or vision changes, no sour taste, no sneezing, no runny nose no sneezing
- SKIN: skin is warm to touch, no redness or itching…
- CARDIOVASCULAR: no palpations, no chest pressure, denies chest pain or edema
- RESPIRATORY: No shortness of breath, no wheezing, denies cough or sputum
- GASTROINTESTINAL: No diarrhea, no constipation no abdominal pin no anorexia
- GENITOURINARY: no changes in urinary pattern, no urgency, no burning sensation, no incontinence
- NEUROLOGICAL: Denies tingling, no dizziness, no headache, no paralysis, no confusion no syncope
- MUSCULOSKELETAL: No pain or weakness of the joints, no stiffness
- HEMATOLOGIC: No history of anemia, no bleeding no bruising
- LYMPHATICS: No swollen lymph nodes, has no history of splenectomy
- ENDOCRINOLOGIC: No cold or heat intolerance
Objective:
Vitals: Temp 96.4, Pulse rate of 84, Respiration rate 18, B/P 128/78
Diagnostic results: The Hamilton Anxiety rating yielded 26 an indication of the prevalence of generalized anxiety disorder
Laboratory results: CBC within normal ranges
Assessment:
Mental Status Examination: He is an 18-year–old Caucasian male who appears his age. He cooperates during the session though seems restless. He fidgets on the chair and is having trouble concentrating throughout the interview. He is well dressed though has unkempt hair He keeps pressing his fingers during the interview. Has no signs of hallucinations. He denies suicidal thoughts.
Diagnostic Impression: Generalized anxiety disorder (GAD). The differential diagnoses are major depressive disorder, dysthymia, social anxiety disorder, and panic disorder
Generalized anxiety disorder
The DSM-5 diagnostic criteria for GAD entails several symptoms including the presence of excessive anxiety and worry over events and activities for at least six months. The worry tends to be too much and difficult to control. The worry and anxiety should be accompanied by three of the following: edginess or restlessness, tiring easily, irritability, increases muscle soreness or pain, and difficulty sleeping (American Psychiatric Association, 2013).
Major depressive disorder
The first differential diagnosis is a major depressive disorder. The diagnosis of major depressive disorder should be supported by the presence of five or more symptoms which must appear for at least two weeks, The symptoms include loss of pleasures in activities that one enjoyed, insomnia, depressed mood, weight gain or loss, agitation, and retardation (Mullen et al., 2018). Major depressive disorder results in poor life, escalation of medical costs, and overall unhappiness among the patients. It, therefore, communicates the need for early screening and diagnosis to adopt the best treatment and management procedure to improve functioning and quality of life.
Dysthymia (persistent depressive disorder)
Dysthymia refers to a condition characterized by loss of interest in pleasurable activities, hopelessness, low appetite, low self-esteem, poor concentration, low energy levels, and sleep changes. Nursing Literature shows that dysthymia can be difficult to diagnose until it later manifests as major depressive disorder (Schramm et al., 2020). It is therefore vital for the healthcare practitioners to accurately diagnose the condition with the ultimate goal of putting the patients under the correct treatment plans.
Social anxiety disorder
Social anxiety disorder is also referred to as a social phobia. People with this disorder have everyday social interactions with others causing irrational anxiety, fear, embarrassment, and self-consciousness. Symptoms of a social anxiety disorder include excessive fear, worry of being embarrassed, humiliated, and judged. Due to the fear of humiliation and rejection, social anxiety disorder is often associated with avoidance behavior that subsequently impairs a person’s social life (Chadelaine, et al., 2018). It has negative consequences on a person’s educational attainment, relationships, occupational performance, and quality of life.
Panic disorder
Panic disorder according to the DSM-5 refers to abrupt surges of fear and discomfort which peak within minutes. Individuals with the condition usually fear having panic attacks. According to Kim (2019), the prevalence of panic disorders in the general population is 2.1 to 2.7 percent. Panic disorders are usually associated with chronic progression, escalating medical costs, and low quality of life.
Reflections:
What I would do differently with this patient is to modify the management process which I used. Initially, I only recommended medication only for the management of the condition. If I were to change the treatment regimen, I would recommend the use of a combination of pharmacological agents and therapy. I initiated the treatment process with Escitalopram which is a selective serotonin reuptake inhibitor that is recommended as first-line treatment. I would therefore combine the medication with therapy. Nursing literature has shown that a combination of therapy and medication is effective in the management of generalized anxiety disorder symptoms.
Case Formulation and Treatment Plan:
Having diagnosed the patient with generalized anxiety disorder, the treatment plan was a combination of psychotherapy and pharmacological agents. The patient was put on selective serotonin reuptake inhibitors (SSRIs) Escitalopram. The medication aimed at lowering the anxiety symptoms and reduce worrying which impaired the patient’s quality of life (Locke et al., 2015).
Some of the side effects of the medication include insomnia, weight changes, yawning, sweating, dizziness, feeling shaky, dry mouth, drowsiness, weakness, decreased sex drive, impotence, difficulty having an orgasm, and loss of appetite among others.
The patient was encouraged to take the medication as indicated to minimize cases of symptoms relapse or better still adverse events which are linked with the discontinuation of medications abruptly.
The client seemed to have an in-depth understanding of the discussion and most importantly agreed to follow the guidelines as advised and discussed during the session.
The patient is required to call 911 in case of any emergency. In case of hives or allergic reactions, the patient should seek healthcare services to minimize cases of adverse events.
The patient is required to return to the clinic after four weeks for follow-up. During the follow-up, the patient and the practitioner will discuss any notable event and the patient’s health as an indication of positive healthcare outcomes as required. The follow-up is also required to improve functioning and lower chronic symptoms which could escalate costs of care and at the same time require a high level of care and management.
References
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Publishing.
Chapelaine, A., Carrier, J. D., Fournier, L., Duhoux, A., & Roberge, P. (2018). Treatment adequacy for social anxiety disorder in primary care patients. PloS one, 13(11), e0206357.
Kim Y. K. (2019). Panic Disorder: Current Research and Management Approaches. Psychiatry investigation, 16(1), 1–3. https://doi.org/10.30773/pi.2019.01.08
Locke, A., Kirst, N., & Shultz, C. G. (2015). Diagnosis and management of generalized anxiety disorder and panic disorder in adults. American family physician, 91(9), 617-624.
Mullen S. (2018). Major depressive disorder in children and adolescents. The mental health clinician, 8(6), 275–283. https://doi.org/10.9740/mhc.2018.11.275
Schramm, E., Klein, D. N., Elsaesser, M., Furukawa, T. A., & Domschke, K. (2020). Review of dysthymia and persistent depressive disorder: history, correlates, and clinical implications. The Lancet Psychiatry, 7(9), 801-812.