NRNP 6675 Focused SOAP NOTE For Anxiety, PTSD, And OCD

NRNP 6675 Focused SOAP Note for Anxiety, PTSD, and OCD

Subjective:

CC (Chief Complaint):
“I feel worried all the time and I have bad dreams. I worry about my mom and my baby brother when I am at school.”

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HPI (History of Present Illness):
Dev Cordoba is a 7-year-old boy who presents with persistent anxiety and worry that has been occurring for several weeks. The onset of symptoms developed gradually and has become more noticeable recently. Dev reports feeling worried most of the time and states that he worries about his mother and baby brother when he is away from home, especially while at school. The location of the distress is emotional and psychological rather than physical, although he frequently complains of stomach aches and headaches during the school day. The character of the symptoms includes constant worry, fear of being separated from his mother, difficulty concentrating in school, and sadness when peers tease him. Associated symptoms include frequent nightmares about being lost and unable to find his family, fear of the dark, difficulty sleeping without a night light and an open door, bedwetting at night, decreased appetite, and recent weight loss of three pounds within three weeks. The timing of symptoms occurs daily and the nightmares occur most nights. The symptoms appear to worsen when Dev is separated from his mother or when he attends school. Relieving factors include reassurance from his mother and sleeping with a night light and an open door. The severity of the symptoms is moderate to significant because they interfere with his sleep, school performance, appetite, and social interactions.

Substance Current Use: No report of alcohol, tobacco, or drug use. His mother did not report any exposure to substances in the home.

Medical History: history of nighttime bedwetting and sleep difficulties. His mother reports frequent headaches and stomach aches, especially when he is expected to attend school. His pediatrician evaluated these symptoms and did not identify a physical medical condition. Dev has also experienced recent weight loss of approximately three pounds within the past three weeks related to decreased appetite.

  • Current Medications: DDAVP (desmopressin) was prescribed by the pediatrician to treat nighttime bedwetting, but his mother reports that the medication has not improved the symptoms.
  • Allergies: No medication, food, or environmental allergies were reported.

ROS

GENERAL: Reports recent weight loss of approximately three pounds within the past three weeks. Decreased appetite noted. No fever, chills, or fatigue reported.

HEENT: Reports frequent headaches. No vision changes, ear pain, nasal congestion, or sore throat reported.

SKIN: No rashes, lesions, or skin infections reported.

CARDIOVASCULAR: No chest pain, palpitations, or syncope reported.

RESPIRATORY: No cough, wheezing, or shortness of breath reported.

GASTROINTESTINAL: Reports frequent stomach aches, especially during school hours. Decreased appetite noted. No vomiting, diarrhea, or constipation reported.

GENITOURINARY: Reports nighttime bedwetting (nocturnal enuresis). No pain with urination or urinary frequency reported during the day.

NEUROLOGICAL: Reports frequent headaches. Difficulty concentrating in school due to worry. No seizures, dizziness, or loss of consciousness reported.

MUSCULOSKELETAL: No muscle pain, joint pain, or mobility problems reported.

HEMATOLOGIC: No history of anemia, bruising, or bleeding disorders reported.

LYMPHATICS: No swollen lymph nodes reported.

ENDOCRINOLOGIC: Recent weight loss noted. No heat intolerance, cold intolerance, or excessive thirst reported.

Objective:

Dev Cordoba is a 7-year-old boy who appears his stated age. He is alert and oriented to time and place during the interview. Dev is cooperative but appears anxious. He reports frequent worry and nightmares about being lost and unable to find his mother or brother. Affect appears sad when discussing teasing at school and concerns about his family.

Diagnostic results: No laboratory tests or imaging studies

Assessment:

Mental Status Examination:

Dev Cordoba is a seven-year-old boy who appears his stated age and is appropriately dressed. He is alert and oriented to person, place, and time. His behavior is cooperative during the interview. Speech is clear and appropriate for his age. Mood is described as worried. Affect appears anxious and sad when discussing school and family concerns. Thought process is logical. Thought content shows excessive worry about his mother and brother. No hallucinations, delusions, or suicidal thoughts reported. Attention and concentration appear reduced. Insight and judgment are appropriate for developmental age.

Diagnostic Impression:

  1. Separation Anxiety Disorder – ICD-10-CM Code F93.0 (Highest Priority)

DSM-5-TR criteria for Separation Anxiety Disorder include excessive fear or anxiety about separation from attachment figures, persistent worry about losing caregivers, reluctance to go to school due to fear of separation, nightmares about separation, and physical symptoms during separation (Harasymiw et al., 2023). Dev meets several of these criteria. Pertinent positives include persistent worry about his mother and baby brother while he is at school, nightmares about being lost and unable to find his family, stomach aches and headaches when attending school, refusal to attend school, and difficulty sleeping unless the door is open and a night light is on. These symptoms interfere with school performance and daily functioning. Pertinent negatives include no hallucinations, no delusions, no suicidal thoughts, and no substance exposure. Dev’s symptoms strongly focus on fear of losing his mother, which directly matches DSM-5-TR criteria for Separation Anxiety Disorder. This diagnosis best explains the pattern and severity of his symptoms.

  1. Generalized Anxiety Disorder – ICD-10-CM Code F41.1

DSM-5-TR criteria for Generalized Anxiety Disorder include excessive anxiety and worry about several activities or events occurring more days than not for at least six months, along with symptoms such as restlessness, difficulty concentrating, irritability, muscle tension, and sleep disturbance. Pertinent positives in Dev’s case include constant worry, headaches, stomach aches, sleep disturbance due to nightmares, and difficulty concentrating in school (Mishra et al., 2023). However, DSM-5-TR criteria require worry across multiple areas of life. Dev’s anxiety is mainly focused on separation from his mother and concern for his family’s safety. Pertinent negatives include the absence of widespread worry about school performance, friendships, or other life domains. Because the anxiety is specifically linked to separation rather than generalized worry, DSM-5-TR criteria do not fully support Generalized Anxiety Disorder as the primary diagnosis.

  1. Adjustment Disorder with Anxiety – ICD-10-CM Code F43.23

DSM-5-TR criteria for Adjustment Disorder include emotional or behavioral symptoms that develop within three months of an identifiable stressor and cause distress or impairment in functioning. Dev has experienced a significant life stressor because his father died during military deployment. Pertinent positives include anxiety, sleep disturbance, behavioral problems at school, and emotional distress related to family concerns (Bermudez et al., 2023). However, DSM-5-TR criteria require that symptoms begin shortly after the stressor and usually resolve within six months once the stressor ends. Pertinent negatives include the timeline of symptoms. Dev’s father died approximately two years ago, and the anxiety symptoms appear ongoing rather than a recent reaction. This pattern makes Adjustment Disorder less likely and helps rule it out as the primary diagnosis.

Reflections:

I would spend more time building rapport with Dev and using age-appropriate communication, such as play-based conversation or drawing, to help him express his worries more comfortably. Dev is only seven years old, so therapeutic play could help him describe his fears about his mother and brother. I would also explore his understanding of his father’s absence because he has not been told that his father died. Clarifying this situation carefully with his mother could help reduce confusion and anxiety. My next intervention would include referral for child-focused cognitive behavioral therapy and family therapy to address separation anxiety and grief. Education for the mother about anxiety symptoms and consistent bedtime routines would also be helpful. Ethical considerations include the responsibility to provide developmentally appropriate information to the child and support parental guidance. Health promotion would include sleep hygiene, school support, and early anxiety management to prevent long-term emotional problems.

Case Formulation and Treatment Plan:

The psychotherapy plan for Dev Cordoba focuses on child-focused cognitive behavioral therapy. This therapy helps children identify anxious thoughts, understand their emotions, and learn coping skills that reduce excessive worry. Cognitive behavioral therapy can also include gradual exposure to separation situations so Dev can develop confidence when he is away from his mother (Harasymiw et al., 2023). Because Dev is seven years old, play therapy may also be useful to help him express feelings through drawing, games, or storytelling. Family therapy should also be included so his mother can learn strategies to support him and improve communication about his worries and fears.

Pharmacologic treatment is not the first option because many children respond well to psychotherapy alone. If symptoms remain severe or continue to interfere with school and daily functioning, a selective serotonin reuptake inhibitor such as fluoxetine may be considered. Fluoxetine is commonly used in pediatric anxiety disorders and can help reduce persistent anxiety symptoms (Harasymiw et al., 2023). Nonpharmacologic strategies include maintaining consistent bedtime routines, relaxation techniques such as deep breathing, and coordination with school staff to provide emotional support and monitor peer teasing.

Alternative approaches may include mindfulness activities, structured play, or art therapy to help Dev express emotions related to grief and anxiety. Follow-up should occur in two to four weeks to evaluate symptom improvement, sleep patterns, school functioning, and emotional behavior. Health promotion includes establishing healthy sleep habits and consistent daily routines. Patient education will focus on teaching Dev’s mother about childhood anxiety, coping strategies, and the importance of discussing his father’s death in a supportive and developmentally appropriate manner.

 

References

Bermudez, T., Maercker, A., Bierbauer, W., Bernardo, A., Fleisch-Silvestri, R., Hermann, M., & Scholz, U. (2023). The role of daily adjustment disorder, depression and anxiety symptoms for the physical activity of cardiac patients. Psychological Medicine, 53(13), 5992–6001. https://doi.org/10.1017/S0033291722003154

Harasymiw, L. A., Grosse, S. D., Cullen, K. R., Bitsko, R. H., Perou, R., & Sarafoglou, K. (2023). Depressive and anxiety disorders and antidepressant prescriptions among insured children and young adults with congenital adrenal hyperplasia in the United States. Frontiers in Endocrinology, 14, 1129584. https://doi.org/10.3389/fendo.2023.1129584

Mishra, A. K., Varma, A. R., & Varma, A. (2023). A comprehensive review of the generalized anxiety disorder. Cureus, 15(9). https://doi.org/10.7759/cureus.46115

 

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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. Learning Resources

Required Readings

  • Boland, R. Verdiun, M. L. & Ruiz, P. (2022). Kaplan & Sadock’s synopsis of psychiatry (12th ed.). Wolters Kluwer.
    • Chapter 2, “Neurodevelopmental Disorders and Other Childhood Disorders”
      • Section 2.8, “Trauma- and Stressor-Related Disorders in Children” (pp. 167-173)
      • Section 2.13, “Anxiety Disorders of Infancy, Childhood, and Adolescence: Separation Anxiety Disorder, Generalized Anxiety Disorder, and Social Anxiety Disorder (Social Phobia)” (pp. 194-200”)
      • Section 2.14, “Selective Mutism” (pp.  201-202)
      • Section 2.15, “Obsessive-Compulsive Disorder in Childhood and Adolescence” (pp. 203-206)
    • Chapter 8, “Anxiety Disorders”
    • Chapter 9, “Obsessive-Compulsive and Related Disorders”
    • Chapter 10, “Trauma- and Stressor-Related Disorders
  • Thapar, A., Pine, D. S., Leckman, J. F., Scott, S., Snowling, M. J., & Taylor, E. A. (Eds.). (2015). Rutter’s child and adolescent psychiatry  (6th ed.). Wiley Blackwell.
    • Chapter 26, “Psychosocial Adversity”
    • Chapter 27, “Resilience: Concepts, Findings, and Clinical Implications”
    • Chapter 29, “Child Maltreatment”
    • Chapter 30, Child Sexual Abuse”
    • Chapter 58, “Disorders of Attachment and Social engagement Related to Deprivation”
    • Chapter 59, “Post Traumatic Stress Disorder”
  • Zakhari, R. (2021). The psychiatric-mental health nurse practitioner certification review manual . Springer Publishing Company.
    • Chapter 6, “Physical Assessment, Diagnostic Tests, and Differential Diagnosis”
    • Chapter 12, “Anxiety Disorders”
  • Document: Career Planner GuideDownload Career Planner Guide
  • Document: Focused SOAP Note TemplateDownload Focused SOAP Note Template
  • Document: Focused SOAP Note ExemplarDownload Focused SOAP Note Exemplar

Required Media

 

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.

The Assignment

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-TR  diagnostic 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. Also 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).

By Day 7 of Week 3

Submit your Focused SOAP Note.

submission information

Rubric

NRNP_6675_Week3_Assignment_Rubric

NRNP_6675_Week3_Assignment_Rubric
Criteria Ratings Pts
This criterion is linked to a Learning OutcomeCreate documentation in the Focused SOAP Note Template about your assigned patient.In the Subjective section, provide: • Chief complaint• History of present illness (HPI)• Past psychiatric history• Medication trials and current medications• Psychotherapy or previous psychiatric diagnosis• Pertinent substance use, family psychiatric/substance use, social, and medical history• Allergies• ROS 15 to >13.0 ptsExcellent 90%–100%The response throughly and accurately describes the patient’s subjective complaint, history of present illness, past psychiatric history, medication trials and current medications, psychotherapy or previous psychiatric diagnosis, pertinent histories, allergies, and review of all systems that would inform a differential diagnosis.

13 to >11.0 ptsGood 80%–89%The response accurately describes the patient’s subjective complaint, history of present illness, past psychiatric history, medication trials and current medications, psychotherapy or previous psychiatric diagnosis, pertinent histories, allergies, and review of all systems that would inform a differential diagnosis.

11 to >10.0 ptsFair 70%–79%The response describes the patient’s subjective complaint, history of present illness, past psychiatric history, medication trials and current medications, psychotherapy or previous psychiatric diagnosis, pertinent histories, allergies, and review of all systems that would inform a differential diagnosis but is somewhat vague or contains minor innacuracies.

10 to >0 ptsPoor 0%–69%The response provides an incomplete or inaccurate description of the patient’s subjective complaint, history of present illness, past psychiatric history, medication trials and current medications, psychotherapy or previous psychiatric diagnosis, pertinent histories, allergies, and review of all systems that would inform a differential diagnosis. Or the subjective documentation is missing.

 15 pts
This criterion is linked to a Learning OutcomeIn the Objective section, provide:• Physical exam documentation of systems pertinent to the chief complaint, HPI, and history• Diagnostic results, including any labs, imaging, or other assessments needed to develop the differential diagnoses 15 to >13.0 ptsExcellent 90%–100%The response thoroughly and accurately documents the patient’s physical exam for pertinent systems. Diagnostic tests and their results are thoroughly and accurately documented.

13 to >11.0 ptsGood 80%–89%The response accurately documents the patient’s physical exam for pertinent systems. Diagnostic tests and their results are accurately documented.

11 to >10.0 ptsFair 70%–79%Documentation of the patient’s physical exam is somewhat vague or contains minor innacuracies. Diagnostic tests and their results are documented but contain minor innacuracies.

10 to >0 ptsPoor 0%–69%The response provides incomplete or inaccurate documentation of the patient’s physical exam. Systems may have been unnecessarily reviewed. Or the objective documentation is missing.

 15 pts
This criterion is linked to a Learning OutcomeIn the Assessment section, provide:• Results of the mental status examination, presented in paragraph form• At least three differentials with supporting evidence. List them from top priority to least priority. Compare the DSM-5 diagnostic criteria for each differential diagnosis and explain what DSM-5 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. 20 to >17.0 ptsExcellent 90%–100%The response thoroughly and accurately documents the results of the mental status exam…. Response lists at least three distinctly different and detailed possible disorders in order of priority for a differential diagnosis of the patient in the assigned case study, and it provides a thorough, accurate, and detailed justification for each of the disorders selected.

17 to >15.0 ptsGood 80%–89%The response accurately documents the results of the mental status exam…. Response lists at least three distinctly different and detailed possible disorders in order of priority for a differential diagnosis of the patient in the assigned case study, and it provides an accurate justification for each of the disorders selected.

15 to >13.0 ptsFair 70%–79%The response documents the results of the mental status exam with some vagueness or innacuracy…. Response lists at least three different possible disorders for a differential diagnosis of the patient and provides a justification for each, but may contain some vagueness or innacuracy.

13 to >0 ptsPoor 0%–69%The response provides an incomplete or inaccurate description of the results of the mental status exam and explanation of the differential diagnoses. Or the assessment documentation is missing.

 20 pts
This criterion is linked to a Learning OutcomeIn the Plan section, provide:• Your plan for psychotherapy• 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. • Incorporate one health promotion activity and one patient education strategy. 25 to >22.0 ptsExcellent 90%–100%The response provides an evidence-based, detailed, and appropriate plan for psychotherapy for the patient…. The response provides an evidence-based, detailed, and appropriate plan for treatment and management, including pharmacologic and nonpharmacologic treatments, alternative therapies, and follow-up parameters. A strong rationale for the plan is provided that demonstrates critical thinking and content understanding…. The response includes at least one evidence-based health promotion activity and one evidence-based patient education strategy.

22 to >19.0 ptsGood 80%–89%The response provides an evidence-based and appropriate plan for psychotherapy for the patient…. The response provides an evidence-based and appropriate plan for treatment and management, including pharmacologic and nonpharmacologic treatments, alternative therapies, and follow-up parameters. An adequate rationale for the plan is provided…. The response includes at least one health promotion activity and one patient education strategy.

19 to >17.0 ptsFair 70%–79%The response provides a somewhat vague or inaccurate plan for psychotherapy for the patient…. The response provides a somewhat vague or inaccurate plan for treatment and management, including pharmacologic and nonpharmacologic treatments, alternative therapies, and follow-up parameters. The rationale for the plan is weak or general…. The response includes one health promotion activity and one patient education strategy, but it may contain some vagueness or innacuracy.

17 to >0 ptsPoor 0%–69%The response provides an incomplete or inaccurate plan for psychotherapy for the patient…. The response provides an incomplete or inaccurate plan for treatment and management, including pharmacologic and nonpharmacologic treatments, alternative therapies, and follow-up parameters. The rationale for the plan is inaccurate or missing…. The health promotion and patient education strategies are incomplete or missing.

 25 pts
This criterion is linked to a Learning Outcome• Discussion include what may be done differently with this patient if student conducted the session again. Discussed the next intervention if you could follow up with this patient. The discussion was related to legal/ethical considerations (demonstrated critical thinking beyond confidentiality and consent for treatment!), social determinates of health, health promotion, and disease prevention that take into consideration patient factors (such as age, ethnic group, etc.), PMH, and other risk factors (e.g., socioeconomic, cultural background, etc.). 5 to >4.0 ptsExcellent 90%–100%Reflections are thorough, thoughtful, and demonstrate critical thinking. Reflections contain a discussion of all elements described within assignment directions.

4 to >3.5 ptsGood 80%–89%Reflections demonstrate critical thinking. Reflections contain 2 out of 3 (legal/ethical considerations, social determinate of health, health promotion) with consideration of patient factors and risk factors.

3.5 to >3.0 ptsFair 70%–79%Reflections are somewhat general or do not demonstrate critical thinking. Reflections contain 2 out of 3 (legal/ethical considerations, social determinate of health, health promotion) without consideration of patient factors and risk factors.

3 to >0 ptsPoor 0%–69%Reflections are incomplete, inaccurate, or missing.

 5 pts
This criterion is linked to a Learning OutcomeProvide 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). 10 to >8.0 ptsExcellent 90%–100%The response provides at least three current, evidence-based resources from the literature to support the assessment and diagnosis of the patient in the assigned case study. The resources reflect the latest clinical guidelines and provide strong justification for decision making.

8 to >7.0 ptsGood 80%–89%The response provides at least three current, evidence-based resources from the literature that appropriately support the assessment and diagnosis of the patient in the assigned case study.

7 to >6.0 ptsFair 70%–79%Three evidence-based resources are provided to support the assessment and diagnosis of the patient in the assigned case study, but they may only provide vague or weak justification.

6 to >0 ptsPoor 0%–69%Two or fewer resources are provided to support the assessment and diagnosis decisions. The resources may not be current or evidence based.

 10 pts
This criterion is linked to a Learning OutcomeWritten Expression and Formatting – The paper follows correct APA format for parenthetical/in-text citations and reference list. 5 to >4.0 ptsExcellent 90%–100%Uses correct APA format with no errors

4 to >3.5 ptsGood 80%–89%Contains 1-2 APA format for parenthetical/in-text citations and reference list errors

3.5 to >3.0 ptsFair 70%–79%Contains 3-4 APA format for parenthetical/in-text citations and reference list errors

3 to >0 ptsPoor 0%–69%Contains five or more APA format for parenthetical/in-text citations and reference list errors

 5 pts
This criterion is linked to a Learning OutcomeWritten Expression and Formatting – English Writing Standards: Correct grammar, mechanics, and punctuation 5 to >4.0 ptsExcellent 90%–100%Uses correct grammar, spelling, and punctuation with no errors

4 to >3.5 ptsGood 80%–89%Contains 1-2 grammar, spelling, and punctuation format errors

3.5 to >3.0 ptsFair 70%–79%Contains 3-4 grammar, spelling, and punctuation format errors

3 to >0 ptsPoor 0%–69%Contains five or more grammar, spelling, and punctuation format errors that interfere with the reader’s understanding

 5 pts

Total Points: 100

 

 

 

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