Posted: July 14th, 2022

Excess anxiety and worry

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.
• Review the Case Study: Dev Cordoba. 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.

CASE STUDY: DEV CARDOBA TRANSCRIPT

Case Study: DEV CARDOBA: You will use this case as the basis of this Assignment.

Dr. Jenny: Hi dear, my name is Dr. Jenny. Can you tell me your name and how old you are?

Dev: My name is Dev and I am 7 years old

Dr. Jenny: Wonderful! Dev, can you tell me what the month and the day it is, and where are we right now?

Dev: Today is St. Patrick’s Day, March 17th,

Dr. Jenny: Do you know where we are?

Dev: We’re at the school

Dr. Jenny: Did your mom tell you why you here today to see me?

Dev: She said, you are going to help me get better.

Dr. Jenny: Yes, I am here to help you. Have you ever come to see or talk to someone like me before to help you with your mood?

Dev: No, never

Dr. Jenny: Ok, I would like to start with getting to know you a little bit better if that’s ok

Dr. Jenny: What do you like to do for fun when you at home?

Dev: Oh! I have a dog, his name is Sparky, we play policeman in my room, I have Lagos and I can build something if you want

Dr. Jenny: I would love to see what you build with your Lagos, maybe you can bring that in for me on your next appointment

Dr. Jenny: Who else are in your home

Dev: My mom and my baby brother and Sparky

Dr. Moore: Do you help your mom with your bother?

Dev: No, he’s a Bratt, smells like bad milk all the time, he cries a lot, and my mom spends more time with him.

Dr. Jenny: How do feel most of the time? Do you feel sad, worry, mad or happy?

Dev: Worry!

Dr. Jenny: What types of things do you worry about?

Dev: I don’t know, just everything, I don’t know.

Dr. Jenny Ok, so your mom tells me you also have a lot of bad dream.

Dr. Jenny: Can you tell me a little more about your bad dream, like what they’re about? how many nights you might have them?

Dev: I dream a lot that I’m lost, I can’t find my mom or my little brother, it seems like they happen almost every night, maybe not some nights.

Dr. Jenny: That must be horrible, have you ever been lost before maybe when you are not asleep

Dev: No, No and I don’t like the dark. My mon puts me a night light with the door open, so I know she’s really there.

Dr. Jenny: I think that’s probably would help

Dr. Jenny: Do you like to go to school? Or would you rather not go?

Dev: I worry about my mom and brother when I’m at school. All I think about is what they doing? Are they ok? Beside nobody likes me there. They call me Mr. Smelly

Dr. Jenny: Well, that’s not nice at all, why do feel they call you names?

Dev: I don’t’ know, my mom says because I won’t take my bath like she tells me to and I have night accidents.

Dr. Jenny: How is that make you feel.

Dev: Sad and really bad. They don’t’ how it feels for their daddy to never come home. What if my mon does not come home to?

Dr. Jenny: Yes, you seem to worry about that a lot. Does this worry stop you from being able to learn in school?

Dev: Well, my teacher is all the time telling all the time to sit down, telling to focus, I get in trouble for looking out of the window. She moves my chair besides her desk but don’t like it because Billy won’t leave me alone now.

Dr. Jenny: Billy, have you ever hit Billy or anyone else?

Dev: No but I did throw my book at him

Dr. Jenny: What about yourself? Have ever you hit yourself or thought about doing something to hurt yourself?

Dev: No

Dr. Jenny Ok

Dr. Jenny: Well Dev, I would like to talk to your mom now, we are going to work together. We going to make feel happier, less worry and be able to enjoy school more. Is that Ok?

Dev: Yes, thank you

Dr. Jenny: Hi, thank you Ms. Cardoba for bringing in Dev. I feel we can help him. So, tell me, what is your main concern for Dev

Mrs. Cordoba: Well, he just seems so anxious and worried all the time, silly things, like I’m going to die, or I won’t pick him up from school, he says “I love his brother more than him”. He throws things around the house. He gets in trouble at school for throwing things. He has a difficult time going to sleep. He wants his light on, doors open, gets up frequently. He’s all the time wanting to come home from school claims stomachs, headaches, almost daily. He won’t eat, he lost 3 pounds in the past 3 weeks. Our pediatrician sent us to you because he does not believe anything is physically wrong. Oh, I almost forgot, he still wets the bed at night. We’ve tried everything. His pediatrician did give him DDVAP, but it does not seem to help.

Dr. Jenny: Ok, can you tell me? any blood relatives have any mental health or substances use issues

Cardoba: No, not really

Dr. Jenny: What about his father? He says, he never came home

Cordoba: Yes, his father was deployed in the Military when Dev was 5 years old. I told Dev, he was on Vacation. I did not know what to tell him, I thought he was too young to know about war. His father was killed, so Dev still does not understand that his father did not just leave him. I just feel so guilty, this my fault

Dr. Jenny: Ms. Cardoba, you did the right thing by bringing in Dev, we can help you with him.

Cardoba: Thank you

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 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.
• 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).

Follow Assignment Instructions
Carefully read and answer each bullet point of the assignment (answer briefly).
All references require creditable sources, nothing less than 5 years. References require doi or
http. Please add conclusion. APA needs to be 7th Edition. No running head needed.

No Plagiarism Please!

Thank you

Resources Preferred to Use

Centers for Disease Control and Prevention. (2020, April 3). Adverse childhood experiences (ACEs) [Video].
https://www.cdc.gov/violenceprevention/aces/index.html

Dartmouth Films. (2018, September 25). Resilience [Video]. YouTube. https://www.youtube.com/watch?v=bAXZVYDNURY

NCTSN. (2007). The promise of trauma-focused therapy for childhood sexual abuse [Video]. https://www.nctsn.org/resources/promise-trauma-focused-therapy-childhood-sexual-abuse-video

Comprehensive Psychiatric Focused SOAP notes
Student’s name
Institution Affiliation
Faculty Name
Assignment Due Date

Comprehensive Psychiatric Focused SOAP notes
Patient information
Patients initial :D.C age: 7 Gender: Male
Subjective:
CC (chief complaint): excess anxiety and worry
HPI:
The 7-year-old Dev is brought in by his mother who reports that he has recently developed anxiety on most occasions, she says that the child has poor concentration in studies, depressed and anxious. The patients claims that he is worried about the safety of his family members. He is aggressive both at school and at home. Generally, the patients report poor sleep patterns, injurious behaviors, poor appetite anhedonia, Repetitive compulsive behaviors, distressing memories of trauma, sleep disturbance, detached feelings and estrangement from others. The mum is concerned about his weight loss she reports that the patient has lost 3 pounds in the past 3 weeks the mother claims that she had initially sought medical advice from a pediatrician, whereby the child was been put under medication following the observation of the symptoms. However, the symptoms persisted and were referred. to pediatrician.
Past psychiatric history– the patient has no past psychiatric history; the patient has seen a pediatrician relating to general anxiety.
Family psychiatric disorder. the mother claims there are no history of mental disorder in the family.
Social History- the patient lives with his mother and brother. He lost his dad that was deployed on the military but he currents knows that he is on vacation. The mother does not how to break the news of the passing of his dad to the patient for fear it might worsen the already existing symptoms.
Substance Current Use: Patient denies any substance use
Medical History: no history of medical trials for psychotic conditions

• Current Medications: the patient is currently on DDVAP
• Allergies: no known allergies
• Reproductive Hx: No known reproductive related issues
ROS:
• GENERAL: drastic weight loss over the past weeks, No fever, occasional weakness, and fatigue.
• HEENT: Eyes: no blurred vison, double vison, yellow sclerae or visual loss no hearing loss congestion or sore throat.
• SKIN: no itching or rash
• CARDIOVASCULAR: Denies chest pains or discomfort, palpitation, fast or slow heart rates, orthopnea or edema.
• RESPIRATORY: denies dyspnea, stubborn coughs, Denies noisy breathing or sputum.
• GASTROINTESTINAL: reports abdominal pain, and anorexia.
• GENITOURINARY: frequent urination, no odor or odd color
• NEUROLOGICAL: reports headaches change in bladder control, dizziness, no black out spells or syncope
• MUSCULOSKELETAL: no joint pain, back pain or stiffness
• HEMATOLOGIC: reports change in weight, occasional bruising, no asemia
• LYMPHATICS: No history of splenectomy or enlarged nodes
• ENDOCRINOLOGIC: no polyuria or polydipsia, no report of colds or sweating
Objective
The patients present at least three of the six clinical criteria for GAD thus supports an adequate diagnosis.
ECG: normal stimulus rhythm
Thyroid function tests: normal thyroid stimulating hormone.
Diagnostic results:
Differential diagnosis
Social phobia- notably the patient suffers social phobia which is associated with anxiety whereby he fears social scrutiny, being judged, bullied, and negative Assessments especially from his friends at school who call him names. Through this the patient reactivated by throwing things. This is often portrayed from irrational fear an embarrassment during social interactions especially at school.
Panic phobia-The patient presented symptoms of anxiety, entailing fear of the death of his family members, sleep disorders, bad dreams. Among the many symptoms of panic phobia being the fear of dying that the patient attributes.
Obsessive compulsive disorder – furthermore, the patients suffer from obsessive compulsive disorder characterized by poor concentrations in school, excess worry and restlessness
Primary diagnosis
The primary diagnosis of the patient was characterized by anxiety and worry while undergoing his day-to-day activities, this was pronounced through the excessive worry of his family members safety, irritability, sleep inconsistencies. His mother said that the patients’ symptoms have persisted over the past few months due to the absence of his dad, thus, the primary diagnosis being genialized anxiety disorder.
Assessment:
Mental Status Examination:
He is a 7-year-old who looks his stated age, and was quite cooperative during the session. His speech his clear, with normal volume and tone and particular very coherent, he loses his concentration to the slightest form of distraction. However, there is no evidence of looses of flight of ideas as there is no abnormal motor activity.
Diagnostic Impression:

The overall diagnosis being the generalized anxiety disorder
Reflections:
Case Formulation and Treatment Plan:
The treatment plan for generalized anxiety disorder is dependent of the extent it affects the day-to-day function of a patient. The main treatment option plans include medication and psychotherapy can be used separately in combination to achieve better results.
For Dev Cordoba’s case, the first line of treatment recommended for his anxiety is putting him under cognitive behavioral theory, anxiety management. the therapies are initiated before any for of medication is introduced. The cognitive behavioral therapy is a short-term treatment plan that works to focuses technique the patient the appropriate skills that help to manage his worried and ease the anxiety. During this particular visit, there was no vaccination administered nor prescription of medication. The ECG and thyroid function tests were order. No lab test order, the main recommendation be psychoeducation education, anxiety management training and cognitive behavioral therapy to be used.
Other recommendations that the patient’s mother should adopt is lifestyle changes. They include prioritizing sleep, adopting relation techniques such as yoga and meditation to ensure the patient is relation. Notably, by introducing healthy eating to boost the patient’s appetite. Additionally, the patient’s mother was advised to adhere to non-drug therapies and make follow up visits. It is also important for the patient’s mother to inform him of the passing of his father so he can learn to familiarize with the situation. Notably, he will overcome the shock and depression through the sessions and therapies. Continued treatments will ensure that the symptoms are address and prevent the need for higher level of care.

References

Jordan, P., Shedden-Mora, M. C., & Löwe, B. (2017). Psychometric analysis of the Generalized Anxiety Disorder scale (GAD-7) in primary care using modern item response theory. PloS one, 12(8), e0182162.

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