NRNP PRAC 6665 Week 3: FOCUSED SOAP NOTE FOR ANXIETY, PTSD, AND OCD

Subjective:

CC “My mom said you can help me with my fears”

HPI: D.C., a 7-year-old Caucasian boy, arrives with his mother for psychiatric evaluation. While in class, the client worries about his mother and brother. He’s worried about what they’re doing and if they ‘re alright. Nearly each evening, he dreams he’s trapped and can’t locate his mother or sibling. He disputes ever getting lost. His instructor told him to settle down and concentrate so much that she placed his seat next to hers. He was irritated and threw a textbook at a classmate. The mother confirmed what the kid said. She says D.C. is constantly scared about dying. She says he tosses stuff at home and in class. She also said he has difficulties falling asleep, has lost appetite, and fakes sickness to avoid school (Walden University, 2021).). DDVP doesn’t help the child’s enuresis. The child’s family doctor sent him to the facility since he isn’t physiologically ill. No psychiatric history.

Substance Current Use:

There s no substance use history given

Medical History:

He has no diagnosed chronic medical conditions.

· Current Medications:

He is currently receiving DDVP to manage anuresis

· Allergies:

No allergy history

· Reproductive Hx:

Reproduction history is absent

ROS:

· GENERAL: the patient denies having chills, or fever. He admits to losing weight in the previous 3 weeks

· HEENT: eyes: he denies double vision, or blurred viion.he denies any recent chabges in vision. Ears: he denies ringing in the ears. He also denies changes in hearing. Nose: no congestion or running nose reported. Throat: no sore throat, or swallowing difficulties.

· SKIN: no lesions, abnormal pigmentation, or bruises.

· CARDIOVASCULAR: no palpitations, edema of the extremities, capillary refill is two seconds. No abnormal heart sounds and no chest pain reported.

· RESPIRATORY: no coughing, wheezing, or breathing difficulties. Breathing is unlaboured

· GASTROINTESTINAL: no nausea or vomiting, diarrhea, or constipation

· GENITOURINARY: the patient report being treated for anuresis.

· NEUROLOGICAL: no headaches, sezures, syncope or los sensation.

· MUSCULOSKELETAL: no musle or joint pain or stiffness.

· HEMATOLOGIC: no abnormal bleeding or anemia.

· LYMPHATICS: no lymph node swelling, pain or tendernes.

· ENDOCRINOLOGIC: no sensitivity to cold or hot temperatures. No extreme hunger or thirst reported.

Objective:

Diagnostic results:

The case study did not include any diagnostic procedures or testing. Because they could be utilized to exclude a variety of mental diseases, self-assessment surveys like the Beck anxiety inventory and the Hamilton anxiety score and also thorough physical examinations are particularly important. According to Painter and Scannapieco (2021), it is extremely important for the most of kids who have psychological illnesses or are suspected to be generating one to undertake X-ray scanning so as to establish any unordinary adjustments and verify their cognitive evolution. This is because the testing can determine whether or not the child is forming a psychiatric illness.

Assessment:

Mental Status Examination:

“DC” (7 years old) is a healthy white kid who comes with symptoms of anxiety and worry all the time. He also reports having horrible nightmares, losing his appetite, being unable to concentrate, and being irritable. At the time of evaluation, the client is attentive, clean, and well-dressed; he speaks clearly and normally in both volume and pitch. Cognitive processes are goal-oriented and rational, and his temperament is euthymic; his emotion is apprehensive. He is Alert and oriented to place, person, and time. He retains both his distant and current memories. Homicide or suicide thoughts are denied by the client, and there is no indication of visual or aural hallucinations.

Diagnostic Impression:

· Generalized Anxiety Disorder

Nervousness or irritation, persistent fear, affective distress, trouble falling asleep, a loss of focus, and dread or anxiousness are all DSM-5 criteria for determining generalized anxiety disorder (GAD), as per Zakhari (2021). The patient is frequently distressed and concerned about his mother and his younger sibling. In addition, he is agitated, unable to sleep, and distracted at school, and his appetite is diminished. The fact that D.C. exhibits the bulk of these clinical manifestations confirms the diagnosis.

· Attention-deficit/ hyperactivity disorder (ADHD)

D.C. mentions that he is constantly overwhelmed and worried. His mother claims that he is deceptive and displays hostile conduct both in school and at home.  According to the DSM-5, several of the indications and manifestations of ADHD are hostility toward one’s contemporaries, dishonest conduct, difficulties in maintaining focus, feelings of worry, wrath, and inattentiveness (Gould et al., 2018). As a result of the patient exhibiting a number of these manifestations, the diagnosis may be made.

· Post-traumatic stress disorder (PTSD):

The child has never recovered from his father’s departure. D.C.’s father passed away in battle when he was five years old, as per his mother, but the child is unaware of it and believes his father ditched them, resulting in abandonment PTSD. As a consequence, D.C. has acquired a phobia of the darkness, believing that, like his dad, his mother would desert him. In addition, he has frequent nightmares of having lost his mother and younger brother. In addition to this, he has decreased his appetite, is agitated, finds it difficult to concentrate, and has difficulties falling or staying asleep. To be diagnosed with PTSD, a person must have significant distrust or anxiety, nightmares, sleeplessness, lack of appetite, restlessness, aggression, lethargy, loss of pleasure in hobbies, and interpersonal separation, according to the DSM-5 criteria (Painter, & Scannapieco, 2021). Because the child exhibits a number of such complaints, this may be concluded as the diagnosis.

Reflections:

I feel like the examiner has exhausted all possible questions for the patient. What I would do differently is to ask his mother to disclose the information concerning the death of his father, since that seems to be the source of his anxiety. This would be done step by step, to ensure that it does not pose more mentall problems for him, at that I would help her to do so. I would also encourange his mother, to spend most time with him, show him affection, to assure him that he will always be there for him. D.C is a little child, and needs his mothers affection all around him, and that would be the best treatment- making him feel loved.

Case Formulation and Treatment Plan:

Citalopram 10mg dose per oral will be started by DC. in order to lessen or eradicate anxiety. Cognitive-behavioral therapy (CBT) will also be used in D.C.’s treatment (CBT). Anxiety management may be improved via CBT, according to Gould et al. (2018). Cognitive behavioral therapy (CBT) aims to teach patients how to deal with events that cause them worry. In addition to managing GAD, CBT is beneficial in managing PTSD and ADHD, so it may assist with any other ailment. Additionally, according to Gould et al. (2018), the child’s preferred conduct would be encouraged via CBT.

Involvement of the child’s institution in the treatment process would be important. It is also important to discuss the experience while playing it out, in order to understand and relieve any hidden emotions. Self-soothing exercises and meditation methods may help himcope with stress and worry. Considering that parents often play a significant part in any therapy, psychotherapy that involves the whole family is often recommended (Thapar, et al., 2015).

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