Posted: June 12th, 2024

7-year-old male brought in by mother for evaluation of anxiety symptoms

Sample focused SOAP note for the case of Dev Cordoba:

Subjective:
CC: 7-year-old male brought in by mother for evaluation of anxiety symptoms
HPI: Dev is a 7-year-old Hispanic male who presents with his mother for evaluation of worsening anxiety over the past 3 weeks. Symptoms include frequent worries about his mother dying or not picking him up from school, nightmares about being lost and separated from family, difficulty sleeping, poor appetite with 3lb weight loss, somatic complaints of stomachaches and headaches, and urinary incontinence. He has become more withdrawn and oppositional, throwing objects when upset. Anxiety is interfering with his ability to focus and learn at school. Symptoms began around age 5 after his father was deployed in the military and was later killed, which Dev does not fully understand. No prior psychiatric history. No known family psychiatric history.
Medications: Desmopressin for enuresis without benefit
Allergies: NKDA
ROS:
GENERAL: Fatigue, 3lb weight loss over 3 weeks
HEENT: Denies headaches
SKIN: No rash or lesions
CARDIOVASCULAR: No chest pain or palpitations
RESPIRATORY: No cough or dyspnea
GASTROINTESTINAL: Intermittent abdominal pain, decreased appetite, denies nausea/vomiting/diarrhea
GENITOURINARY: Nocturia, enuresis. No dysuria or hematuria.
NEUROLOGICAL: No seizures, dizziness, weakness. No suicidal ideation.
MUSCULOSKELETAL: Denies joint pain, swelling, trauma
ENDOCRINE: No polydipsia, polyuria, heat/cold intolerance
ALLERGIC/IMMUNOLOGIC: No hay fever, frequent illnesses

Objective:
Vital Signs:
Height: 4’2″ (50th percentile)
Weight: 48lbs (25th percentile)
BMI: 14.8 (10th percentile)
Physical Exam: Deferred, as exam done recently by pediatrician
Diagnostic results: Recent physical exam and labs unremarkable per pediatrician

Mental Status Exam: Dev is a 7-year-old Hispanic male who appears stated age. He is cooperative but anxious, making poor eye contact. Speech is normal rate and volume. Thought process is goal-directed. Thought content is notable for worries about harm to family members. He denies suicidal or homicidal ideation. Mood is “worried.” Affect is anxious. Attention and concentration are fair. He is alert and oriented x3. Insight and judgment are limited by age.

Assessment:
Differential Diagnoses:
1. Separation anxiety disorder: This is the most likely diagnosis given Dev’s age, persistent worry about separation from mother, refusal to go to school, and associated somatic symptoms and sleep disturbance meeting DSM-5 criteria. Onset of symptoms occurred after a major stressor of losing his father.
2. Generalized anxiety disorder: While he has excessive worry and associated physical symptoms, his anxiety is primarily focused on separation from caregivers rather than a range of events. Worries have not been present for at least 6 months so this is less likely.
3. Adjustment disorder with anxiety: Symptoms developed after father’s death which was a major stressor. However, the severity and duration of symptoms is more consistent with separation anxiety disorder rather than an adjustment disorder.

Diagnosis: F93.0 Separation anxiety disorder

Plan:
– Sertraline 12.5mg po daily, titrate by 12.5mg every 2 weeks up to 25mg po daily
– Psychoeducation to mother about diagnosis, treatment, and supporting Dev
– Referral for individual CBT focusing on coping skills, exposure/response prevention
– Encourage good sleep hygiene with consistent routine
– Follow up in 2 weeks to assess response and titrate medication
– Consider referral for grief counseling if symptoms persist
– Coordinate with school counselor to provide accommodations and support

Reflection: This case highlighted the importance of assessing for unresolved grief and attachment disruptions as potential triggers for anxiety disorders in children. I would delve deeper into the circumstances around Dev’s father’s death and how this was explained to him. More education and support around the grieving process may be helpful for both Dev and his mother. From an ethical perspective, Dev’s age raises issues of assent vs. consent for treatment. Even though he is only 7, efforts should be made to involve him in treatment decisions in a developmentally appropriate way. Proper education to the family on medication side effects and alternatives is also critical. In terms of health promotion, helping Dev develop healthy coping skills now can build resilience and prevent worsening anxiety or depression later in life. Socioeconomic stressors also seem to be impacting the family, so connecting them with social support services could help alleviate anxiety. During follow up, it will be important to monitor for any worsening depression or emergence of suicidal ideation. If Dev’s symptoms do not improve with initial interventions, a higher level of care may need to be considered.

References:

Bagnell, A. L. (2020). Anxiety disorders in children and adolescents: Epidemiology, pathogenesis, clinical manifestations, and course. In T. A. Rummans, T. G. Reus & S. Y. Yang (Eds.), UpToDate. Retrieved April 12, 2023 from https://www.uptodate.com/contents/anxiety-disorders-in-children-and-adolescents-epidemiology-pathogenesis-clinical-manifestations-and-course

Cheng, K., Myers, K. M., & Bui, E. (2022). Clinical handbook of anxiety disorders: From theory to practice. Humana Press.

Walter, H. J., Bukstein, O. G., Abright, A. R., Keable, H., Ramtekkar, U., Ripperger-Suhler, J., & Rockhill, C. (2020). Clinical practice guideline for the assessment and treatment of children and adolescents with anxiety disorders. Journal of the American Academy of Child & Adolescent Psychiatry, 59(10), 1107-1124.

Wehry, A. M., Beesdo-Baum, K., Hennelly, M. M., Connolly, S. D., & Strawn, J. R. (2015). Assessment and treatment of anxiety disorders in children and adolescents. Current psychiatry reports, 17(7), 52.

Zeanah, C. H., & Lieberman, A. F. (2016). Defining relational pathology in early childhood: The diagnostic classification of mental health and developmental disorders of infancy and early childhood DC: 0–5 approach. Infant mental health journal, 37(5), 509-520.

===============Wk 3 Assignment.
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.

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).

========================
Subjective:
CC (chief complaint):
HPI:
Substance Current Use:
Medical History:

• Current Medications:
• Allergies:
• Reproductive Hx:
ROS:
• GENERAL:
• HEENT:
• SKIN:
• CARDIOVASCULAR:
• RESPIRATORY:
• GASTROINTESTINAL:
• GENITOURINARY:
• NEUROLOGICAL:
• MUSCULOSKELETAL:
• HEMATOLOGIC:
• LYMPHATICS:
• ENDOCRINOLOGIC:
Objective:
Diagnostic results:
Assessment:
Mental Status Examination:
Diagnostic Impression:
Reflections:
Case Formulation and Treatment Plan:

References

INSTRUCTIONS ON HOW TO USE EXEMPLAR AND TEMPLATE—READ CAREFULLY
If you are struggling with the format or remembering what to include, follow the Focused SOAP Note Evaluation Template AND the Rubric as your guide. It is also helpful to review the rubric in detail in order not to lose points unnecessarily because you missed something required. After reviewing full details of the rubric, you can use it as a guide.
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
Read rating descriptions to see the grading standards!
In 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.
Read rating descriptions to see the grading standards!

In 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-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.
• Read rating descriptions to see the grading standards!
Reflect on this case. Include: Discuss what you learned and what you might do differently. Also include in your reflection a discussion related to legal/ethical considerations (demonstrate critical thinking beyond confidentiality and consent for treatment!), social determinates of health, 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.).
(The FOCUSED SOAP psychiatric evaluation is typically the follow-up visit patient note. You will practice writing this type of note in this course. You will be focusing more on the symptoms from your differential diagnosis from the comprehensive psychiatric evaluation narrowing to your diagnostic impression. You will write up what symptoms are present and what symptoms are not present from illnesses to demonstrate you have indeed assessed for illnesses which could be impacting your patient. For example, anxiety symptoms, depressive symptoms, bipolar symptoms, psychosis symptoms, substance use, etc.)
EXEMPLAR BEGINS HERE
Subjective:
CC (chief complaint): A brief statement identifying why the patient is here. This statement is verbatim of the patient’s own words about why presenting for assessment. For a patient with dementia or other cognitive deficits, this statement can be obtained from a family member.
HPI: Begin this section with patient’s initials, age, race, gender, purpose of evaluation, current medication and referral reason. For example:
N.M. is a 34-year-old Asian male presents for medication management follow up for anxiety. He was initiated sertraline last appt which he finds was effective for two weeks then symptoms began to return.
Or
P.H., a 16-year-old Hispanic female, presents for follow up to discuss previous psychiatric evaluation for concentration difficulty. She is not currently prescribed psychotropic medications as we deferred until further testing and screening was conducted.
Then, this section continues with the symptom analysis for your note. Thorough documentation in this section is essential for patient care, coding, and billing analysis.
Paint a picture of what is wrong with the patient. First what is bringing the patient to your follow up evaluation? Document symptom onset, duration, frequency, severity, and impact. What has worsened or improved since last appointment? What stressors are they facing? Your description here will guide your differential diagnoses into your diagnostic impression. You are seeking symptoms that may align with many DSM-5 diagnoses, narrowing to what aligns with diagnostic criteria for mental health and substance use disorders.
Substance Use History: This section contains any history or current use of caffeine, nicotine, illicit substance (including marijuana), and alcohol. Include the daily amount of use and last known use. Include type of use such as inhales, snorts, IV, etc. Include any histories of withdrawal complications from tremors, Delirium Tremens, or seizures.
Current Medications: Include dosage, frequency, length of time used, and reason for use. Also include OTC or homeopathic products.
Allergies: Include medication, food, and environmental allergies separately. Provide a description of what the allergy is (e.g., angioedema, anaphylaxis). This will help determine a true reaction vs. intolerance.
Reproductive Hx: Menstrual history (date of LMP), Pregnant (yes or no), Nursing/lactating (yes or no), contraceptive use (method used), types of intercourse: oral, anal, vaginal, other, any sexual concerns
ROS: Cover all body systems that may help you include or rule out a differential diagnosis. Please note: THIS IS DIFFERENT from a physical examination!
You should list each system as follows: General: Head: EENT: etc. You should list these in bullet format and document the systems in order from head to toe.
Example of Complete ROS:
GENERAL: No weight loss, fever, chills, weakness, or fatigue.
HEENT: Eyes: No visual loss, blurred vision, double vision, or yellow sclerae. Ears, Nose, Throat: No hearing loss, sneezing, congestion, runny nose, or sore throat.
SKIN: No rash or itching.
CARDIOVASCULAR: No chest pain, chest pressure, or chest discomfort. No palpitations or edema.
RESPIRATORY: No shortness of breath, cough, or sputum.
GASTROINTESTINAL: No anorexia, nausea, vomiting, or diarrhea. No abdominal pain or blood.
GENITOURINARY: Burning on urination, urgency, hesitancy, odor, odd color
NEUROLOGICAL: No headache, dizziness, syncope, paralysis, ataxia, numbness, or tingling in the extremities. No change in bowel or bladder control.
MUSCULOSKELETAL: No muscle, back pain, joint pain, or stiffness.
HEMATOLOGIC: No anemia, bleeding, or bruising.
LYMPHATICS: No enlarged nodes. No history of splenectomy.
ENDOCRINOLOGIC: No reports of sweating, cold, or heat intolerance. No polyuria or polydipsia.
Objective:
Diagnostic results: Include any labs, X-rays, or other diagnostics that are needed to develop the differential diagnoses (support with evidenced and guidelines).
Assessment:
Mental Status Examination: For the purposes of your courses, this section must be presented in paragraph form and not use of a checklist! This section you will describe the patient’s appearance, attitude, behavior, mood and affect, speech, thought processes, thought content, perceptions (hallucinations, pseudohallucinations, illusions, etc.)., cognition, insight, judgment, and SI/HI. See an example below. You will modify to include the specifics for your patient on the above elements—DO NOT just copy the example. You may use a preceptor’s way of organizing the information if the MSE is in paragraph form.
He is an 8-year-old African American male who looks his stated age. He is cooperative with examiner. He is neatly groomed and clean, dressed appropriately. There is no evidence of any abnormal motor activity. His speech is clear, coherent, normal in volume and tone. His thought process is goal directed and logical. There is no evidence of looseness of association or flight of ideas. His mood is euthymic, and his affect appropriate to his mood. He was smiling at times in an appropriate manner. He denies any auditory or visual hallucinations. There is no evidence of any delusional thinking. He denies any current suicidal or homicidal ideation. Cognitively, he is alert and oriented. His recent and remote memory is intact. His concentration is good. His insight is good.
Diagnostic Impression: You must begin to narrow your differential diagnosis to your diagnostic impression. You must explain how and why (your rationale) you ruled out any of your differential diagnoses. You must explain how and why (your rationale) you concluded to your diagnostic impression. You will use supporting evidence from the literature to support your rationale. Include pertinent positives and pertinent negatives for the specific patient case.
Also included in this section is the reflection. Reflect on this case and discuss whether or not you agree with your preceptor’s assessment and diagnostic impression of the patient and why or why not. What did you learn from this case? What would you do differently?
Also include in your reflection a discussion related to legal/ethical considerations (demonstrating critical thinking beyond confidentiality and consent for treatment!), social determinates of health, 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.).
Case Formulation and Treatment Plan
Includes documentation of diagnostic studies that will be obtained, referrals to other health care providers, therapeutic interventions including psychotherapy and/or psychopharmacology, education, disposition of the patient, and any planned follow-up visits. Each diagnosis or condition documented in the assessment should be addressed in the plan. The details of the plan should follow an orderly manner. *See an example below. You will modify to your practice so there may be information excluded/included. If you are completing this for a practicum, what does your preceptor document?
Risks and benefits of medications are discussed including non- treatment. Potential side effects of medications discussed (be detailed in what side effects discussed). Informed client not to stop medication abruptly without discussing with providers. Instructed to call and report any adverse reactions. Discussed risk of medication with pregnancy/fetus, encouraged birth control, discussed if does become pregnant to inform provider as soon as possible. Discussed how some medications might decreased birth control pill, would need back up method (exclude for males).

Discussed risks of mixing medications with OTC drugs, herbal, alcohol/illegal drugs. Instructed to avoid this practice. Encouraged abstinence. Discussed how drugs/alcohol affect mental health, physical health, sleep architecture.

Initiation of (list out any medication and why prescribed, any therapy services or referrals to specialist):

Client was encouraged to continue with case management and/or therapy services (if not provided by you)

Client has emergency numbers: Emergency Services 911, the Client’s Crisis Line 1-800-_______. Client instructed to go to nearest ER or call 911 if they become actively suicidal and/or homicidal. (only if you or preceptor provided them)

Reviewed hospital records/therapist records for collaborative information; Reviewed PMP report (only if actually completed)

Time allowed for questions and answers provided. Provided supportive listening. Client appeared to understand discussion. Client is amenable with this plan and agrees to follow treatment regimen as discussed. (this relates to informed consent; you will need to assess their understanding and agreement)

Follow up with PCP as needed and/or for:

Labs ordered and/or reviewed (write out what diagnostic test ordered, rationale for ordering, and if discussed fasting/non fasting or other patient education)

Return to clinic:
Continued treatment is medically necessary to address chronic symptoms, improve functioning, and prevent the need for a higher level of care.

References (move to begin on next page)
You are required to include at least three evidence-based, peer-reviewed journal articles or evidenced-based guidelines which relate to this case to support your diagnostics and differentials diagnoses. Be sure to use correct APA 7th edition formatting.

=========================
[MUSIC PLAYING] DR. JENNY: Hi there. My name is Dr. Jenny. Can you tell me your
name and how old you are? DEV CORDOBA: My name is Dev,
and I am seven years old. DR. JENNY: Wonderful. Dev, can you tell me what
the month and the date is? And where are we right now? DEV CORDOBA: Today
is St. Patrick’s Day. It’s March 17th. DR. JENNY: Do you
know where we are? DEV CORDOBA: We’re
at the school. DR. JENNY: Good. Did your mom tell you why
you’re here today to see me? DEV CORDOBA: She
thought you were going to help me be better. DR. JENNY: Yes, I
am here to help you. Have you ever come to see
someone like me before, or talked to someone like
me before to help you with your mood? DEV CORDOBA: No, never. DR. JENNY: OK. Well, I would like
to start with getting to know you a little bit
better, if that’s OK. What do you like to do for
fun when you’re at home? DEV CORDOBA: Oh, I have a dog. His name is Sparky. We play policeman in my room. And I have LEGOs, and I could
build something if you want. DR. JENNY: I would love to see
what you build with your LEGOs. Maybe you can bring that
in for me next appointment. Who lives in your home? DEV CORDOBA: My mom and my
baby brother and Sparky. DR. JENNY: Do you help
your mom with your brother? DEV CORDOBA: No. His breath smells like
bad milk all the time. [CHUCKLES] And he
cries a lot, and my mom spends more time with him. DR. JENNY: So how do you
feel most of the time? Do you feel sad or
worried or mad or happy? DEV CORDOBA: Worried. DR. JENNY: What types of
things do you worry about? DEV CORDOBA: 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 dreams. Can you tell me a little
more about your bad dreams, like maybe what they’re
about, how many nights you might have them? DEV CORDOBA: I dream
a lot that I’m lost, that I can’t find my mom
or my little brother. They seem like they happen
almost every night, but maybe not some nights. DR. JENNY: Now that
must feel horrible. Have you ever been lost before
when maybe you weren’t asleep? DEV CORDOBA: Oh, no. No. And I don’t like the dark. My mom puts me in a night
light with the door open, so I know she’s really there. DR. JENNY: That seems like
that probably would help. Do you like to go to school? Or would you rather not go? DEV CORDOBA: I worry
about by mom and brother when I’m at school. All I can think about
is what they’re doing, and if they’re OK. And besides, nobody
likes me there. They call me Mr. Smelly. DR. JENNY: Well. That’s not nice at all. Why do you feel
they call you names? DEV CORDOBA: I don’t know. But my mom says it’s because
I won’t take my baths. [SIGHS] She tells
me to, and it– and I have night accidents. DR. JENNY: Oh, how does
that make you feel? DEV CORDOBA: Sad and really bad. They don’t know how it feels for
their daddy to never come home. What if my mom
doesn’t come home too? DR. JENNY: Yes, you seem
to worry about that a lot. Does this worry stop you from
being able to learn in school? DEV CORDOBA: Well, [SIGHS]
my teacher is, all the time, telling me to sit
down and focus. And I get in trouble for
[SIGHS] looking out the window. And she moved my
chair beside her desk, but I don’t mind because
Billy leaves me alone now. DR. JENNY: Billy. Have you ever hit
Billy or anyone else? DEV CORDOBA: No, but I
did throw my book at him. DR. JENNY: Hmm. DEV CORDOBA: [CHUCKLES] DR. JENNY: What about yourself? Have you ever hit yourself or
thought about doing something to hurt yourself? DEV CORDOBA: No. DR. JENNY: OK. Well, Dev, I would like
to talk to your mom now. We’re going to work
together, and we’re going to help you feel
happier, less worried, and be able to
enjoy school more. Is that OK? DEV CORDOBA: Yes. Thank you. MISS CORDOBA: Hi. DR. JENNY: Thank you, Miss
Cordoba, for bringing in Dev. I feel we can help him. So tell me, what is your
main concerns for Dev? MISS CORDOBA: [SIGHS] 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’ll throw things
around the house, and gets in trouble at
school for throwing things. He has a difficult
time going to sleep. He wants his lights on, doors
open, gets up frequently. And he’s all the time
wanting to come home from school, claims stomach
aches, and headaches almost daily. He won’t eat. He’s lost three pounds
in the past three weeks. Our pediatrician sent us to
you because he doesn’t believe anything is physically wrong. Oh, and I almost forgot. He still wets the bed at night. [SIGHS] We’ve tried everything. His pediatrician
did give him DDVAP, but it doesn’t seem to help. DR. JENNY: Hmm. OK. Can you tell me,
any blood relatives have any mental health
or substance use issues? MISS CORDOBA: No, not really. DR. JENNY: What
about his father? He said that he never came home? MISS CORDOBA: Oh, yes. His father was deployed with
the military when Dev was five. I told Dev he was on vacation. I didn’t know what to tell him. I thought he was too
young to know about war. And his father was
killed, so Dev still doesn’t understand that his
father didn’t just leave him. [SIGHS] I just feel so guilty
that all of this is my fault. DR. JENNY: Miss Cordoba,
you did the right thing by bringing in Dev. We can help you with him. MISS CORDOBA: Oh, thank you. [MUSIC PLAYING]

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