NRNP 6675 Week 3 SOAP Note Anxiety Disorder Example

NRNP 6675 Week 3 SOAP Note Anxiety Disorder Example

Subjective:

Presenting Complaint:

Feelings of excessive anxiety.

HPI:

M.P is a 32-year-old Hispanic female who was well until about seven months ago when she started experiencing anxiety. At first, she would worry that she had left her door unlocked while she was at her workplace. Gradually, the feelings of anxiety became more intense, greatly affecting her performance at work.

She also noticed that she began feeling quite fatigued most of the time. She also became irritable, lost concentration easily, and had difficulty sleeping. These symptoms have become more severe over the past seven months. The patient insists that nothing is wrong, saying that it may be a result of being stressed out and fatigued, and is only here because her co-workers insisted that she seek some help.

ORDER YOUR CUSTOM PAPER HERE

Drug And Substance Use:

Patient does not use tobacco or any other substances. Says that she is a social drinker who takes a glass of wine with her food on the weekends.

Medical History:

            The patient has no known chronic illnesses. No surgical history. No previous hospital admissions.

  • Current Medications:

Currently not on any medication.

  • Allergies:

NKFDA.

  • Reproductive Hx:

LMP 29/05/2022. Cycle is 28 days lasting 3 days. Regular flow. G0T0P0A0L0. No contraceptive. Has one sexual partner currently. Uses condoms as a mode of contraception.

ROS:

  • GENERAL: Denies any other concerns, fever, or body aches.
  • HEENT: Patient does not complain of any headaches. She reports no history of trauma. There are no complaints regarding her throat, nose or ears.
  • SKIN: No complain of any lesions or rashes. The patient reports no eczema.
  • CARDIOVASCULAR: Patient reports no chest pain, no cough, no palpitations, no cyanosis, no orthopnea, no fatiguability.
  • RESPIRATORY: No cough, no difficulty breathing, no wheezing.
  • GASTROINTESTINAL: The patient reports no vomiting, no abnormal bowel movements, no loss of appetite.
  • GENITOURINARY: No dysuria, no hematuria, no urgency, no frequency.
  • NEUROLOGICAL: No visual disturbances, no headaches, no loss of consciousness.
  • MUSCULOSKELETAL: The patient does not complain of any joint pain. No muscle pains.
  • HEMATOLOGIC: No history of easy bruisability or bleeding.
  • LYMPHATICS: Denies any lymph node swelling.
  • ENDOCRINOLOGIC: No heat or cold intolerances, no polyphagia, no polydipsia, no polyuria.

Objective:

VS: Temp: 98.4 F, BP: 110/75, HR: 82, RR: 16, 100% on RA, Height: 5ft, 6in Wt.: 147 lbs.

BMI: 23.7. It is within the normal range.

General: Patient is of good nutritional status. No signs of dehydration. Not in any obvious pain or distress. Appropriately dressed. NRNP 6675 Week 3 SOAP Note: Anxiety Disorder Example

Skin: Warm and moist. Appropriate hair distribution. No ulcers or rashes.

Head: Normocephalic.

Eyes: No conjunctival pallor. No scleral jaundice. Eyelids are normal. Examination reveals normal pupils and irises.

ENT: Appearance of the external ears and nose is normal. No abnormalities in the external auditory canal and eardrum. Unimpaired hearing.

Neck: Supple and no lymphadenopathy.

CV: Chest wall is normal. No parasternal heaves or thrills. No cardiac dullness. Normal heart sounds (S1, S2) heard with no additional sounds. No murmurs.

RS: Chest wall is normal. Movement with respiration. Trachea and apex beat are not displaced. Vesicular and bronchial breath sounds heard. No additional sounds. No wheeze, no grunting, no stridor.

Abdomen: Normal shape. Movement with respiration. No tenderness or organomegaly elicited. Bowel sounds present and normal.

Musculoskeletal: No skeletal deformities or point tenderness. No joint pain or swelling. Range of movement in the joints is not impaired. Appropriate muscle strength and tone.

To rule out underlying conditions that may be the cause of the patient’s presenting complaint, it is important to perform a complete blood count (CBC). Reduced RBC and hemoglobin levels may cause increased fatiguability, and it is important to rule this out. A random blood sugar (RBS) is important to rule out hypoglycemia. Thyroid function tests (TFTs) are vital in ruling out thyroid dysfunction, which may be the cause of the presenting complaints. A CT scan or an MRI can also be performed to rule out any abnormalities or brain injuries that may cause the current presentation.

Assessment:

Mental Status Examination (MSE):

The patient is a 32-year-old Hispanic female. She looks appropriate for her stated age. She is appropriately dressed, clean and her hair well-kempt. She sits quietly and is co-operative during the whole session. She, however, does not maintain eye contact during the interview. She does not display any tics or any other abnormal physical movements. She communicates clearly projecting her voice in a normal tone and volume.

She presents her thoughts clearly and answers the questions posed appropriately. The patient does not display any flight of ideas or loosening of associations. She reports to be in a euthymic mood. Her affect is appropriate for her mood meaning that there is congruency between her mood and affect. M.P denies any hallucinations or delusions. The patient reports that she has not had any thoughts of inflicting self-harm or harm to others. Patient is alert and well-oriented to time, place and person. Memory and concentration are unaffected. Has impaired insight into her condition.

Diagnostic Impression:

Diagnosis in this case scenario is generalized anxiety disorder (GAD). This is a condition marked by generalized excessive anxiety and worry about everyday life events. The worry reaches extreme levels where it affects an individual’s day-to-day activities by impairing concentration, causing insomnia, irritability, fatigue, restlessness, and an unrealistic view towards everyday challenges (DeMartini et al., 2019).

Our patient presented with anxiety for the last seven months. In addition, she complained of impaired concentration, irritability, insomnia, and fatigue. These symptoms are in line with GAD. Differential diagnoses include hyperthyroidism and depression. Normal thyroid hormone levels rule out hyperthyroidism. Depression, on the other hand, presents with prolonged periods of low mood and loss of interest in previously pleasurable activities.

Reflections:

The diagnosis of generalized anxiety disorder (GAD) is in line with my thinking. I have learned about the important features that I need to pick up in my history and MSE to make a diagnosis of GAD. What I would do differently is to inquire further about any history of mental illness or similar episodes in the past and the interventions provided, if any. Legal/ethical considerations to take into account include informed consent, confidentiality, therapeutic misconception, placebo related, vulnerability, exploitation, and operational challenges (Brown et al., 2020).  

Plan Of Management: 

  • The first line drug of choice for GAD are Selective Serotonin Reuptake Inhibitors (SSRIs). Continuous use of the medication for 12 months before tapering off should be encouraged to reduce the risk of relapse. SSRIs greatly minimize the physiological symptoms of anxiety, including muscle tension and headaches (Slee et al., 2019).
  • Psychotherapy is another option that has been proven to be as effective as medication, with CBT having the best results in reference to available evidence.
  • Provide emergency numbers such as 911 and suicide hotlines in case the patient contemplates harm to self or others at any time.
  • Educate patient on the importance of compliance to medication.
  • Follow up and review any arising issues with the patient.
  • Refer to a psychiatrist if patient is not improving.

NRNP 6675 Week 3 SOAP Note: Anxiety Disorder Example References

Brown, C., Ruck Keene, A., Hooper, C. R., & O’Brien, A. (2020). Isolation of patients in psychiatric hospitals in the context of the COVID-19 pandemic: An ethical, legal, and practical challenge. International Journal of Law And Psychiatry, 71, 101572. https://doi.org/10.1016/j.ijlp.2020.101572

DeMartini, J., Patel, G., & Fancher, T. L. (2019). Generalized Anxiety Disorder. Annals of Internal Medicine, 170(7), ITC49–ITC64. https://doi.org/10.7326/AITC201904020

Slee, A., Nazareth, I., Bondaronek, P., Liu, Y., Cheng, Z., & Freemantle, N. (2019). Pharmacological treatments for generalised anxiety disorder: a systematic review and network meta-analysis. Lancet (London, England), 393(10173), 768–777. https://doi.org/10.1016/S0140-6736(18)31793-8

NRNP 6675 Week 3: Anxiety, Obsessive-Compulsive and Related, and Trauma and Stressor-Related Disorders

Anxiety disorders provide a good opportunity to take a close look at the nature/nurture debate as well as the gene/environment interactions that influence the nervous system and neurochemistry. A significant part of most of Sigmund Freud’s theories, the concept of anxiety has been debated and discussed over many years in the psychiatric literature.

While Freud’s theories focused on the “mind” and the unconscious, another way to look at anxiety is with Hans Selye’s concept of “fight or flight” in which the sympathetic nervous system activates a response to stress. As you explore anxiety disorders, you will notice that no two cases of anxiety are the same.

Obsessive-compulsive disorder is characterized by the presence of obsessive thoughts, which manifest as persistent thoughts, images, or even “urges.” The only way that the individual can disperse the anxiety of these persistent thoughts/images and urges is to perform a behavior (the compulsion).

The compulsion could be checking things, counting, reciting a silent prayer, or repeating a number of phrases. The disorder becomes so pervasive that the person can spend a significant amount of time each day attending to the compulsion in order to relieve the anxiety caused by the obsession.

Although trauma and stressor-related disorders stem from exposure to a traumatic or stressful event, not all exposures to trauma or stress will result in a disorder. However, following these types of events, patients may report symptoms that interfere with their ability to function well in one or more areas of their life, such as flashbacks, nightmares, or intense psychological or physiological distress.
This week, you will explore evidence-based treatment methods for patients with anxiety, obsessive-compulsive, as well as trauma and stressor-related disorders.

Learning Objectives

Students will:

Assess patients with anxiety, obsessive-compulsive, and trauma and stressor-related disorders
Develop differential diagnoses for patients with anxiety, obsessive-compulsive, and trauma and stressor-related disorders
Develop appropriate treatment plans for patients with anxiety, obsessive-compulsive, and trauma and stressor-related disorders
Advocate health promotion and patient education strategies for patients with anxiety, obsessive-compulsive, and trauma and stressor-related disorders

Learning Resources

Required Readings (click to expand/reduce)

Sadock, B. J., Sadock, V. A., & Ruiz, P. (2015). Kaplan & Sadock’s synopsis of psychiatry (11th ed.). Wolters Kluwer. (For review as needed)

Chapter 9, “Anxiety Disorders”
Chapter 10, “Obsessive-Compulsive and Related Disorders”
Chapter 11, “Trauma- and Stressor-Related Disorders”
Chapter 12, “Dissociative Disorders”
Chapter 26, “Physical and Sexual Abuse of Adults”
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 Guide

Document: Focused SOAP Note Template

Document: Focused SOAP Note Exemplar

Required Media (click to expand/reduce)

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

Walden University. (2021). Case study: Dev Cordoba. Walden University Blackboard. https://class.waldenu.edu

Accessible player
Medication Review
Review the FDA-approved use of the following medicines related to treating anxiety disorders, OCD, PTSD, and related disorders:

Anxiety Generalized anxiety disorder Panic disorder
alprazolam
amitriptyline
amoxapine
buspirone
chlordiazepoxide
citalopram
clomipramine
clonazepam
clonidine
clorazepate
cyamemazine
desipramine
diazepam
dothiepin
doxepin
duloxetine
escitalopram
fluoxetine
fluvoxamine
gabapentin (adjunct)
hydroxyzine
imipramine
isocarboxazid
lofepramine loflazepate
lorazepam
maprotiline
mianserin
mirtazapine
moclobemide
nefazodone
nortriptyline
oxazepam
paroxetine
phenelzine
pregabalin
reboxetine
sertraline
tiagabine
tianeptine
tranylcypromine
trazodone
trifluoperazine
trimipramine
venlafaxine
vilazodone alprazolam
citalopram
desvenlafaxine
duloxetine
escitalopram
fluoxetine
fluvoxamine
mirtazapine
paroxetine
pregabalin
sertraline
tiagabine (adjunct)
venlafaxine alprazolam
citalopram
clonazepam
desvenlafaxine
escitalopram
fluoxetine
fluvoxamine
isocarboxazid
lorazepam
mirtazapine
nefazodone
paroxetine
phenelzine
pregabalin
reboxetine
sertraline
tranylcypromine
venlafaxine
Posttraumatic stress disorder Reversal of benzodiazepine effects Social anxiety disorder
citalopram
clonidine
desvenlafaxine
escitalopram
fluoxetine
fluvoxamine
mirtazapine
nefazodone
paroxetine
prazosin (nightmares)
propranolol (prophylactic)
sertraline
venlafaxine flumazenil
citalopram
clonidine
desvenlafaxine
escitalopram
fluoxetine
fluvoxamine
isocarboxazid
moclobemide
paroxetine
phenelzine
pregabalin
sertraline
tranylcypromine
venlafaxine

Obsessive-compulsive disorder
citalopram
clomipramine
escitalopram
fluoxetine
fluvoxamine
paroxetine
sertraline
venlafaxine
vilazodone

Assignment: 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.

Photo Credit: Photographee.eu / Adobe Stock

In this Assignment, you use a case study to develop a focused SOAP note based on evidence-based approaches.

To Prepare

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? NRNP 6675 Week 3 SOAP Note: Anxiety Disorder Example

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-TRcriteria 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 and Grading Information

To submit your completed Assignment for review and grading, do the following:

Please save your Assignment using the naming convention “WK3Assgn+last name+first initial.(extension)” as the name.
Click the Week 3 Assignment Rubric to review the Grading Criteria for the Assignment.
Click the Week 3 Assignment link. You will also be able to “View Rubric” for grading criteria from this area.
Next, from the Attach File area, click on the Browse My Computer button. Find the document you saved as “WK3Assgn+last name+first initial.(extension)” and click Open.
If applicable: From the Plagiarism Tools area, click the checkbox for I agree to submit my paper(s) to the Global Reference Database.

Click on the Submit button to complete your submission.