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. 

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?
• 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).

By Day 7 of Week 3

Submit your Focused SOAP Note.

Submission and Grading Information

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 GuideDocument: Focused SOAP Note TemplateDocument: Focused SOAP Note ExemplarRequired 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.htmlDartmouth Films. (2018, September 25). Resilience [Video]. YouTube. https://www.youtube.com/watch?v=bAXZVYDNURYNCTSN. (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.eduDefault player –Downloads–Download Video w/CCDownload AudioDownload Transcript

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

Medication Review

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