NRNP 6675 Week 3 Assignment Soap Note
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
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
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.
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 symptomatology 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-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).
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.
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 and lasts 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 complaints 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 fatigability.
■ 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.
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. NRNP 6675 Week 3 Assignment Soap Note
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 beats 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 fatigability, 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 drugs 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 patients on the importance of compliance to medication.
■ Follow up and review any arising issues with the patient.
■ Refer to a psychiatrist if the patient is not improving.
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 generalized 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
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What\’s Coming Up in Week 4?
In Week 4, you will explore substance-related and addictive disorders, which are complicated mental health disorders that involve physical addiction as well as psychological or emotional dependence.
Photo Credit: [BrianAJackson]/[iStock / Getty Images Plus]/Getty Images Looking Ahead to the Week 10 Assignment: Nurse Practitioner Career Planner
For this Assignment, you will create a professional Career Planner that includes a cover letter, resume, philosophy statement, and letters of recommendation that you may use as you pursue your next professional role. It is recommended that you review the Career Planner guide in this week’s resources and work on your planner throughout the term. See the Week 10 Assignment area for complete instructions.
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