Focused SOAP Note for Generalized anxiety disorder, Panic disorder, Social anxiety Disorder and Dysthymia

Week (enter week #): (Enter assignment title)

 

Student Name

College of Nursing-PMHNP, Walden University

NRNP 6675: PMHNP Care Across the Lifespan II

Faculty Name

Assignment Due Date

 

 Subjective:

CC (chief complaint): Patient D is brought to the clinic for excessive worrying and anxiety about different issues in his life

HPI: The 7-year-old is accompanied by the mother to the hospital. He asserts that he worries about his mother and sibling which has been affecting his concentration in class. He now sits next to the teacher for easy monitoring and supervision. He is restless and has trouble concentrating.

Substance Current Use: None

Medical History:

  • Current Medications: The patient has been on vitamin D supplements
  • Allergies: No reported allergies
  • Reproductive Hx: Not sexually active

ROS:

  • GENERAL: No weight loss/gain, no fatigue, no chills
  • HEENT: No eye pain, redness or significant vision changes, no sneezing, no nasal congestion, no runny nose
  • SKIN: no itching, redness, or eczema
  • CARDIOVASCULAR: no palpations, no chest pressure or pain no edema
  • RESPIRATORY: no shortness of breath, denies cough or sputum, no wheezing
  • GASTROINTESTINAL: no diarrhea , no constipation, no anorexia, no abdominal pain
  • GENITOURINARY: no changes in the urinary pattern, no urgency, no burning sensation, no incontinence
  • NEUROLOGICAL: no dizziness, no headache, no paralysis, denies tingling, no confusion
  • MUSCULOSKELETAL: no muscle weakness or pain, no stiffness
  • HEMATOLOGIC: no history of anemia, no bruising or bleeding
  • LYMPHATICS: no swollen lymph nodes, has no history of splenectomy
  • ENDOCRINOLOGIC: no heat or cold intolerance

Objective:

Vitals: Temp 96.4, Pulse rate of 76, Respiration rate 18 non labored, B/P 100/65

Diagnostic results: The patient scored 30 on the Screening for Child Anxiety Related Disorders Inventory which indicates that the patient has generalized anxiety disorder (Mossman et al., 2017).

 

Assessment:

Mental Status Examination: The patient is a 7-year-old Caucasian male who appears his age. He is cooperative during the session though appears restless and fidgety. He also has trouble concentrating. He has no signs of hallucinations or troubling speech.

Diagnostic Impression: The diagnostic impression is a generalized anxiety disorder. The differential diagnoses are social anxiety disorder, panic disorder, and dysthymia

Generalized anxiety disorder (GAD)

The DSM-5 diagnostic criteria for GAD entails the presence of excessive anxiety and worry about various events or topics, the worry experienced is challenging to control (Gale & Millichamp, 2016). The anxiety and worry symptoms must be accompanied by at least three of the following symptoms, edginess or restlessness, impaired concentration, tiring easily, irritability, difficulty sleeping, and increased muscle aches or soreness. The case study shows that D keeps worrying about his mom and his brother. The case study also shows that in school the teacher keeps on telling him to sit down and to focus since he keeps looking outside the window. It is therefore evident that he has issues with concentration and excessive worrying which needs to be managed.

Panic disorder

Panic disorder is abrupt surges of fear and discomfort which peak within a short time. Individuals must present with at least four of the symptoms. The disorder is associated with recurring panic attacks, fear of losing control, feeling of derealization and depersonalization, accelerated heart rate and breath, chest pain, trembling and shaking, and excessive worry about a future attack (Kim, 2019).

Social anxiety Disorder

Social anxiety disorder is also known as social phobia. Individuals diagnosed with the condition experience various symptoms like the excessive worry of being embarrassed, excessive fear, fear of being humiliated and judged. Social interactions tend to cause irrational anxiety, embarrassment, fear, and self-consciousness. Since individuals fear being humiliated and being rejected, the condition is often associated with avoidance behavior which tends to impair a person’s social interactions (Chadelaine et al., 2018). The conditions result in impaired educational attainment, occupational performance, quality of

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