Focused SOAP Psychiatric Evaluation
Follow Assignment Instructions
Carefully read and answer each bullet point of the assignment (answer briefly).
All references require creditable sources, nothing less than 5 years. References require doi or
http. Please add conclusion. Help write my thesis – APA needs to be 7th Edition. No running head needed.
No Plagiarism Please!
To Prepare
• 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 Case Study: Dev Cordoba. You will use this case as the basis of this Assignment
• Consider what history would be necessary to collect from this patient.
• Consider what interview questions you would need to ask this patient.
CASE STUDY: DEV CARDOBA TRANSCRIPT (SEE ATTACHMENTS BELOW)
Focused SOAP Psychiatric Evaluation
Subjective:
CC (chief complaint): “I worry about everything”, “ I have lots of bad dreams, and sleepless nights”.
HPI:
Patients Initials: D.C Age: 7yrs
B.P: 95-110 Temp: 36 pulse: 90 WT: 46 lb Ht: 47.7
Gender: M Ethnicity: African Religious affiliation: none Immunization: up-to-date. Allergies: none
The evaluation aims at improving Dev’s mental health by reducing too much fear and worry, which affects his social life in school, and his relationship with his parent and sibling. The primary purpose of the referral is because the pediatrician could not find anything wrong with Dev physically. The child had complained of headaches, stomach aches, and other health issues such as lack of sleep and loss of weight. The pediatrician gave the child DDVAP, which is never worked. Currently, the patient is not using any drugs. Dev, the seven-year-old boy, is not yet prescribed any medicine because he has not been tested for any psychiatric disorder.
The patient is having a mental health issue, which may have been caused by a lack of enough attention from the mother, and that the boy cannot stop thinking about the father. However, the condition makes Dev worry too much, become aggressive and agitated, hence throwing things around the house (Viner,et,al.,2021). Additionally, Dev feels like the little brother has taken all attention, spending little time with the mother. Dev experience symptoms, such as difficulties falling asleep, socializing with others in school due to aggression. The symptoms have worsened since the last appointment with the pediatrician. The severity of the condition is based on the number of times the child has been sent home for being violent and complex time sleeping even in school. On the other hand, bed wetting is one issue that makes Dev become anxious and worried, especially after being scolded and called “smelly” by the mother. Dev has also lost weight for the past three weeks, making him look weak and unhealthy.
The main stressors in the absence of dad, making him worry about losing his mother too. Parental neglect and verbal abuse are some of the main stressors Dev goes through (Biddle,et,al.,2019). For instance, the mother calls Dev names, names such as ‘smelly”.The child also acts as a stressors, where Dev becomes worried and agitated when the mother does not give him much attention.
Substance Use History:
None
Current Medications:
The current medicine is the Desmopressin (DDVAP) drug prescribed by the pedestrian. The main aim of the drug is to treat bed wetting is one of the symptoms or rather issues faced by Dev. DDVAP works by decreasing the amount of urine produced by the body, preventing a person from bed wetting. However, the DDVAP does not seem to work.
Allergies:
None
Reproductive Hx:
Normal
ROS:
Example of Complete ROS:
GENERAL: loss of three pounds for the last three weeks, no fever, and 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 discomfort. No vibrations or edema.
RESPIRATORY: No shortness of breath, cough, or sputum.
GASTROINTESTINAL: stomach ache, No nausea, vomiting, or diarrhea. No abdominal pain or blood.
GENITOURINARY: urgency, hesitancy, odor, odd color
NEUROLOGICAL: claim to have 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:
Through warning signs, such as irritability, persistent worrying, and withdrawal from social interactions, mental health can be assessed among the seven-year. The child is diagnosed with obsessive-compulsive disorder, which is an anxiety disorder. The mental health disorder is diagnosed by checking and rechecking the individual’s items, such as bags, rearranging objects, and rechecking the door. What differentiates the diagnostic from other diagnostic types is that individuals with OCD often feel anxious, which is characteristic of worrying too much, depressed, concentrating, perfectionist, and obsessed. The disorder can e diagnosed through an X-ray and a blood sample. A structured clinical interview is a tool used to check whether the symptoms are compatible with OCD (Tanir,et,al.,2020). The tool, however, asks about the symptoms and moods to check whether the symptoms match with the provided for treatment purposes.
Assessment:
Mental Status Examination:
Dev is a seven-year-old boy who looks s his age. The boy is attentive and cooperative, especially during the interview process. Dev is well-groomed with clean and appropriate clothes. Dev is thin and short. The seven-year-old does not maintain eye contact, appears restless, and gets very quickly, especially when asked about his brother. Dev referee to his brother as a brat, which is abusive. Dev has typical gait/motor, hence able to walk around well. Despite his inability to sleep well, and bed wet, the seven-year have average intelligence. Dev has an anxious and worried mood, which was evident in his speech. His speech was fluent, hence able to understand and ask questions easily. The perception of the patient is on point and free from any form of illusions. The whole time Dev was restless and could jump from one sit to another, have an ordinary judgment, and memory, for instance, could remember episodes.
Diagnostic Impression:
OCD, Attention-deficit/hyperactive disorder (ADHD), and opposition defiant disorder are the three diagnoses to my diagnostic impression, which is OCD (Tanir,et,al.,2020). I ruled out the opposition defiant disorder because the condition is only characterized by symptoms of agitation, anger, spitefulness, annoyance, and blaming others. Also, I ruled out the ADHD disorder because the condition is caused by premature delivery, exposure to toxic environments, brain injury, or alcohol use during pregnancy, which is not stated in the case study. I concluded to OCD, where the child gets too persistent when it comes to attention, worry too much, and have unwanted thoughts that lead to anxiety, such as what if am left alone/, what if dad never comes back?, my small brother is loved more than I? Dev have obsessions, such as obsession towards his mother, and anything else attached to him (Tanir,et,al.,2020). However, based on the case study, having OCD would assist Dev to think effectively, which leads to better behavior, such as taking extra caution to protect the mother.
Reflection.
Dev, the son of Mrs. Cordoba, is always anxious and worried. The seven-year-old also feels like her mother loves the small brother more than him, making him more worried and agitated. Dev finds it hard to make friends and leave in peace with others due to his aggressive and irritable nature. On the other hand, the boy may be suffering from OCD, where he is obsessive and controlling (Tanir,et,al.,2020). Dev wants things to be done in his favor and becomes needy when denied attention. I agree with my assessment and diagnostic impressions of Dev because the child has emotional and behavioral aspects that show his mental status. I learned that children also go through mental health issues, hence require attention from parents. It is essential for parents to monitor their children, especially when they become too needs, daydream, have scary dreams and compare themselves with other siblings (Viner,et,al.,2021).
On the other hand, I have learned that it is essential to tell our children the truth concerning our families, such as the absence of the father or whereabouts of one parent, to protect them from trauma. If I were the parent, I would not use abusive language towards my kids, such as calling them “smelly” I would also ensure they are clean and bedding’s washed if the children are bed wetting instead of shaming them. Patients’ information should be kept safe, for instance, patient’s identification information. Also, if the information is required, asking for consent from the owner is very important, and treating every client equally even though their social, ethnic, economic, and religious background is concerned.
Case Formulation and Treatment Plan
OCD can be prevented and treated by finding help from cognitive behavior therapists. The therapist offers therapy and counseling that assist in making the child feel wanted and making the child believe that they are loved, safe, and essential like everybody else (MacLean, et.al.,2019). Children are also taught how to manage stress and deal with emotional and behavioral disorders that disrupt their perception. On the other hand, apart from family therapy and cognitive therapy, Dev should be provided with selective serotonin reuptake inhibitors(SSRIs), which raise the chemical in the brain. Also, antibiotics prevent the child from getting infections, such as the streptococcal infection. The medication has no significant side effects since more treatment is focused on psycho-therapy than intake of medications. The patient, however, is encouraged to continue with mental health clinic visits for assessment and therapy sessions at least two times a week.
The client has emergency numbers: Emergency Services 911
.
References
Biddle, S. J., Ciaccioni, S., Thomas, G., & Vergeer, I. (2019). Physical activity and mental health in children and adolescents: An updated review of reviews and an analysis of causality. Psychology of Sport and Exercise, 42, 146-155.
MacLean, S. A., Agyeman, P. O., Walther, J., Singer, E. K., Baranowski, K. A., & Katz, C. L. (2019). Mental health of children held at a United States immigration detention center. Social Science & Medicine, 230, 303-308.
Tanir, Y., Karayagmurlu, A., Kaya, İ., Kaynar, T. B., Türkmen, G., Dambasan, B. N., … & Coşkun, M. (2020). Exacerbation of obsessive compulsive disorder symptoms in children and adolescents during COVID-19 pandemic. Psychiatry Research, 293, 113363.
Viner, R. M., Russell, S., Saulle, R., Croker, H., Stansfield, C., Packer, J., … & Minozzi, S. (2021). Impacts of school closures on physical and mental health of children and young people: a systematic review. MedRxiv.
