SOAP PP
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LastSOAP.docx
Comprehensive Psychiatric Evaluation Template
Encounter date: _____21/06/2023___
Patient Initials: ____P.F.__ Gender: M/F/Transgender __Female__ Age: __10___ Race: __Caucasian___ Ethnicity _White___
Reason for Seeking Health Care: " We are concerned about our daughter's repetitive behaviors and constant intrusive thoughts. She often experiences an intense fear of contamination and constantly washes her hands excessively and avoids touching certain objects. She also asks us to constantly repeat certain phrases three times or perform rituals to alleviate her anxiety. She also spends hours checking and rechecking if doors are locked and if switches are off. These behaviors and rituals are affecting her daily life and we do not know what to do to help her."
HPI: The patient who is a 10-year-old girl is brought to the clinic by her very concerned parents. The patient's mother admitted that the symptoms began 5 months ago. She admitted that the symptoms began with her daughter constantly washing her hands, taking long showers, and using excessive amounts of hand sanitizer. She admitted that the child's symptoms have gradually escalated as she now spends several hours a day performing rituals like checking if doors are locked, if the switches are turned off, arranging objects precisely, repeatedly seeking reassurance from us, and asking us to repeat specific phrases 3 times. The mother admitted that these symptoms occur daily and that the child engages in these rituals repeatedly throughout the day with no significant improvement. The mother also admitted that the child also experiences intrusive and distressing thoughts mostly of fear of contamination and worries about harm coming to herself or her family if she does not perform her rituals. The mother admitted that these symptoms often tend to worsen whenever the child experiences stressful situations, such as upcoming exams or social events, and any disruption to her rituals or attempts to resist the compulsions significantly heightens her anxiety levels. The mother admitted however that whenever the child can complete her rituals exactly as she believes they should be done, she experiences a brief reduction in anxiety. The mother admitted that to help P.F., they have tried implementing a structured routine which has provided some temporary relief, but they have not had a significant impact on reducing her symptoms or preventing their recurrence. On a scale of 1-10, the mother admitted the severity of the symptoms is at an 8/10 as these symptoms have become a constant distressing part of her daily life. The mother denied any additional symptoms such as pain, fever, nausea, or chills.
SI/HI: The mother denied the child have a history of any suicidal attempt.
Sleep: _The mother admitted that before the child sleeps she must perform certain rituals and finds it hard to sleep if she is not able to do them. Appetite: The mother denied any changes in the child’s appetite.
Allergies (Drug/Food/Latex/Environmental/Herbal): The mother admitted that the child has a peanut allergy which she terms as severe as the child experiences an immediate anaphylactic reaction. The child experiences symptoms such as difficulty breathing, swelling of the face and throat, hives, and a blood drop pressure. The mother admitted that administration of epinephrine helps alleviate the symptoms. The mother also admitted that the child also has a moderate allergy to dust mites and that exposure to dust mites triggers respiratory symptoms in the child, including sneezing, nasal congestion, itchy and watery eyes, and coughing. The mother admitted that regular cleaning and dusting of the child's living environment, using allergen-proof mattresses and pillow covers, and using a high-efficiency particulate air filter in the bedroom often help to reduce the frequency and severity of symptoms. The mother denied any known allergy to drugs, latex, or herbal.
Current perception of Health: Excellent Good Fair Poor
Psychiatric History:
Inpatient hospitalizations:
|
Date |
Hospital |
Diagnoses |
Length of Stay |
|
None
|
None |
None |
None |
|
None |
None |
None |
None |
Outpatient psychiatric treatment:
|
Date |
Hospital |
Diagnoses |
Length of Stay |
|
None |
None |
None |
None |
|
None |
None |
None |
None |
Detox/Inpatient substance treatment:
|
Date |
Hospital |
Diagnoses |
Length of Stay |
|
None |
None |
None |
None |
|
None |
None |
None |
None |
History of suicide attempts and/or self-injurious behaviors: ___The mother denied any history of suicidal attempts or any self-injurious behaviors. _________________________________
Past Medical History
· Major/Chronic Illnesses___ The mother denied the patient having any history of major or chronic diseases.
· Trauma/Injury The mother denied the patient has any history of trauma or injury.
· Hospitalizations __The mother admitted that the child was admitted for two weeks when she was born because she had severe jaundice.
· Past Surgical History____ The mother denied any history of surgery performed on the patient.
Current psychotropic medications:
______________None___________________________ ________________________________
_________________________________________ ________________________________
Current prescription medications:
______________None___________________________ ________________________________
_________________________________________
OTC/Nutritionals/Herbal/Complementary therapy:
_____________None____________________________ ________________________________
Substance use : (alcohol, marijuana, cocaine, caffeine, cigarettes)
|
Substance |
Amount |
Frequency |
Length of Use |
|
None |
None |
None |
None |
|
None |
None |
None |
None |
|
None |
None |
None |
None |
|
None |
None |
None |
None |
Family Psychiatric History:
· The patient's 40-year-old father has a history of Generalized Anxiety Disorder. He experiences chronic worry, restlessness, and difficulty controlling his anxiety. He has been seeking therapy intermittently and uses relaxation techniques to manage his symptoms.
· The patient's 43-year-old maternal aunt was diagnosed with Obsessive-Compulsive Disorder in her early twenties. She experienced intrusive thoughts and engaged in ritualistic behaviors. She received therapy and medication, which have helped in managing her symptoms.
· The patient's 35-year-old paternal uncle has a history of Bipolar Disorder. He has experienced episodes of mania characterized by elevated mood, increased energy, and impulsive behaviors. He has been on mood stabilizers and regular therapy sessions to maintain stability.
· The patient's 16-year-old older sister has a history of Attention-Deficit/Hyperactivity Disorder. She has struggled with impulsivity, hyperactivity, and inattentiveness since childhood. She received diagnosis and treatment when she was 11 years- old, including behavioral therapy and medication to improve focus and impulse control.
· The patient's 68-year-old maternal grandfather had a diagnosis of Major Depressive Disorder. He experienced recurrent depressive episodes throughout his adult life, requiring multiple hospitalizations and various antidepressant medications. He also engaged in psychotherapy to manage his depressive symptoms.
Social History
Lives: Single-family House/Condo/ with stairs: ____5-bedroom family house_______ Marital Status: __ Single______ Education: __4th grade student
Employment Status: __Unemployed____ Current/Previous occupation type: __Student. __
Exposure to: __Mother denies_ Smoke_ Mother denies___ ETOH _Mother denies___ Recreational Drug Use: _Denies____
Sexual Orientation: ____Heterosexual___ Sexual Activity: __Not active__ Contraception Use: _______None_____
Family Composition: Family/Mother/Father/Alone : ____The patient currently lives in a 5-bedroom family house with both father and mother, two older siblings, and a 4-year-old baby brother.
Other: (Place of birth, childhood hx, legal, living situations, hobbies, abuse hx, trauma, violence, social network, marital hx): ______The patient was born in Los Angeles, California and they later relocated to Miami, Florida. The mother admitted that the patient lives in a supportive and nurturing environment, with both parents actively involved in his upbringing. The mother admitted that the child has been mostly happy with his childhood as she has a lot of friends and has never been involved in any criminal or illegal activities. The mother admitted that the patient lives with both parents and three siblings in a comfortable suburban neighborhood. They live in a spacious 5-bedroom family house with an outdoor swimming pool where the patient used to spend most of her after-school practicing swimming as she enjoys swimming. The mother admitted, however, due to her recent struggles with OCD, she has found it challenging to find the motivation to engage in her swimming lessons due to her worsening fear of harm.
Health Maintenance
Screening Tests (submit with SOAP note):
· The mother admitted that the patient underwent a comprehensive well-child check-up on January 3, 2023, which included screening for anxiety using the Screen for Child Anxiety Related Disorders questionnaire. The results indicated mild anxiety symptoms, and the healthcare provider recommended regular monitoring and suggested implementing coping strategies to manage anxiety.
· The mother admitted that during a routine check-up on June 17, 2019, the patient was screened for Attention-Deficit/Hyperactivity Disorder using the Vanderbilt Assessment Scale. The results revealed negative symptoms of inattention and impulsivity.
· The mother admitted that on January 12, 2022, the patient received a hearing screening using pure-tone audiometry. The results indicated normal hearing thresholds bilaterally, ensuring optimal hearing health for the child.
· The mother admitted that on August 10, 2022, the patient received dental prophylaxis and a screening for oral health issues. The dentist assessed the patient's oral hygiene, checked for any dental caries or abnormalities, and provided oral health education and preventive measures.
Exposures: The mother denied the patient being exposed to any harmful substances.
Immunization HX:
The patient's mother admitted that the patient is current on all age-appropriate immunizations such as the DTaP vaccine which she received at 2 months, 4 months, 6 months, 15 months, and 5 years of age. She also received the MMR vaccine at 12-months and a booster dose at 5 years of age.
Review of Systems (at least 3 areas per system):
General: The patient's mother admitted that the patient is constantly washing her hands, checking and locking doors, checking if switches are turned off, and asking the parents and siblings to perform various rituals and phrases. She denies the patient experiencing fever, chills, or significant weight changes in her daughter.
HEENT: The patient's mother denies her daughter experiencing any headaches. She denies noticing any lesions, hair loss, patches, or lumps on her head. There is no history of injuries, illnesses, or ocular discharge. The patient's mother denies that the patient has experienced any ear pain, repeated ear infections, or injuries. The patient’s mother denies that the patient has experienced any nasal discharge, tightness, and nosebleeds. The patient’s mother denies that the patient has experienced any signs of infections, foul breath, missing teeth, or mouth sores. The patient’s mother denies that the patient has experienced any inflammation, discomfort, or throat infections.
Neck: The patient’s mother denies that the patient has experienced any neck movement restrictions, neck injury, lumps, or pain.
Lungs: The patient's mother admits that her daughter experiences an increased breathing rate with shortness of breath during episodes of anxiety when she is unable to complete her rituals. The patient's mother denies that the patient has experienced any wheezing, abnormal lung expansion, or abnormal breathing sounds.
Cardiovascular: The patient's mother admits that her daughter has a slightly increased heart rate and rhythm during anxiety attacks. The patient's mother denies that the patient has experienced any chest pain, chest tightness, or pressure.
Breast: The patient's mother denies noticing any breast swelling, enlargement, injury, or pain in the patient.
GI: The patient's mother denies that the patient has experienced any stomach discomfort, vomiting, or nausea. The patient's mother admitted that the patient has had occasional constipation and diarrhea in the past.
Male/female genital: The patient's mother denies any complaints from the patient of vaginal itching, vaginal sores, discharge, or swelling.
GU: The patient's mother denies any complaints from the patient of experiencing any pain on urination, an urgency to urinate, frequency, or cloudy urine.
Neuro: The patient's mother denies any complaints from the patient of experiencing any headaches, seizures, numbness, or fainting spells.
Musculoskeletal: The patient's mother denies any complaints from the patient of experiencing any injuries, joint pain, swelling, or noticing any restrictions in movement.
Activity & Exercise: The patient's mother admits that her daughter engages in regular physical activity by participating in swimming classes. The mother also admitted that the child also enjoys taking walks after school.
Psychosocial: The patient's mother admits that her daughter experiences fear of contamination, fear of danger to her or her family, and fear of not completing her rituals. The patient's mother denied that the patient has been experiencing hallucinations or suicidal ideations.
Derm: The patient's mother admits that her daughter washes constantly to ensure her skin stays clean due to a fear of contamination. The patient's mother denied noticing any wounds, scars, lesions, or moles on the child's skin.
Nutrition: The patient's mother admits that her daughter has a preference for a healthy diet due to concerns about developing diseases such as obesity and diabetes.
Sleep/Rest: The patient's mother admits that her daughter gets sufficient rest, averaging 7-8 hours of sleep per night. There are no difficulties reported in staying asleep or waking up. However, the mother admitted that if the child does not perform her nighttime rituals before she sleeps it becomes difficult to fall asleep.
LMP: Not applicable, as the patient has not reached menarche yet.
STI Hx: The patient's mother denies the patient experiencing any history of sexually transmitted infections, vaginal infections, or urinary tract infections, as she is not sexually active at her age.
Physical Exam
BP__90/60 mmHg taken while the patient was seated______TPR_96.7F____ HR: ___72__ RR: _16___Ht. _140 cm____ Wt. __35 kg____ BMI ( percentile) _17.9 kg/m2____
General: The patient appears restless and anxious and avoids touching anything. She appears the stated age and can answer questions appropriately. She is dressed in a clean blue dress with no bad smell.
HEENT: The patient has a normocephalic head without any lesions, spots, or lumps. She has a normal distribution of hair without any signs of hair loss. Pupils are equal and react to light appropriately. Visual acuity is adequate, and there is no edema or redness. Ear structures are healthy without aberrant adenopathy, discharge, or damage. There is no nasal discharge or sore sinuses, and the nose appears symmetrical. The oropharynx is healthy without any lesions, rashes, or ulcers.
Neck: The patient has a flexible neck without any scars, bruises, lumps, enlargement, or goiter.
Pulmonary: Upon auscultation, there are no crackles, wheezes, or rhonchi in the lungs. There are no abnormal splits, skips, rubs, gallops, or murmurs. Normal S1 and S2 sounds are heard and no palpable costovertebral angle is detected.
Cardiovascular: During sitting and supine examinations, there are no abnormal pulsations, lifts, or heaves. The point of maximal impulse is at the 5th intercostal space midclavicular line. There are no thrills. S2 is louder at the base, and S1 is louder at the apex. There are no audible murmurs, clicks, or gallops. Regular rate and rhythm are observed.
Breast: The patient's breasts are symmetrical without any deformation, pain, discharge, scars, or lumps noted.
GI: The abdomen appears smooth and uniform without any obvious rashes, ulcers, dilated veins, wounds, peristalsis, or pulsations. The umbilicus is in the middle. Active bowel sounds are heard in each quadrant, but there are no aortic, renal, iliac, or femoral bruits.
Male/female genital: The patient has no pubic hair and normal genital skin color for her ethnicity. A few black dots are noted on the skin. There is no vaginal swelling, pain, or discharge noted.
GU: Upon abdominal palpation, there is no abdominal pain or urinary retention. No clotting or irregular secretion in the vagina is observed. No complaints of urinary urgency, frequency, or cloudy urine from the mother.
Neuro: The patient appears aware, focused, and has a good recall for her age. Speech is normal. Cranial nerves 2-12 are intact, and muscle strength is 5/5. The patient demonstrates good balance and sensitivity to minor touches.
Musculoskeletal: No swelling, pain, graded sensory abnormalities, or asymmetry is present. Posture, walking, and range of motion are all appropriate. Joint stability and muscular strength are average.
Derm: The patient's skin color is appropriate for her ethnicity, and there are no lesions, growths, lumps, itching, or other abnormalities observed. Skin turgor is normal.
Psychosocial: The patient appears conscious and cognizant of time, place, and people. She exhibits signs of agitation and fear of contamination. She expresses concern that if she is not able to complete her rituals something bad will happen.
Miscellaneous: No additional information was collected
Mental Status Exam
Appearance: The patient appears well-groomed and dressed appropriately for her age. She maintains good hygiene and her physical appearance is within the expected age for a 10-year-old girl.
Behavior: The patient's mother reports repetitive behaviors, such as excessive hand washing and checking rituals. The patient appears restless and anxious. She frequently engages in repeatedly cleaning her hands with excessive amounts of hand sanitizer every 5 minutes. She also expresses signs of distress and frustration when unable to perform her rituals.
Speech: The patient's speech is fluent and coherent. However, she often talks about her obsessive thoughts and compulsions, expressing a strong need to perform specific actions or rituals to alleviate her anxiety. She describes her thoughts as intrusive and unwanted.
Mood: The patient's mood is typically anxious, preoccupied, and worried. She expresses frustration and distress when her compulsions are interrupted or not performed as desired.
Affect: The patient's affect is generally anxious and tense. She displays signs of discomfort during discussions related to her OCD symptoms.
Thought Content: The patient's thought content is primarily focused on her obsessive thoughts and compulsions. She expresses concerns about contamination, symmetry, and fear of harm that drive her compulsive behaviors.
Thought Process: The patient's thought process is logical and coherent. However, she exhibits rigid thinking patterns, insisting on specific rituals and behaviors to alleviate her anxiety.
Cognition/Intelligence: The patient's cognitive abilities appear intact for her age. She demonstrates age-appropriate understanding and reasoning skills in areas unrelated to her OCD symptoms.
Clinical Insight: The patient demonstrates some awareness that her obsessions and compulsions are excessive and irrational. She expresses frustration and a desire to control these symptoms but finds it difficult to resist the urge to engage in compulsive behaviors.
Clinical Judgment: The patient's ability to make appropriate decisions is impaired by her OCD symptoms. She struggles with prioritizing tasks and activities due to the interference caused by her obsessions and compulsions.
Plan:
Screening Test: Children's Yale-Brown Obsessive-Compulsive Scale (CY-BOCS). The patient's score of 30 indicated severe symptoms of OCD.
Screening Test: Pediatric Anxiety and Depression Scale (PADS). The patient's score of 18 indicated moderate anxiety symptoms consistent with OCD.
Diagnostic Test: Blood Test for Streptococcal Infection (Strep Test). The patient’s negative result rules out the possibility of Pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections.
Diagnostic Test: Thyroid Function Panel. The patient’s result value of TSH: 2.5 uIU/mL, Free T4: 1.2 ng/dL helps to rule out thyroid-related disorders.
Differential Diagnoses
1. Obsessive-Compulsive Disorder (OCD): ICD-10 Code F42
2. Generalized Anxiety Disorder (GAD) ICD-10 Code: F41.1
Generalized anxiety disorder is a condition of excessive worry about everyday issues and
situations and often last longer than 6 months (Kalin et al., 2020). Children with GAD may
exhibit restlessness, difficulty concentrating, muscle tension, and sleep disturbances
3. Body Dysmorphic Disorder (BDD) ICD-10 Code: F45.2
Body dysmorphic disorder, or body dysmorphia, is a mental health condition
where a person spends a lot of time worrying about flaws in their appearance and these flaws
are often unnoticeable to others (Castle et al., 2021). Children with BDD may engage in
excessive checking of their appearance, seeking reassurance, or performing grooming or
cosmetic rituals. They may also experience significant distress, social withdrawal, and impaired
functioning due to their preoccupations with perceived flaws.
Principal Diagnoses
1. Obsessive-Compulsive Disorder (OCD): ICD-10 Code F42
Obsessive-Compulsive Disorder is a mental health condition characterized by
the presence of obsessions or compulsions that cause significant distress and
impairment in daily functioning and can affect individuals of all ages, including children (Storch
et al., 2020). Common obsessions in children may include fears of contamination, excessive
concern for symmetry or order, aggressive or intrusive thoughts, and excessive doubts.
Compulsions, on the other hand, are repetitive behaviors or mental acts aimed at reducing
anxiety or preventing a feared event. These can include repetitive handwashing, checking,
counting, arranging objects, or mental rituals.
Plan:
The patient has been prescribed a dosage of sertraline 25 mg, to be taken orally once daily in the morning for 12 weeks unless instructed otherwise. Because the medication is usually available in tablet form, the child's mother was instructed that the child should take it with water or with a meal. The estimated cost of 30 tablets of sertraline 100 mg is around $7. Cognitive-behavioral therapy was the recommended psychotherapy for the child to help the child learn coping mechanisms and educate both the child and family about OCD and how to manage it.
Diagnosis #1 Obsessive-Compulsive Disorder
Diagnostic Testing/Screening: Children's Yale-Brown Obsessive-Compulsive Scale and Pediatric Anxiety and Depression Scale
Pharmacological Treatment:
Name: Sertraline
Dosage: 25 mg
Frequency: Once daily in the morning.
Duration: 12 weeks unless instructed otherwise by the healthcare provider.
Estimated Cost: The estimated cost of 30 tablets of sertraline 100 mg is around $7.
Non-Pharmacological Treatment: Cognitive Behavioral Therapy
Patient/Family Education: The patient's mother was instructed to ensure the patient:
1. Engages in regular exercise or physical activity as a healthy outlet for managing anxiety and stress.
2. Has a consistent daily routine to provide structure and predictability, which can help reduce her symptoms.
3. Practices relaxation techniques, such as progressive muscle relaxation or guided imagery, to promote a sense of calm and reduce anxiety.
4. Uses distraction techniques, such as engaging in a favorite hobby such as swimming, when experiencing intrusive thoughts or urges to perform compulsions.
5. Takes medication exactly as prescribed.
6. Keeps a journal to track OCD symptoms, triggers, and progress made during therapy sessions.
Referrals: Psychotherapist
Follow-up: 2 weeks to examine if symptoms have progressed and to assess medication adherence.
Anticipatory Guidance:
1. The patient's mother was instructed to ensure the patient has established clear and reasonable consequences for engaging in compulsive behaviors and rewards for successfully resisting them.
2. The patient's mother was instructed to ensure the patient has limited exposure to media or content that may reinforce or trigger her symptoms.
3. The patient's mother was instructed to encourage open communication with parents, teachers, or friends, about her OCD to reduce feelings of isolation and seek support when needed.
4. The patient's mother was instructed to ensure the patient utilizes thought-stopping techniques to interrupt and challenge obsessive thoughts as they arise.
5. The patient's mother was instructed to ensure the patient implements organizational strategies, such as using a visual schedule or labeling systems, to reduce anxiety related to cleanliness or orderliness.
6. The patient's mother was instructed to encourage the child to practice self-care activities, such as engaging in hobbies, spending time with friends, and getting enough sleep.
Signature (with appropriate credentials): __________________________________________
Cite current evidenced based guideline(s) used to guide care (Mandatory)_______________
References
Castle, D., Beilharz, F., Phillips, K. A., Brakoulias, V., Drummond, L. M., Hollander, E., ... & Fineberg, N. A. (2021). Body dysmorphic disorder: A treatment synthesis and consensus on behalf of the International College of obsessive-compulsive spectrum disorders and the obsessive-compulsive and R-related disorders network of the European College of neuropsychopharmacology. International Clinical Psychopharmacology, 36(2), 61.https://doi.org/10.1097%2FYIC.0000000000000342
Kalin, N. H. (2020). The critical relationship between anxiety and depression. American Journal of Psychiatry, 177(5), 365-367. https://doi.org/10.1176/appi.ajp.2020.20030305
Storch, E. A., Schneider, S. C., Guzick, A., McKay, D., & Goodman, W. K. (2020). Impact of COVID-19 on exposure and response prevention for obsessive-compulsive disorder: Present and post-pandemic considerations. Psychiatry Research, 292, 113310.https://doi.org/10.1016%2Fj.psychres.2020.113310
DEA#: 101010101 STU Clinic LIC# 10000000
Tel: (000) 555-1234 FAX: (000) 555-12222
Patient Name: (Initials)________P.F.______________________ Age __10_________
Date: __________21/06/2023_____
RX __________Sertraline ____________________________
SIG: Sertraline 25 mg is taken orally, once daily in the morning. The estimated cost of 30 tablets of sertraline 100 mg is around $7.
Dispense: ____30_______ Refill: _____0____________
No Substitution
Signature: ____________________________________________________________
Rev. 2272022 LM
