Comprehensive Focused SOAP Psychiatric Evaluation

 

Subjective:

CC (chief complaint): The patient reports constantly worrying about his mom and brother. Additionally, he experiences recurrent nightmares in which he is lost and cannot find his brother and mother.

HPI: The patient (Dev Cordoba) is a seven-year-old male. He presents with a chief complaint of worrying about his mom and brother. Additionally, he experiences recurrent nightmares in which he is lost and cannot find his brother and mother. According to him, he is ever worried about everything. Dev Cordoba is afraid that, just like his dad, his mother will not return home. This has affected his academics significantly. He reports that this condition (worry) has affected his concentration, as evidenced by regular complaints from his teacher. He rarely focuses while in class and is always looking out the window.

Furthermore, the patient has a bad relationship with his peers at school. He has been nicknamed Mr Smelly, and he reports that he threw his book at Billy. Miss Cordoba says that Dev is always worried and anxious about her.

Additionally, Dev feels he loves his little brother more than he does. Dev has difficulty sleeping and sleeps with the lights on and open the door. According to Miss Cordoba, Dev has poor nutritional habits and has shed approximately three pounds over three weeks. Additionally, the patient is on medication for nocturnal enuresis. The patient denies any suicidal ideations and thoughts of harming others.

Substance Current Use: None

Medical History:

• Current Medications: Desmopressin (DDVAP) for nocturnal enuresis.
• Allergies: No known drug and food allergies.

• Reproductive Hx: No pertinent history

ROS:

• GENERAL: The patient has lost three pounds over the last three weeks—no chills, weakness, or fever.
• HEENT: Normal visual acuity, no blurred vision, conjunctivitis, or diplopia. Normal hearing function. No running nose or rhinitis. No pharyngitis or mucosal inflammation.
• SKIN: No pruritus, rashes, ulcers, pallor, or bruises.
• CARDIOVASCULAR: No tachycardia, bradycardia, or heart gallop.
• RESPIRATORY: No difficulty breathing, orthopnea, dyspnea, or sputum production.
• GASTROINTESTINAL: The patient reports frequent stomachaches—no nausea, vomiting, constipation, diarrhea, or melena.
• GENITOURINARY: No dysuria, polyuria, lesions, or anuria. Nocturnal enuresis was reported.
• NEUROLOGICAL: The patient claims to have headaches frequently—no drowsiness, syncope paresthesia, or ataxia.
• MUSCULOSKELETAL: No myalgia, spasms, arthralgia, or myositis.
• HEMATOLOGIC: No anemia, polycythemia, or bleeding.
• LYMPHATICS: Normal lymphatic drainage
• ENDOCRINOLOGIC: No polyphagia, polydipsia, hyperhidrosis, or cold intolerance.

Objective:

Diagnostic results: The patient manifests adequate orientation to time and place. His thoughts and speech are organized, and he responds to all questions objectively. He demonstrates signs and symptoms of anxiety and stress-related disorder.

Assessment:

Mental Status Examination: The patient reported the patient’s previous physical appearance. He is cooperative and responds to the psychiatrist’s questions with adequate use of verbal and non-verbal communication cues. His speech and thoughts are organized.

Diagnostic Impression: The patient’s possible patients include separation anxiety disorder (SAD), generalized anxiety disorder, and post-traumatic stress disorder. The patient’s signs and patients involve worrying, anxiety, nightmares, and difficulty sleeping. According to the DSM-5-TR, a patient with SAD should fulfill at least three components of the diagnostic criteria (Lavallee & Schneider, 2019). Firstly, the patient experiences periodic distress when they anticipate or are separated from their homes or attachment figures. Secondly, the patient is worried about losing people they are attached to or concerned that these people may get hurt (Lavallee & Schneider, 2019). Thirdly, the patient is concerned about facing a disastrous event that can separate them from the people they are attached to. An example of such a devastating event is getting lost. Fourthly, the patients are reluctant to leave their homes since they fear separation from the people they are attached to (Edwards, 2021). Fifthly, the patient is afraid of sleeping without a critical attachment figure. According to the DSM-5-TR diagnostic criteria, patients with separa