Focused SOAP Note

Patient Information: The patient is a 9-year old boy

SUBJECTIVE.

CC: Patient feels worried

HPI: XX is a 9-year-old boy who presents with anxiety and worry. The patient reports that he is worried and anxious most of the time. The patient also has difficulties sleeping and is afraid of being left alone in his room at night. He has also been having nightmares (with the said nightmares being themed around losing and being unable to find his mother or brother). He has difficulties in school in terms of being unable to relate well with other children and has gotten in trouble in the past for throwing things. He does not like staying in school for lengthy periods of time and is often worried about his mum dying or failing to turn up to pick him at school. Most times, he complains of headaches or stomach aches especially when he is in school and wants to go back home. The client also wets the bed at night and has lost a number of pounds over the last few weeks.

Current Medications: None. The client was referred by the family pediatrician who believes there is nothing physically wrong with the 9-year-old.

Allergies: NKA

PMHx: Patients immunizations are current.

Substance Use History: The client does not have any history of substance abuse/use.

Soc Hx: Client is in grade 4. He appears to be experiencing difficulties in as far as his relationship with other children in school/class is concerned.

Fam Hx: The patient lives with his mother and younger brother. His father was a military man and was killed at war. No history of mental illness among fist degree relatives.

OBJECTIVE.

Mental Status Exam (MSE): Patient is well-groomed. However, in as far as hygiene is concerned, there is a faint ammonia-like foul smell (most likely as a consequence of poor hygiene). His posture is appropriate. He is, however, constantly disrupted and appears to be finding it difficult to concentrate on a single task (our engagement) for a lengthy time period. There is no evidence of psychomotor agitation or retardation. In as far as mood is concerned, the client appears tense. The clients thought content could be defined as being delusional. His insight is fair. His judgment is also fair.

ASSESMENT.

1. Separation Anxiety Disorder (SAD): The primary diagnosis in this case would be separation anxiety disorder. The client presents with a number of symptoms that are consistent with the manifestation of the said disorder under DSM-5. It would be prudent to note that as Vaughan, Coddington, Ahmed, and Erel (2016) observe, this happens to be one of the most common disorders among children of school-going age. More specifically, in the words of the authors, some of SADs many consequences...

311). As per DSM-5 criteria, persons presenting with SAD often demonstrate anxiety or fear that could be deemed excessive about imminent separation from certain attachment figures such as parents. The said anxiety or fear has to be evidenced by a minimum of three symptoms out of a total of 8 symptoms. The client in this case presents with 4 of the highlighted symptoms. To begin with, the client presents with what has been defined as persistent and excessive worry about losing major attachment figures or about possible harm to them, such as illness, injury, disasters, or death under DSM-5 (Goldstein and DeVries, 2016, p. 236). It has been indicated that when in school, the client keeps worrying about the wellbeing of his mom and younger brother. As his mother indicates, the client is often worried that she will die or will not show up to pick him at school. Secondly, as per DSM-5 criteria, persons suffering from SAD are likely to present persistent and excessive fear of or reluctance about being alone or without major attachment figures at home or in other settings (Goldstein and DeVries, 2016, p. 236). In the present scenario, the client wants to go back home from school all the time. Third, as per the DSM-5 criteria, persons suffering from SAD are likely to report constant or routine nightmares which have a separation theme (Goldstein and DeVries, 2016). According to the client, he often dreams of losing and being unable to find his mom as well as brother. Fourth, under DSM-5, SAD is associated with repeated complaints of physical symptoms (such as headaches, stomachaches, nausea, or vomiting) when separation from major attachment figures occurs or is anticipated (Goldstein and DeVries, 2016. p. 237). In the present scenario, the clients mother reports that the client often presents excuses to avoid school, i.e. by claiming headaches as well as stomachaches.

2. Generalized Anxiety Disorder (GAD): In basic terms, GAD, according to Gale and Millichamp (2016), could be defined as tension or worry that appears excessive with regard to daily undertakings with the said tension or worry largely overwhelming a person and preventing them from focusing on key day-to-day activities. Indeed, under DSM-5, one presenting symptom of GAD happens to be worry and anxiety that occurs most days and that affects a person for a period of more than 6 months. The client in the present scenario reports being worried (about just everything) most of the time. Secondly, as per the DSM-5 diagnostic criteria, the worry ought to be overwhelming and difficult for a person to control. It is clear in this case that the client is unable to control the way he feels. Third, the DSM-5 criteria lists a total of six symptoms which are associated with the said worry or and anxiety. Three of these ought to be present for a person to be diagnosed with GAD. The said symptoms are inclusive of restlessness or feeling keyed upor on edge, being easily fatigued, difficulty concentrating or mind going blank, irritability, muscle tension, sleep disturbance (difficulty falling or staying asleep, or restless unsatisfying sleep) (Goldstein and DeVries, 2016, p. 412). The client presents with only two of these, i.e. sleep disturbance, irritability (as indicated by his throwing of objects around), and difficulty concentrating (which resulted in his sitting position in class being changed). However, under the DSM-5, for a person to be diagnosed with GAD, the disturbance observed must not be associated with any other mental disorder such as separation anxiety (Goldstein and DeVries, 2016). In the present scenario, there are clear indications…