ANSWER
Concentrated SOAP Noted for the Case Study: Dev Cordoba
Patient: Dev Cordoba
Date: [Enter Date]
[Insert Time] Time is
DoB/Age: [Insert Patient’s Age and Date of Birth]
Male: Gender
Source of Information: Individual Patient
“I’ve been feeling very anxious lately, and I can’s seem to be constantly thinking about some things over and over,” the subjective chief complaint (CC) says.
History of Present Illness (HPI): The patient notes that over the previous two weeks, her ongoing anxiety for the past six months has gotten worse. He talks about too much concern that interferes with his capacity for relaxation at home and focus at work. He also has frequent, intrusive thoughts about locking doors and making sure the stove is switched off, which fuels repeated checking behaviour. There are reported disruptions in sleep; trouble falling and keeping asleep. He disputes any recent changes in his life or big stresses.
Psychiatric Timeline:
Two years ago diagnosed with little anxiety but neglected treatment.
There is no past of psychotherapy or psychiatric hospitalisations.
Medical History: Not one major medical problem noted. No allergies that are known of.
Family Heritage:
Mother: Anxiety’s past is something else.
Father: Hypertension.
Not one known psychiatric hospitalisation in the family.
Social Evolution:
Lives alone; keeps only little contact with friends and relatives.
Works full-time in IT and reports modest job-related tension.
Denies usage of recreational drugs, tobacco, or alcohol.
Review of Systems (ROS) :
Psychiatric: Compulsive behaviour, intrusive thoughts, and anxiety.
Neurological: Denies headache, memory problems, or vertigo.
Reports general tiredness and trouble focusing.
Mental Status Examined Objectively (MSE):
Look: neatly groomed, excellent cleanliness.
Behaviour: Collaborative yet obviously restless.
Emotion: nervous.
Restricted yet suitable for a chat.
Speech: Standard tone and pace.
Thought Process: Logistically but obsessed with invading ideas.
Thought Content: Nothing delusional or hallucinations. One can find intrusive compulsive thoughts.
Alert, tuned to time, place, and person.
Judging/insight: Not very clear about the extreme frequency of his checking actions.
Evaluating
main diagnosis:
Meets DSM-5 criteria for obsessive-compulsive disorder (OCD), including the presence of time-consuming, daily functioning impairing obsessions (intrusive thoughts about securing doors and stove safety) and compulsions (repeated checking behaviours).
Variations in diagnosis:
Generalised Anxiety Disorder (GAD): Though compulsive behaviour and obsessions indicate more strongly to OCD, excessive concern and sleep difficulties are present.
Disorder with Adjustment and Anxiety: Not one clear stressor event major life change linked to the start of symptoms.
Post-Traumatic Stress Disorder (PTSD): Not having any trauma history, so this diagnosis is ruled out.
Plan: Psychotherapy
Start cognitive-behavioral therapy (CBT) for OCD with an eye towards exposure and response prevention (ERP) strategies.
Pharmaceutical Treatment:
Because Sertraline 25 mg daily is so effective in controlling OCD and concomitant anxiety symptoms, start 25 mg daily and titrate up as needed.
Teach patient about possible adverse effects (e.g., sleeplessness, stomach pain).
Changes in Lifestyle:
Promote a regular sleeping routine and mindfulness practices to lower general anxiety.
To improve mental health, advise modest physical activity—such as yoga or walking.
Patient Instruction:
Share knowledge on OCD, its symptoms, and the need of therapeutic adherence.
Talk through ways to identify and control triggers.
Following-up:
Plan a two-week follow-up visit to evaluate therapy response and modify interventions as needed.
Thought back on
This case emphasises the need of differentiating between anxiety disorders and OCD since different treatment approaches apply in both. Improving therapeutic rapport will help me to make sure the patient feels supported in talking about upsetting ideas and actions. Long-term involvement calls for patient-centered approaches and culturally relevant treatment. Maintaining confidentiality and guarantees informed permission for treatment constitute ethical issues. Future visits will evaluate the patient’s medication and therapy adherence, thereby addressing any adverse effects or difficulties.
Citations
American Psychiatric Association (2022) Fifth edition of Diagnostic and Statistical Manual of Mental Diseases (text revision).
Fenske, J. N.; Schwenk, T. L. (20211). Mania in obsessive-compulsive disorder: diagnosis and treatment American Family Physician, 83(2), 125–130.
Koran, L. M., et al. (20211). Treating individuals with obsessive-compulsive disorder: practice guidelines 82(4), e6279 Journal of Clinical Psychiatry.
QUESTION
TO PREPARE
- Review this week’s Learning Resources. Consider the insights they provide about assessing and diagnosing anxiety, obsessive compulsive, and trauma-related disorders.
- 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 video, Case Study: Dev Cordoba. You will use this case as the basis of this Assignment. In this video, a Walden faculty member is assessing a mock patient. The patient will be represented onscreen as an avatar.
- Consider what history would be necessary to collect from this patient.
- Consider what interview questions you would need to ask this patient.
Walden University. (2021). Case study: Dev Cordoba. Walden University Canvas. https://waldenu.instructure.com