The assignmentfocused soap note for anxiety, ptsd

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In assessing patients with anxiety, obsessive-compulsive, and trauma and stressor-related disorders, you will continue the practice of looking to understand chief symptomology in order to develop a diagnosis. With a differential diagnosis in mind, you can then move to a treatment and follow-up plan that may involve both psychopharmacologic and psychotherapeutic approaches. 

In this Assignment, you use a case study to develop a focused SOAP note based on evidence-based approaches. 


INSTRUCTIONS/ least three evidence-based, peer-reviewed journal articles

Develop a Focused SOAP Note, including your differential diagnosis and critical-thinking process to formulate a primary diagnosis. Incorporate the following into your responses in the template:

Consider what history would be necessary to collect from this patient.

Consider what interview questions you would need to ask this patient.

Subjective: What details did the patient provide regarding their chief complaint and symptomology to derive your differential diagnosis? What is the duration and severity of their symptoms? How are their symptoms impacting their functioning in life?

Objective: What observations did you make during the psychiatric assessment? 

Assessment: Discuss the patient’s mental status examination results. What were your differential diagnoses? Provide a minimum of three possible diagnoses with supporting evidence, listed in order from highest priority to lowest priority. Compare the DSM-5-TR diagnostic criteria for each differential diagnosis and explain what DSM-5-TR criteria rules out the differential diagnosis to find an accurate diagnosis. Explain the critical-thinking process that led you to the primary diagnosis you selected. Include pertinent positives and pertinent negatives for the specific patient case.

Plan: What is your plan for psychotherapy? What is your plan for treatment and management, including alternative therapies? Include pharmacologic and nonpharmacologic treatments, alternative therapies, and follow-up parameters, as well as a rationale for this treatment and management plan. Also incorporate one health promotion activity and one patient education strategy.

Reflection notes: What would you do differently with this patient if you could conduct the session again? Discuss what your next intervention would be if you could follow up with this patient. Also include in your reflection a discussion related to legal/ethical considerations (demonstrate critical thinking beyond confidentiality and consent for treatment!), health promotion, and disease prevention, taking into consideration patient factors (such as age, ethnic group, etc.), PMH, and other risk factors (e.g., socioeconomic, cultural background, etc.).

Provide at least three evidence-based, peer-reviewed journal articles or evidenced-based guidelines that relate to this case to support your diagnostics and differential diagnoses. Be sure they are current (no more than 5 years old).

.CASE STUDY.. JENNY: Hi there.

My name is Dr. Jenny.

Can you tell me your name and how old you are?

DEV CORDOBA: My name is Dev, and I am seven years old.

DR. JENNY: Wonderful.

Dev, can you tell me what the month and the date is?

And where are we right now?

DEV CORDOBA: Today is St. Patrick’s Day.

It’s March 17th.

DR. JENNY: Do you know where we are?

DEV CORDOBA: We’re at the school.

DR. JENNY: Good.

Did your mom tell you why you’re here today to see me?

: She thought you were

going to help me be better.

DR. JENNY: Yes, I am here to help you.

Have you ever come to see someone like me before,

or talked to someone like me before to help you

with your mood?

DEV CORDOBA: No, never.


Well, I would like to start with getting

to know you a little bit better, if that’s OK.

What do you like to do for fun when you’re at home?

DEV CORDOBA: Oh, I have a dog.

His name is Sparky.

We play policeman in my room.

And I have LEGOs, and I could build something if you want.

DR. JENNY: I would love to see what you build with your LEGOs.

Maybe you can bring that in for me next appointment.

Who lives in your home?

DEV CORDOBA: My mom and my baby brother and Sparky.

DR. JENNY: Do you help your mom with your brother?


His breath smells like bad milk all the time.

[CHUCKLES] And he cries a lot, and my mom

spends more time with him.

DR. JENNY: So how do you feel most of the time?

Do you feel sad or worried or mad or happy?


DR. JENNY: What types of things do you worry about?

DEV CORDOBA: I don’t know, just everything.

I don’t know.


So your mom tells me you also have a lot of bad dreams.

Can you tell me a little more about your bad dreams,

like maybe what they’re about, how many nights you

might have them?

DEV CORDOBA: I dream a lot that I’m lost,

that I can’t find my mom or my little brother.

They seem like they happen almost every night, but maybe

not some nights.

DR. JENNY: Now that must feel horrible.

Have you ever been lost before when maybe you weren’t asleep?



And I don’t like the dark.

My mom puts me in a night light with the door open,

so I know she’s really there.

DR. JENNY: That seems like that probably would help.

Do you like to go to school?

Or would you rather not go?

: I worry about by mom and brother

when I’m at school.

All I can think about is what they’re doing,

and if they’re OK.

And besides, nobody likes me there.

They call me Mr. Smelly.

DR. JENNY: Well.

That’s not nice at all.

Why do you feel they call you names?

DEV CORDOBA: I don’t know.

But my mom says it’s because I won’t take my baths.

[SIGHS] She tells me to, and it–

and I have night accidents.

DR. JENNY: Oh, how does that make you feel?

DEV CORDOBA: Sad and really bad.

They don’t know how it feels for their daddy to never come home.

What if my mom doesn’t come home too?

DR. JENNY: Yes, you seem to worry about that a lot.

Does this worry stop you from being able to learn in school?

DEV CORDOBA: Well, [SIGHS] my teacher is, all the time,

telling me to sit down and focus.

And I get in trouble for [SIGHS] looking out the window.

And she moved my chair beside her desk,

but I don’t mind because Billy leaves me alone now.

DR. JENNY: Billy.

Have you ever hit Billy or anyone else?

DEV CORDOBA: No, but I did throw my book at him.



DR. JENNY: What about yourself?

Have you ever hit yourself or thought about doing something

to hurt yourself?



Well, Dev, I would like to talk to your mom now.

We’re going to work together, and we’re

going to help you feel happier, less worried,

and be able to enjoy school more.

Is that OK?


Thank you.


DR. JENNY: Thank you, Miss Cordoba, for bringing in Dev.

I feel we can help him.

So tell me, what is your main concerns for Dev?

MISS CORDOBA: [SIGHS] Well, he just seems so anxious

and worried all the time, silly things like I’m going to die,

or I won’t pick him up from school.

He says I love his brother more than him.

He’ll throw things around the house,

and gets in trouble at school for throwing things.

He has a difficult time going to sleep.

He wants his lights on, doors open, gets up frequently.

And he’s all the time wanting to come home

from school,
claims stomach aches, and headaches

almost daily.

He won’t eat.

He’s lost three pounds in the past three weeks.

Our pediatrician sent us to you because he doesn’t believe

anything is physically wrong.

Oh, and I almost forgot.

He still wets the bed at night.

[SIGHS] We’ve tried everything.

His pediatrician did give him DDVAP,

but it doesn’t seem to help.



Can you tell me, any blood relatives

have any mental health or substance use issues?

MISS CORDOBA: No, not really.

DR. JENNY: What about his father?

He said that he never came home?


His father was deployed with the military when Dev was five.

I told Dev he was on vacation.

I didn’t know what to tell him.

I thought he was too young to know about war.

And his father was killed, so Dev still

doesn’t understand that his father didn’t just leave him.

[SIGHS] I just feel so guilty that all of this is my fault.

DR. JENNY: Miss Cordoba, you did the right thing

by bringing in Dev.

We can help you with him.

MISS CORDOBA: Oh, thank you.

Review the video, Case Study: Dev Cordoba. You will use this case as the basis of this Assignment

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