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Posted: September 14th, 2022

Dev Cordoba presented with symptoms of anxiety

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.

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.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:
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).

Subjective:
Based on the case study video, Dev Cordoba presented with symptoms of anxiety, depression, and trauma. They reported feeling constantly on edge, having difficulty sleeping, and experiencing flashbacks to a traumatic event from their past. Dev stated these symptoms have been ongoing for 6 months and are significantly impacting their ability to function at work and in relationships.
Objective:
During the psychiatric assessment, I observed that Dev appeared restless, with rapid speech and fidgety movements. Their affect was anxious and their mood depressed. No abnormal thoughts were reported or observed.
Assessment:
My initial differential diagnoses were:
Posttraumatic Stress Disorder (PTSD): Dev’s symptoms of re-experiencing a traumatic event through flashbacks and their onset align with the DSM-5 criteria for PTSD (American Psychiatric Association, 2013).
Generalized Anxiety Disorder: Dev’s persistent and excessive worry about various events or activities does fit the diagnostic criteria for GAD, however the duration of their symptoms is shorter than the minimum 6-month requirement (American Psychiatric Association, 2013).
Major Depressive Disorder: While Dev reported depressed mood, their primary complaint was of anxiety symptoms rather than depressed mood. They did not report sufficient criteria to qualify for MDD (American Psychiatric Association, 2013).
After considering the DSM-5 diagnostic criteria and ruling out alternatives based on Dev’s reported history and presentation on examination, my primary diagnosis is PTSD. Dev’s symptoms developed after experiencing a traumatic event and are consistent with Criterion B (intrusion symptoms), Criterion C (avoidance), Criterion D (negative alterations in cognitions and mood), and Criterion E (alterations in arousal and reactivity) as defined in the DSM-5 (American Psychiatric Association, 2013).
Plan:
My treatment plan for Dev involves both psychotherapeutic and psychopharmacological approaches. I am referring them to trauma-focused cognitive behavioral therapy (CBT) to help process the traumatic memories and change maladaptive thought patterns (National Center for PTSD, 2019). Medication may also help reduce Dev’s symptoms of anxiety, so I am prescribing a low dose of sertraline to be taken daily (Deacon et al., 2013).
To promote wellness, I am recommending Dev engage in regular exercise and spend time with their support system. I will follow up with Dev in 4 weeks to monitor their progress and make any necessary adjustments to their treatment plan. If symptoms do not improve, I may consider adding an additional medication or increasing the sertraline dose.
Deacon, B., Lickel, J., & Abramowitz, J. S. (2013). Medical management of anxiety disorders. In M. J. Zvolensky, A. Bernstein, & A. A. Vujanovic (Eds.), Distress tolerance: Theory, research, and clinical applications (pp. 401–420). Guilford Press. https://www.ncbi.nlm.nih.gov/books/NBK92764/
National Center for PTSD. (2019, October 30). Cognitive processing therapy for PTSD. U.S. Department of Veterans Affairs. https://www.ptsd.va.gov/understand_tx/cpt_for_ptsd.asp
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). https://doi.org/10.1176/appi.books.9780890425596

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