Running head: SOAP NOTE ON GENERALIZED ANXIETY DISORDER 1

Soap Note on Generalized Anxiety Disorder

Student’s Name

Institutional Affiliation
SOAP NOTE ON GENERALIZED ANXIETY DISORDER 2

Soap Note on Generalized Anxiety Disorder

Name: Date:
Age: 7 years Sex: Male
SUBJECTIVE
Historian: Mother

CC: “My boy has been restless and he gets fatigued very easily. He also has poor concentration,

irritability and excessive worry.”

Child profile:

Child is able to dress herself, catch a ball more easily using his hands, and tie his shoes with

ease. He has started to show more independence, and show more attention to friendship and

teamwork and wants to be accepted by friends. His concentration in activities at home and

school work at school is poor. He gets irritated easily and he is restless and has excessive worry

about family, earthquakes and punctuality.

Child sits in his child car sit at the rear seat of the car and he is supervised when playing in water

or near water bodies. He is also supervised when he is risking games like climbing and

household equipments and products that are potentially harmful are kept out of each of the child.
HPI:

A 7 years old boy is brought to the office by her mother who reports that he has been getting

irritated easily and he is restless most times. She adds that the child has poor concentration in his

activities and studies, he gets fatigued easily and he has excessive worry She says that the child

has never been diagnosed with depression and he has never had traumatic events in the past.

Mother states that the child has been having excessive worry about his academics, about the

safety of his family members especially when they stay out late. She also says that the child is

excessively worried about earthquakes and being punctual. Child is not under any medication.

Mother states that child has been having these symptoms for the past 65 months and that his

teacher has complained about the symptoms and she has also observed the symptoms.
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Medication: None.
PMH:

Immunization: Patient received the Influenza vaccine last years in October and other

vaccinations are up to date.

Medication intolerances: None.

Allergies: None

Surgeries: None.

Chronic diseases: None.

Major traumas: None.

Hospitalization: None.
Family History: parents and siblings have no history of chronic or mental ailments.
Social history: Patient is in grade 2 and stays with his biological parents and siblings. His mother

denies drug abuse, alcohol and smoking. Patient’s activities such as swimming and climbing to

ensure his safety.

ROS
General: Denies fever, increase or decrease in Psychiatric: Reports restless and he gets

energy levels, sudden changes in weight, high fatigued very easily. He also has poor

body temperatures and sweating at night. concentration, irritability and excessive worry

about safety of family members, punctuality,

academic performance and earthquakes.

Respiratory: Denies noisy breathing, dyspnea Neurological: Denies black out spells, loss of

and stubborn coughs. consciousness, transient paralysis, weakness,

headaches and syncope.

Cardiovascular: Denies chest pains, Heme/Lymph/Endo: Denies changes in energy

palpitation, fast or slow heart rates and levels, increased hunger and thirst, abrupt

orthopnea. changes in weight and bruising.

OBJECTIVE
Resp: 23 Temp: 98.2 Weight: 50 lbs
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BMI: 15.3 kg/m2

BP: 111/74 Pulse: 98 Height: 4’ 0”
Weight-for-age percentile: 45% Height-for-age percentile: 51%
General Appearance: Patient looks tired and tried to be very organized with his toys. He alos

keeps stealing glances at his mother as he plays.

Respiratory: Respirations are easy and wheezes are absent.
Cardiovascular: S1 and S2 are with regular rate and rhythm. Pulse is 3+ throughout and

capillaries refill in 2 seconds.

Neurological: Patient’s speech is clear and not slurred, his tone is also or normal rate and he has

a stable balance. Patient also has a normal gait and erect posture.
Psychiatric: Patient is restless and looks fatigued. His concentration is unusual and he gets

irritated easily and is excessively worried about catastrophic events like earthquakes, her parent’s

safety and arrangement of his toys.

Lab tests:

Clinical diagnosis: Patient meets clinical criteria for GAD as he presents with at least three of the

possible six required to make a diagnosis.

Thyroid function tests: Normal thyroid-stimulating hormone and thyroxine.

ECG: Normal sinus rhythm

Pediatric Assessment tool: Vital signs: Temperatures and other vital signs are consistent with

the age of the patuient. Dental development: Teeth and gum are in good health and patient has

two milk teeth removes. Diet: the common meal of the patient includes milk, cereals, green

vegetables and red and white meet. Developmental: Patient has excess worry about his

performance and physical activities, his family’s safety, punctuality and catastrophic events like

earthquakes. He also gets irritated and fatigued easily and he has restlessness, and poor

concentration.
DIAGNOSIS
Differential Diagnosis:

F41. 0 - Panic Disorder: This disorder is characterized by recurrent episodes of abrupt onset of

anxiety with at least symptoms entailing dyspnea, shakiness, palpitations, dizziness, fear of
SOAP NOTE ON GENERALIZED ANXIETY DISORDER 5

dying, hot and cold flashes and dizziness. Patient presented with symptoms of anxiety but did not

present with hot and cold flashes, shakiness, nausea, dyspnea and some of other symptoms of

panic disorder. He also did not present with abrupt onset of symptoms hence ruling out the

diagnosis.

F40. 11 - Social phobia: This disorder sis associated with anxiety that is limited to situations and

excessive fear of social scrutiny and embracement (Coplan, Schneider, Ooi, & Hipson, 2018). It

symptoms include fear of being judged, evaluated negatively, and rejected in a social or

performance situation. It is also characterized by avoidance behavior and it causes irrational fear,

anxiety and self awareness and embarrassment even during everyday social interactions. Patient

reported fears of school work and sports performance, safety of family, and catastrophic events.

F42. 9 - Obsessive-compulsive disorder: This is anxiety disorder that is primarily directed on

obsessions and compulsions. Patient presented with anxiety symptoms such as excess worry,

restlessness, irritability, fatigue and poor concentration but the symptoms were not primarily

directed on obsessions and compulsions.

Primary Diagnosis:

F41. 1 - Generalized Anxiety Disorder: This is a disorder that is characterized by worry that is

difficult to control and which interferes with day to day activities. In children, the disorder

present through fatigue, irritability, sleeping problems, trembling, nervousness, nausea sweating,

excess worry about school performance and sports, safety of family members, catastrophic

events like earthquakes, and punctuality (Cho, Przeworski & Newman, 2019). Patient presented

with most of these symptoms which his mother said have been persistent for the past 6 months.

Patient also met all the meets clinical criteria for GAD as he presents with at least three of the

possible six required to make a diagnosis. Other lab tests also confirmed generalized anxiety
SOAP NOTE ON GENERALIZED ANXIETY DISORDER 6

disorder as the primary diagnosis.

Treatment Plan and Education:

The recommended first line treatment for children with generalized anxiety disorder is cognitive

behavioral therapy and non drug therapy such as psycho-education and anxiety management

training (Bandelow, Michaelis, & Wedekind, 2017). These therapies are given before medication

for mild to moderate case.

No vaccinations were administered in this visit and no medication was prescribed during this

visit.

Lab tests ordered: None.

Diagnostic tests ordered: Thyroid function tests and ECG

Recommended cognitive behavioral therapy, psycho-education, and anxiety management

training.

Patient’s mother was advised on relaxation techniques, sleep hygiene, exercises and meditation

training and self to be used on the patient. Mother was advised to use these non drug therapies on

the patient alongside cognitive behavioral therapy.

Patient to make a follow up visit if symptoms persist even after treatment.

References
Bandelow, B., Michaelis, S., & Wedekind, D. (2017). Treatment of anxiety disorders. Dialogues

in clinical neuroscience, 19(2), 93.

Cho, S., Przeworski, A., & Newman, M. G. (2019). Pediatric generalized anxiety disorder.

In Pediatric Anxiety Disorders (pp. 251-275). Academic Press.

Coplan, R. J., Schneider, B. H., Ooi, L. L., & Hipson, W. E. (2018). Peer-based interventions for

behaviorally inhibited, socially withdrawn, and socially anxious children.

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Growth chart for a 7 years old boy Weight-for-age percentile: 45%, Height-for-age percentile:
51%
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