Obsessive Compulsive Disorder OCD SOAP Note SAMPLE

Obsessive Compulsive Disorder OCD SOAP Note SAMPLE Clinical SOAP Note. This is an Obsessive Compulsive Disorder OCD SOAP Note Example completed for a PMHNP student

Patient Initials: _____A.N__ Age: ___24____ Gender: __Female_____

SUBJECTIVE DATA:

Chief Complaint (CC): ‘They brought me because I clean my bathroom three times a day. I feel guilty if I have not cleaned at regular intervals.’

History of Present Illness (HPI): A.N is a 24-year-old woman of Alaskan Native ethnicity. A.N is the chief informant herself and admits to sleeping less than 4 hours and cleaning the bathroom two times while the house is cleaned twice. It gets complicated because the time for cleaning the bathroom does not coincide with that of cleaning the house so she ends up having four waking shifts two of which are at night. She confesses feeling guilty if she fails to do the cleaning at 7 00 am, 1:00 pm 7:00 pm, and 1:00 am. She doesn’t use other people’s toilets and boils her kitchenware with bleach to avoid infections. Per the patient, her obsession with cleanliness started with the fear of dying after her neighborhood friend lost her only son to a cholera outbreak two weeks ago. She has a history of physical, verbal, and sexual abuse by her stepfather after the mother remarried when she was 11 years old.

Medications: currently not taking any medications

Allergies: NKDA

Past Medical History (PMH): She reports having a history of bulimia nervosa where she eats all types of food indiscriminately, then self-induces vomiting since she was sixteen years. She also has a history of panic disorder treated using fluoxetine 10mg P.O. daily.

Past Surgical History (PSH): No past operations.

Sexual/Reproductive History: Menarche at age 13 years, first child normal vaginal delivery. Last MP three weeks ago. No history of STIs.

Personal/Social History:  a single parent of three, two boys ad one girl aged between 8 and I year. She is an accountant.

Health Maintenance: Does not smoke or take alcohol, has regular checkups for weight blood pressure, and a Pap smear test twice. First age 21 years and last month.

Immunization History: Patient reports receiving all her childhood immunizations and receives the flu jab regularly. She had the Johnsons and Johnson’s vaccine for COVID-19 two months ago.

Significant Family History: 

Mother died at 41 after committing suicide. Her father and younger brother succumbed to Typhoid. Maternal grandmother is aged 62 and is on medication for generalized anxiety disorder. Paternal uncle living with depression.

Review of Systems:

Vital signs: 

BP 119/76, H.R. 69, R.R. 19. T 98.7 Ht 5’5” Wt. 111 lbs. BMI 18.9

General: Generally, health looking, no changes in strength or exercise tolerance gained 10lbs in the last 12 months.

HEENT:  Denies headaches, no head injury, no eye pain, changes in eyesight or discharge, no earache or discharge, hearing is intact, negative for runny nose, nose bleeds, no voice hoarseness or difficulties in swallowing.

Respiratory: No wheezing, dyspnea, negative for cough.

Cardiovascular/Peripheral Vascular: Regular rate, rhythm, no murmurs, no chest discomfort or pain.

Gastrointestinal: No nausea, vomiting, active bowel sounds in all quadrants.

Genitourinary: Regular emptying of the bowels about three times a day.  

Musculoskeletal: No gait impairment despite a history of suitable hip replacement at 9. Normal range of motion, no joint pains

Neurological: No history of seizures alert, awake, oriented to time, place, and space. CN II- XII grossly intact.

Psychiatric: Has a history of bulimia nervosa, neglect, and physical, verbal, and sexual abuse.

Skin/hair/nails: Has uneven toenails, denies wearing open shoes, admits to wearing boots only.

Lymphatic: No glandular swellings

Hematologic: No unusual bleeding, no history of splenectomy

Endocrinologic: Negative for excessive thirst, frequent urination, or heat intolerance.

OBJECTIVE DATA:

Mental Status Exam

Well-groomed for the occasion, appears her stated age and ethnicity. A.N is alert and oriented to self, place, and time. During the interview, she remains calm, cooperative and is also pleasant. Her mood and affect are congruent euthymic. Thought content and process coherent. Judgment fair.

Memory both short and remote are intact Motor activity is normal

Patient has no audio or visual hallucinations. Has no suicidal or homicidal ideations. Patient has no access to firearms.

Diagnostic results:

Kidney function tests, CMP, CBC, TSH, and HgA1c are normal.

ASSESSMENT: Differential Diagnosis

DSM-5 300.3(F 42) Obsessive Compulsive Disorder (OCD) – confirmed

Sassano-Higgins & Pato (2015) note that for a psychiatrist to confirm a diagnosis of OCD, obsessions defined recurrent and persistent thoughts and urges that happen during the disturbance and compulsions, meaning repetitive behavior in response to the obsession. The patient of dirt and contamination and repetitively cleaning the bathroom and house and washing the kitchenware in bleach helped confirm the OCD diagnosis. All the test orders had normal results and helped rule out organic or physiological causes.

Generalized Compulsive Disorder-Refuted

Like OCD, people with GAD worry a lot, but they do not engage in repetitive and ritualistic behaviors, whether mentally or physically, to relieve the stress caused by the obsession. Hence GAD was ruled out because A.N had both obsessions and compulsions.

Hypochondriasis –Refuted 

Hypochondriasis is a mental disorder in which the individual is preoccupied with either having or getting a severe condition and worries about minor symptoms or body sensations (Meng et al., 2019). Most importantly, even with negative test results, physician visits hardly reassure the patient. It was ruled out because OCD patients have obsessions related to various themes like contamination, sexuality or religion, amongst others which a hypochondriac has an obsession with concerns connected to their health. A.N fears contamination and that she might get Typhoid, not exaggerating some sensations and attributing them to Typhoid.

PLAN

The treatment plan includes cognitive behavioral therapy as first-line treatment, particularly exposure and response prevention (ERP) therapy (Sassano-Higgins & Pato, 2015). Medication intervention will entail Clonazepam 1mg PO PRN daily and Vortioxetine 10 mg P.O. daily for one month (Kayser, 2020). Counselling and patient education on ERP and the side effects of Vortioxetine like nausea, sexual dysfunction and constipation, A follow up clinic in four weeks to assess the efficacy of the two-pronged approach to this treatment. No referral is considered at this point.

References

Kayser, R. R. (2020). Pharmacotherapy for treatment-resistant obsessive-compulsive disorder. The Journal of clinical psychiatry, 81(5), 0-0.

Meng, J., Gao, C., Tang, C., Wang, H., & Tao, Z. (2019). Prevalence of hypochondriac symptoms among health science students in China: A systematic review and meta-analysis. PloS one, 14(9), e0222663.

Patriquin, M. A., & Mathew, S. J. (2017). The neurobiological mechanisms of generalized anxiety disorder and chronic stress. Chronic Stress, 1, 2470547017703993.

Sassano-Higgins, S. A., & Pato, M. T. (2015). Obsessive-compulsive disorder: diagnosis, epidemiology, etiology, and treatment. Focus, 13(2), 129-141.