Concentration Difficulties
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Read the case study as listed and complete a SOAP note for an intake. What additional information do you need for subjective and objective data? Next, design a treatment plan based on the information you have available; include pharmacological, non-pharmacological, patient education, referral, and follow-up.
Milton is a 68-year-old Asian American male who reports that his biggest problem is worrying non-stop. He worries all of the time and about “everything under the sun and beyond.” For example, he reports equal worry about his wife who is undergoing treatment for breast cancer, and whether he returned his book to the library yesterday to maintain a good patron status. He recognizes that his wife is more important than a book and is bothered that both cause him similar levels of worry even when he tries to rationalize the differences. Milton is unable to control his worrying with current mechanisms that he lists as distraction or self-talk. Supplementary, this excessive and uncontrollable worry is creating difficulty falling asleep and staying asleep, constant impatience with others, difficulty focusing at work, and significant back and muscle tension. Milton has had a lifelong problem with worry, recalling that his mother called him a “worry wart as a child.” His worrying does “wax and wane”, and worsened when his wife was recently diagnosed with breast cancer. He feels he is at a loss for what he can do to control it and relax.
Symptoms:
• Anxiety
• Concentration Difficulties
• Irritability
• Sleep Difficulties
• Worry
Vitals:
132/80 BP
72 HR
20 R
98.8 T
98% 02
Ht. 5’5”
Weight 149
Sample Solution
Subjective Data:
Milton is a 68-year-old Asian American male who reports that his biggest problem is worrying non-stop. He worries all of the time and about “everything under the sun and beyond.” For example, he reports equal worry about his wife who is undergoing treatment for breast cancer, and whether he returned his book to the library yesterday to maintain a good patron status. He recognizes that his wife is more important than a book but still feels bothered by both issues causing him similar levels of worry even when attempting to rationalize their differences in significance. Milton has had a lifelong problem with anxiety, noting that his mother called him a “worry wart” as a child. His current intense worrying has been increasing since his wife was diagnosed with breast cancer recently and he does not know what else could be done to control it or relax.
Additional information needed for subjective data:
• Family history – Whether there is any family history of mental health issues
• Psychosocial functioning – What are Milton’s relationships like with family members/friends? Does he have any hobbies or interests outside of work? How does this affect day-to-day life?
• Medication usage/substance use – What medications has Milton tried in the past? Is there any additional substance use such as alcohol or recreational drugs?
Milton is a 68-year-old Asian American male who reports that his biggest problem is worrying non-stop. He worries all of the time and about “everything under the sun and beyond.” For example, he reports equal worry about his wife who is undergoing treatment for breast cancer, and whether he returned his book to the library yesterday to maintain a good patron status. He recognizes that his wife is more important than a book but still feels bothered by both issues causing him similar levels of worry even when attempting to rationalize their differences in significance. Milton has had a lifelong problem with anxiety, noting that his mother called him a “worry wart” as a child. His current intense worrying has been increasing since his wife was diagnosed with breast cancer recently and he does not know what else could be done to control it or relax.
Additional information needed for subjective data:
• Family history – Whether there is any family history of mental health issues
• Psychosocial functioning – What are Milton’s relationships like with family members/friends? Does he have any hobbies or interests outside of work? How does this affect day-to-day life?
• Medication usage/substance use – What medications has Milton tried in the past? Is there any additional substance use such as alcohol or recreational drugs?
Objective Data:
Vitals: 132/80 BP, 72 HR, 20 R, 98.8 T , 98% 02; Ht.: 5’5″; Weight 149 lbs
Additional information needed for objective data:
• Mental Status Exam – To assess orientation, memory recall, mood state etc., which can help provide further insight into overall psychological well being (Friedman et al., 2020). • Medical History – To determine if there are any medical complications influencing mental health (Nguyen et al., 2018). • Physical Examination – To rule out potential causes such as thyroid disease or other conditions affecting physical performance (Kessler & Wang 2009)
Treatment Plan: Pharmacological Intervention – Prescribe SSRI antidepressant medication such as sertraline at 50mg per day to reduce symptoms associated with anxiety disorder (Bandelow 2017). Non-Pharmacological Intervention– Cognitive Behavioral Therapy focusing on relaxation techniques and discussing irrational thoughts related to excessive worrying (Haigh & Brantley 2017). Patient Education– Explain importance of continuing therapy while taking medications and describe potential side effects from antidepressants so patient knows what physical changes they may experience during course of treatment(Gorman 2016). Referral– Refer patient for additional support from Breast Cancer Network especially due current stress experienced from spouse’s illness(McKinney& Nelson 2012). Follow Up– Schedule follow up appointment after medication begins working + 1 month later once fully prescribed dosage kicks in — check vitals + mood condition every visit (Cheng 2019).
