Week 9 : Focused SOAP Note and Patient Case Presentation

 

Subjective:

CC (chief complaint): ‘ I have struggled with anxiety and depression since my mother’s death. ‘

HPI: GG is a 24 years old African American female who presented to the office for an initial evaluation. She stated she has always had mild depression and anxiety and had never been formally treated. When her mother passed away six months ago after suffering a heart attack, her anxiety and depression increased she was having a hard time with daily tasks. She has been struggling with PTSD because her mother’s death was Traumatic, and she was being treated with prazosin to help with nightmares. She was diagnosed with ADHD, and she was treated with Adderral. GG is a nursing student pursuing an online program which has been difficult due to poor concentration, increased anxiety, and depression. GG was born and raised in western Massachusetts in a family of five. She has one older sister and one younger sister, and she is the second born. Her mother mostly raised her because her dad divorced her mom when she was five years old. She does not keep with her dad because, after he remarried, he moved out of the country. She comes from a family positive for mental illness.  Her mother had bipolar, depression, and both sisters are addicted to opioids. 

Substance Current Use: She denies using the substance.

Medical History: Denies medical history.

 

  • Current Medications: Adderall
  • Allergies: No known drug allergies. 
  • Reproductive Hx: She is shingle and has no children. She stated she broke up with her boyfriend last year. 

ROS

  • GENERA
  • HEENT: 
  • SKIN: 
  • CARDIOVASCULAR: 
  • RESPIRATORY: 
  • GASTROINTESTINAL: 
  • GENITOURINARY: 
  • NEUROLOGICAL: 
  • MUSCULOSKELETAL: 
  • HEMATOLOGIC: 
  • LYMPHATICS: 
  • ENDOCRINOLOGIC: 

Objective:

Diagnostic results

Assessment:

Mental Status Examination: 

Diagnostic Impression: 

Reflections:

Case Formulation and Treatment Plan: 

 

 

 

Please use the following Template- Thanks 

NRNP/PRAC 6665 & 6675 Comprehensive Focused SOAP Psychiatric
Evaluation Template
© 2022 Walden University Page 2 of 3
Subjective:
CC (chief complaint):
HPI:
Substance Current Use:
Medical History:
ï‚· Current Medications:
ï‚· Allergies:
ï‚· Reproductive Hx:
ROS:
ï‚· GENERAL:
ï‚· HEENT:
ï‚· SKIN:
ï‚· CARDIOVASCULAR:
ï‚· RESPIRATORY:
ï‚· GASTROINTESTINAL:
ï‚· GENITOURINARY:
ï‚· NEUROLOGICAL:
ï‚· MUSCULOSKELETAL:
ï‚· HEMATOLOGIC:
ï‚· LYMPHATICS:
ï‚· ENDOCRINOLOGIC:
Objective:
Diagnostic results:
Assessment:
Mental Status Examination:
Diagnostic Impression:
Reflections:
Case Formulation and Treatment Plan:

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