Answer for PRAC 6665 WEEK 9 Focused SOAP Note and Patient Case Presentation, Part 1 Subjective: CC (chief complaint): “My nightmares are unbearable.”

Answer for PRAC 6665 WEEK 9 Focused SOAP Note and Patient Case Presentation, Part 1

Subjective:

CC (chief complaint): “My nightmares are unbearable.”

HPI: B.L. is a 14-year-old boy who reports experiencing recurrent, involuntary, and intrusive distressing memories of a traumatic event that occurred six months ago, involving a car accident where he witnessed a severe injury to his sister. He describes frequent nightmares related to the trauma and flashbacks during the day, which lead to significant distress. The patient avoids talking about the event, avoids activities, places, and people that remind him of the trauma, and shows a marked decrease in interest in activities he previously enjoyed. He also reports feeling detached from friends and family and having difficulty experiencing positive emotions. Additionally, the patient mentions having an exaggerated startle response, difficulty concentrating, and trouble sleeping. There are no reports of substance use or self-harm. Family history includes anxiety disorders.

Substance Current Use: The patient has denied using any substance.

Medical History:

• Current Medications: The patient is currently using over-the-counter sleeping pills to improve his sleeping habits and patterns. No other medication was reported.
• Allergies: No known allergies

• Reproductive Hx: No notable reproductive history. The patient is not sexually active.

ROS:

• GENERAL: She reports no recent weight loss. Denies fever, chill, weakness, or fatigue.
• HEENT: No headache or trauma, no lumps, bumps, or lesions. No double vision or vision change, no eye discharge, redness or pain, no hearing loss, no ear discharge or pain. No nasal discharge or congestion. No dysphagia or hoarseness.
• SKIN: No itch, lesions, bruising, abnormal pigmentation, or rashes.
• CARDIOVASCULAR: No edema or palpitations, no chest discomfort, chest pressure, or chest pain. Normal heart rate and rhythm
• RESPIRATORY: No sputum, cough, or shortness of breath. No signs of respiratory distress
• GASTROINTESTINAL: No abdominal pain, vomiting, and nausea. No constipation
• GENITOURINARY: No hesitancy, urgency, or burning on urination
• NEUROLOGICAL: No weakness, tingling, or numbness.
• MUSCULOSKELETAL: No muscle stiffness, joint pain, or back pain
• HEMATOLOGIC: No bruising, bleeding or anemia
• LYMPHATICS: No history of splenectomy, no enlarged nodes
• ENDOCRINOLOGIC: No polydipsia or polyuria. Reports no intolerance to heat or cold.

Objective:

Diagnostic results: Children’s Depression Inventory to help asses the depressive symptoms and rule out major depressive disorder and Screen for Child Anxiety Related Disorders (SCARED) to help rule out other anxiety disorders.

Assessment:

Mental Status Examination: The patient is a 14-year-old patient who visited the facility for an assessment. He is appropriately dressed and well-groomed. He is also alert and oriented in person, place, and time. The patient appears anxious and exhibits signs of hypervigilance during the interview. He is cooperative but has a restricted affect. His mood is anxious and fearful. He maintains appropriate eye contact intermittently but occasionally looks away, especially when talking about distressing memories. His speech is of normal rate and rhythm, clear and coherent, and soft-spoken. He exhibits logical and coherent thought processes. He denies visual or auditory hallucinations. There are no signs of self-harm or physical injury. He denies suicidal thoughts or ideation.

Diagnostic Impression:

1. Posttraumatic Stress Disorder (PTSD): This is a condition that may develop after a person witnesses or experiences a traumatic event and may present with symptoms such as alterations in reactivity and arousal, negative changes in cognition and mood, avoidance, and intrusive memories (Merians et al.,2023). The patient presented with intrusive symptoms, avoidance, negative changes in mood and cognition, trouble sleeping, and difficulty concentrating, which have persisted for six months. Therefore, PTSD is the primary diagnosis.
2. Acute Stress Disorder: This is an illness characterized by the development of severe anxiety and other symptoms within a month of experiencing or witnessing a traumatic event (Geoffrion et al.,2022). The patient presents with negative moods, avoidance and arousal, and intrusion symptoms such as flashbacks, nightmares, and di