NRNP 6675 Week 3 Assignment – Focused Soap Note for Anxiety, PTSD and OCD Example Focused SOAP Note: PTSD, Anxiety, and OCD Disorders Patient’s Initials D.C.

NRNP 6675 Week 3 Assignment – Focused Soap Note for Anxiety, PTSD and OCD Example

Focused SOAP Note: PTSD, Anxiety, and OCD Disorders

Patient’s Initials D.C.

Age: 7 years

Subjective:

CC (chief complaint): “Well, he seems so anxious and worried all the time, silly

things like I’m going to die, or I won’t pick him up from school.”

HPI:

D.C., a 7-year-old male Caucasian patient, has been referred by his pediatrician to a psychiatrist for an evaluation. The patient’s mother indicated that although the doctor prescribed DDAVP to help the patient stop wetting the bed, it had no effect. However, she omitted including the frequency and dose of DDAVP treatment. The patient worries excessively and harbors terrible ideas about his mother and brother. He believes his classmates dislike him and call him “Mr smelly” and other derogatory names.

The patient claims that his teacher seems to be picking on him and that his classmates are oblivious to how he feels about his father not returning home. Although the mother mentions that he has trouble sleeping and worries about his mother’s death and abandonment, he has never tried to hurt himself. Due to his poor eating habits, he has lost three pounds in three weeks. D.C.’s mother decided not to inform her kid that his father had died in battle, and now she regrets it because she wonders what effect it would have had on her son.

Substance Current Use: The patient has no history of substance abuse. No one abuses drugs at home.

Medical History: No medical history has been provided.

Current Medications: The patient is prescribed DDVP for bedwetting.

Allergies: No allergies reported.

Reproductive Hx: No record

ROS

GENERAL: No fatigue, fever, or cold. The client has lost 3 pounds over three weeks.

HEENT: No diplopia, hearing loss, sore throat, runny nose, or sneezing reported.

SKIN: No bruising, rash, itching, or scars noted.

CARDIOVASCULAR: No palpitations, no chest pain, no edema, no chest discomfort.

RESPIRATORY: No shortness of breath, no cough, or sputum.

GASTROINTESTINAL: No reports of nausea, vomiting, abdominal pain, diarrhea, or blood in the stool.

GENITOURINARY: The client reports enuresis. No burning sensation on urination or odd odor of urine.

NEUROLOGICAL: No dizziness, headache, paralysis, ataxia, or tingling sensations on the extremities.

MUSCULOSKELETAL: No joint stiffness, no muscle pain, or back pains.

HEMATOLOGIC: No history of bleeding, bruising, or anemia.

LYMPHATICS: No lymph node enlargement and no history of splenectomy.

ENDOCRINOLOGIC: No reports of intolerance to heat or cold, no polydipsia or polyuria.

Objective:

Diagnostic results: No diagnostic tests are required or ordered at this stage.

Assessment

Mental Status Examination:

The patient looks appropriate for his age. D.C. appears tidy and well-groomed. He sits still, makes eye contact, and refrains from fidgeting. He is cooperative yet exudes excessive worry and melancholy. He walks steadily, but his voice is not very clear. The patient always worries that his mother will not pick him up from school, his brother and mother will not be found, and his mother might pass away.

He has lost his appetite, has trouble falling asleep, is agitated, has trouble concentrating, and claims to have bad dreams. His reasoning process is logical, and his communication is goal-oriented. In addition, he is unduly worried and in a euthymic state. D.C. does not intend to hurt anybody and does not have suicidal ideations. The client does not report any hallucinations. He is oriented X4 to time, place, person, and situation. His long-term and short-term memories are intact.

Diagnostic Impression

Primary diagnosis: Posttraumatic Stress Disorder (PTSD)

PTSD is a chronic condition resulting from exposure to a traumatic event, resulting in social, medical, and family functioning disturbances (Polimanti & Wendt, 2021). In addition to physical symptoms like headache and stomachache, children with PTSD may experience long-term symptoms like melancholy, anxiety, nervousness, violence, flashbacks, trouble in school, enuresis, difficulty concentrating, and physical symptoms like depression and anxiety (