NRNP/PRAC 6665 & 6675 Comprehensive Focused SOAP Psychiatric Evaluation Template

 

 

Subjective:

CC (chief complaint): C.N, a 42 years old Jamaican female, presents for a checkup for aniety

syndromes. Psychiatrical medications are not being prescribed until further screening, and the

exact problem is identified.

HPI: C.N has been experiencing sleepless difficulties, for example, feeling tiresome in the

mornings despite being asleep for a whole night. Another sign she had is being stressed and

therefore being restless. She also has experienced the feeling of worrying, thus developing fear

with time and tension all over her body. She had had these symptoms for approximately two

weeks. The primary stressor that has been identified is family affairs. From the last visit, I can

conclude that the patient has not improved but has worsened off. The signs observed in the

previous visit are similar symptoms that the patient is being honored with (Andrews et al., 2018).

Previously, the patient has been offered treatment through CBT, and Behavioral, cognitive

therapy, also called talk therapy, primarily used to treat phobias and aniety disorders.

Substance Current Use: Small amount intake of alcohol. The patient is a stimulants-active and

has a history of using phencyclinide, alcohol and opiates.

Medical History: C.N had a high-level consumption of alcohol in her late 30s and a small

amount of caffeine. The high consumption of alcoholic drinks daily could be a source of aniety.

At 41 C.N, cut down the increased alcohol consumption and withdraw from caffeine use

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