Week 3 Assignment: FOCUSED SOAP NOTE FOR ANXIETY, PTSD, AND OCDAdjewa Nadege KouassiNRNP/PRAC 6675: Psychiatric Mental Health Nurse Practitioner Care Across The Lifespan IICollege of Nursing-PMHNP, Walden University

NRNP/PRAC 6665 & 6675 Comprehensive Focused SOAP Psychiatric

Evaluation Template

Subjective:

Patient Information

Name: Dev Cordoba (D.C)

Age: 7 years

Sex: Male

Race: African American

CC (chief complaint): "I came to visit you because my mum claimed you can help me feel

better."

HPI: Dev Cardoba, age 7, came to the clinic with his mother to have a mental health assessment.

Even when he is in school, Dev displayed ongoing concern for his mother and younger brother.

He clarified that worries regarding their safety and possible actions always dominate his

thoughts. In response to a question concerning his frequent nightmares, he disclosed that,

although never having truly been lost, he has nearly always dreamed of being lost and unable to

locate his mother and younger brother. Dev also said that he was having trouble at school. When

he doesn't sit still and pay attention in class, his teacher frequently punishes him, which leads to

the movement of his chair closer to the teacher's desk. He acknowledged being violent and

throwing books at other classmates. When Dev's mother was interviewed, she largely supported

what he said. She mentioned that he frequently fears her passing and is extremely worried about

her well-being. Additionally, Dev has expressed sentiments of not being as loved as his younger

brother, which has resulted in disruptive behavior at home, such as object tossing and persistent

problems at school. His inability to fall asleep, frequent awakenings, and insistence on leaving

the door open and lights on are other signs of disturbed sleep patterns. He has lost three pounds

in the last three weeks due to a decrease in hunger. Despite the pediatrician's prescription of

DDVP, Dev's mother reported that he still wets the bed at night. Despite the fact that there has

never been a history of mental health troubles, she requested this evaluation because she thinks

there are no physical problems driving his symptoms.

Substance Current Use: Denied use of alcohol, tobacco, or illegal drugs by the client or his

family.

Medical History: Did not report any medical history

Current Medications: Currently, not taking any medication, used DDVP for bedwetting.

Allergies: Denied food, drug, or environmental allergies.

Reproductive Hx: Did not report.

ROS:

GENERAL: Report weight loss by mother. Denied fever, chills, fatigue or weakness.

HEENT: Denied Diplopia, blurred vision, visual loss or double vision. Head is

normocephalic, no hearing loss, ear pain, ear discharge, runny nose, sore throat, or

sneezing.

SKIN: Denied rashes, bruises or itching.

Diagnostic results: In the presented case study, there were no diagnostic tests conducted. To

effectively eliminate the possibility of various mental disorders, a thorough physical examination

is a crucial component. Additionally, the utilization of various scales or questionnaires, such as

the Hamilton Anxiety Scale or Beck Anxiety Inventory Scale, can be valuable in assessing the

extent of the child's anxiety, especially given the mother's observations regarding his high levels

of anxiety and worry. As noted by Zakhari (2018), for many children who either suffer from

mental illnesses or are at risk of developing them, undergoing an X-ray examination can provide

valuable insights into any unusual brain changes and facilitate an assessment of their brain

development.

Assessment:

Mental Status Examination: A 7-year-old boy named D.C. visited the clinic with his mother,

who indicated that she herself is not currently experiencing any psychiatric issues but has

concerns about her child's persistent anxious demeanor. During the assessment, D.C. appeared to

be cooperative, w

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