Week 9: Focused SOAP Note and Patient Case Presentation College of Nursing-PMHNP, Walden UniversityNRNP 6665: PMHNP Care Across the Lifespan I

Demographic Information

Initials: M.T. Age: 78 years Sex: Female Race: Hispanic

CC (chief complaint): “They want to poison me.”

H.P.I.: M.T. is a 78-year-old Hispanic female brought to the clinic with a chief complaint, “They

want to poison me.” She is restless and hyper-vigilant. The patient is reported to have vomited

before eating. No family member has reported any illness before and after eating dinner. The

patient denies any history of diarrhea, stomachache, or abdominal distention. She has a history of

generalized anxiety disorder but was treated using propranolol and sertraline. She is brought to

the clinic accompanied by her daughter, who reports that M.T. has been feeling restless and has

difficulty controlling her worries about her last-born son. The son recently moved out of the

house since he got employment overseas, and they have been living together. She explains that

her son cannot live abroad alone due to cultural differences. She also indicates that he trusted

him to prepare his meals and has not been vomiting as she did in the previous episode. The

patient also reports staying awake at night, being easily fatigued, and having difficulty

concentrating.

Substance Current Use:

The patient reports tobacco and alcohol use. She smokes one packet of cigarettes daily and could

smoke another half when anxious. She denies any history of illicit drug use, including

prescription pain medication addiction.

Family History

The patient reports that her mother was diagnosed with major depressive disorder and her father

died of type II diabetes mellitus complications. He also had hypertension and anxiety that

worsened his cardiovascular disease symptoms. Her maternal grandmother had high cholesterol 

NRNP/PRAC 6665 & 6675 Comprehensive Focused SOAP Psychiatric

Evaluation

and generalized anxiety disorder. Her maternal grandfather committed suicide after overdosing

on pain medication following the death of his wife. His paternal grandfather had alcohol use

disorder and posttraumatic stress disorder following his service in the military. His paternal

grandmother was delusional but was not diagnosed with any mental illness because she believed

in traditional healing methods and detested modern medicine.

Medical History:

The patient g5 p5 lc 6 and reports that her previous hospitalizations with all pregnancies. She

states that she underwent a tonsillectomy as a child and has had remarkable health for asthma.

She also has a history of generalized anxiety disorder managed by propranolol and sertraline.

Current Medications: Propranolol and sertraline

Allergies: She reports an allergic reaction to cats, and she denies any known drug

allergies or seasonal, environmental, or food allergies.

Reproductive Hx: She is currently sexually inactive.

R.O.S.:

General: she reports general fatigue and weakness. However, she denies fever or chills.

She seems on edge, anxious, and paranoid.

HEENT: She reports occasional headaches. Eyes: No blurred vision, visual loss, or

double vision. Ears, Nose, and Throat: denies ear discharge or hearing loss, no sneezing,

congestion, or runny nose. She denies having a sore throat.

Skin: Denies itching or rashes

Cardiovascular: Denies chest pain, chest pressure, or discomfort.

Respiratory: Denies coughs or sputum production. She reports shortness of breath when

anxious

 

Order this paper