FOCUSED SOAP NOTE AND PATIENT CASE PRESENTATION,

Week (enter week #): (Enter assignment title)

PMHNP Care Across the Lifespan I

Faculty Name

Assignment Due Date

Subjective:

CC (chief complaint):

1. HPI: B: L is 59 years AA female who presents with feeling anxious Stated she was high jacked twice and lost her car twice in gun point, says two young boys high jacked her car in gun point which is increasing her paranoid thoughts and feel very anxious when she goes out. Patient admits going through lot of stress and lost so much money and getting more sicker and says her stress level and anxiety level is high. Says recently she is looking the surroundings and feels somebody is watching her after the incidents and feel more paranoid. Patient admits she is worried about her physical condition also say she lost 40 IBS in 8 months and says her blood sugar is uncontrollable . Patient stated she feel more anxious about her weight loss says she feels like her energy is leaving off from her muscles and say she is really curious about huge weight lost and say she is looking like skeleton. Patient is alert and oriented x4, communicating good, cooperative with the assessment. Her appearance is age appropriate thin body built. Her speech is normal is rate and volume. Patient Dx with Anxiety , Depression mood, anhedonia, insomnia, Fatigue and difficulty concentrating and adjustment disorder. Patient stated on Vistaril 25 mg BID PRN . Follow up in four 4-week Plan is to continue current medications.

Substance Current Use:

Medical History:

· Current Medications:

· Allergies:

· Reproductive Hx:

ROS:

· GENERAL:

· HEENT:

· SKIN:

· CARDIOVASCULAR:

· RESPIRATORY:

· GASTROINTESTINAL:

· GENITOURINARY:

· NEUROLOGICAL:

· MUSCULOSKELETAL:

· HEMATOLOGIC:

· LYMPHATICS:

· ENDOCRINOLOGIC:

Objective:

Diagnostic results:

Assessment:

Mental Status Examination:

Diagnostic Impression:

Anxiety ,

Depression mood,

Anhedonia,

insomnia,

Fatigue and difficulty concentrating and adjustment disorder.

Reflections:

Case Formulation and Treatment Plan:

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