Week (3): : FOCUSED SOAP NOTE FOR ANXIETY, PTSD, AND OCD
Name:
College of Nursing-PMHNP, Walden University
NRNP 6675: PMHNP Care Across the Lifespan II-Summer 2025
Dr. Ashley Lockhart
Assignment due date : 16th June, 2025
, Subjective:
CC (chief complaint): “I am told by my mother that you can be of massive help to me in
making me a better person”
HPI: DC, a Caucasian child, aged 7, has been presented at the medical facility by his mom for an
evaluation of his mental state. The client expresses persistent concern for his mom as well as his
brother, right through his period in class. He expressed that his mind is completely focused on
his mom and younger brother's actions and welfare. He stated that he frequently has visions
when he cannot find his mom or younger sibling, which leads to a sense of being disoriented.
The client, however, denies ever being lost. According to him, his tutor consistently instructs him
to take a seat as well as concentrate throughout lessons to such an extent that the tutor has
brought DC’s seat very close to her seat. He admitted to being frustrated and throwing objects at
other students. The mom confimed almost everything DC talked about during the interview. As
described by his mom, D.C. continuously suffers from nervousness and fear around her
imminent death. Based on the mother's evaluation, DC has a tendency to throw stuff within the
house and often gets into trouble at school because of his habit of throwing things. Furthermore,
she said that DC suffers from insomnia, has exhibited a reduced appetite leading to a 3-pound
weight loss over a span of 3 weeks, and consistently feigns illness to leave school early,
expressing a reluctance to attend. DC has been experiencing a urinary condition as well as fails
to demonstrate a response to DDVP. The family physician directed him to the medical facility
due to his conviction that there is no discernible physical condition afflicting DC. He has no
previous psychiatric medical records.
Substance Current Use: There is no record of previous substance misuse.
Name:
College of Nursing-PMHNP, Walden University
NRNP 6675: PMHNP Care Across the Lifespan II-Summer 2025
Dr. Ashley Lockhart
Assignment due date : 16th June, 2025
, Subjective:
CC (chief complaint): “I am told by my mother that you can be of massive help to me in
making me a better person”
HPI: DC, a Caucasian child, aged 7, has been presented at the medical facility by his mom for an
evaluation of his mental state. The client expresses persistent concern for his mom as well as his
brother, right through his period in class. He expressed that his mind is completely focused on
his mom and younger brother's actions and welfare. He stated that he frequently has visions
when he cannot find his mom or younger sibling, which leads to a sense of being disoriented.
The client, however, denies ever being lost. According to him, his tutor consistently instructs him
to take a seat as well as concentrate throughout lessons to such an extent that the tutor has
brought DC’s seat very close to her seat. He admitted to being frustrated and throwing objects at
other students. The mom confimed almost everything DC talked about during the interview. As
described by his mom, D.C. continuously suffers from nervousness and fear around her
imminent death. Based on the mother's evaluation, DC has a tendency to throw stuff within the
house and often gets into trouble at school because of his habit of throwing things. Furthermore,
she said that DC suffers from insomnia, has exhibited a reduced appetite leading to a 3-pound
weight loss over a span of 3 weeks, and consistently feigns illness to leave school early,
expressing a reluctance to attend. DC has been experiencing a urinary condition as well as fails
to demonstrate a response to DDVP. The family physician directed him to the medical facility
due to his conviction that there is no discernible physical condition afflicting DC. He has no
previous psychiatric medical records.
Substance Current Use: There is no record of previous substance misuse.
