PRA 6665 Week 7 Assignment
2; Focused SOAP Note and
Patient Case Presentation
, Week 7: Assignment 2 Focused SOAP Note and Patient Case Presentation
Subjective:
CC (chief complaint): “Everything scares me, I feel like I live with fear every day.”
HPI: JT is a 12-year-old Caucasian female, presented for her initial assessment with her mother.
Mother states that JT had symptoms of generalized fear and anxiety around the age of 7 but JT
seemed to get better, her symptoms returned around the age of 11. Mother reports no identifiable
stressors and denies panic attacks. JT is currently tearful and depressed. JT stated that about a
year ago I started “getting an overactive mind”. Mother responded with, “she started some rituals
and obsessions around that time as well”. Because of her symptoms, JT began to withdrawal
from her friends, had fear of being in her classroom and thus was pulled from school and is
currently homeschooled. JT denies suicidal ideation or homicidal ideation. JT admits to have
compelling thoughts; almost, but not clearly, a voice making her sense that something horrible
will happen or something or somebody will die. JT explained that she has to clean her rabbits
cage perfectly or her rabbit will die. She also stated that she has to walk a number of steps and
she needs to stop on a specific number in order to prevent something horrible from happening,
like her parents dying. She also expressed that she doesn’t like things facing her at an angle and
likes to straighten things to make her feel better. I was obvious that things on the providers desk
were triggering her and she began to straighten things within reach. Mother reported that these
obsessions interrupt and distract JT daily.
Past Psychiatric History:
General Statement: JT reports anxiety and fear when she was 7 and then again about a year
ago.
Caregivers (if applicable): JT lives with both parents and her younger brother.
Hospitalizations: JT has never been hospitalized.
Medication trials: None
Psychotherapy or Previous Psychiatric Diagnosis: JT has had no psychotherapy or previous
psychiatric diagnosis.
Social and Personal History: JT was an excellent student prior to dropping out for home
schooling. No drug or alcohol abuse or use. Has a younger brother.
Family Psychiatric/Substance Use History:
Mother, a physician: with generalized anxiety
2; Focused SOAP Note and
Patient Case Presentation
, Week 7: Assignment 2 Focused SOAP Note and Patient Case Presentation
Subjective:
CC (chief complaint): “Everything scares me, I feel like I live with fear every day.”
HPI: JT is a 12-year-old Caucasian female, presented for her initial assessment with her mother.
Mother states that JT had symptoms of generalized fear and anxiety around the age of 7 but JT
seemed to get better, her symptoms returned around the age of 11. Mother reports no identifiable
stressors and denies panic attacks. JT is currently tearful and depressed. JT stated that about a
year ago I started “getting an overactive mind”. Mother responded with, “she started some rituals
and obsessions around that time as well”. Because of her symptoms, JT began to withdrawal
from her friends, had fear of being in her classroom and thus was pulled from school and is
currently homeschooled. JT denies suicidal ideation or homicidal ideation. JT admits to have
compelling thoughts; almost, but not clearly, a voice making her sense that something horrible
will happen or something or somebody will die. JT explained that she has to clean her rabbits
cage perfectly or her rabbit will die. She also stated that she has to walk a number of steps and
she needs to stop on a specific number in order to prevent something horrible from happening,
like her parents dying. She also expressed that she doesn’t like things facing her at an angle and
likes to straighten things to make her feel better. I was obvious that things on the providers desk
were triggering her and she began to straighten things within reach. Mother reported that these
obsessions interrupt and distract JT daily.
Past Psychiatric History:
General Statement: JT reports anxiety and fear when she was 7 and then again about a year
ago.
Caregivers (if applicable): JT lives with both parents and her younger brother.
Hospitalizations: JT has never been hospitalized.
Medication trials: None
Psychotherapy or Previous Psychiatric Diagnosis: JT has had no psychotherapy or previous
psychiatric diagnosis.
Social and Personal History: JT was an excellent student prior to dropping out for home
schooling. No drug or alcohol abuse or use. Has a younger brother.
Family Psychiatric/Substance Use History:
Mother, a physician: with generalized anxiety
