NRNP/PRAC 6665 & 6675 Comprehensive Focused SOAP Psychiatric
Evaluation Template
Week 3 Assignment: Focused SOAP note on Anxiety, Obsessive-Compulsive and Related, and
Trauma and Stressor-Related Disorders
College Of Nursing-PMHNP, Walden University
NRNP 6675: PMHNP Care Across the Lifespan 11.
December 15, 2024
, This evaluation examines the case of Dev, a 7-year-old male exhibiting considerable
anxiety and associated symptoms. Dev's situation is intricate, characterized by a history of
extreme anxiety, sleep disruptions, somatic complaints, and behavioral problems intensified by
the stress and sorrow stemming from his father's absence. This evaluation seeks to elucidate
Dev's psychological condition, the influence of his familial and social context, and the
formulation of a suitable treatment strategy to meet his mental health requirements. The
assessment encompasses subjective and objective data, diagnostic evaluations, and an elaborate
case formulation, succeeded by an extensive treatment plan that incorporates both
pharmacological and non-pharmacological approaches. through aims to delineate effective ways
for controlling Dev's anxiety, treating his trauma, and enhancing his general well-being through a
comprehensive exploration of his situation.
Subjective:
CC: "My mum said you can help me get better."
History of Present Illness (HPI): Dev, a 7-year-old male, exhibits a notable history of anxiety
and apprehension, specifically concerning the welfare of his mother and brother, harboring fears
regarding their potential absence and a belief that his mother favors his brother. He recounts
recurrent nightmares concerning being lost and unable to locate his family. These nightmares
transpire nearly every night. Dev constantly has anxiety and articulates fears around his mother's
mortality or her failure to collect him from school. He has an aversion to darkness and requires a
nightlight and an open door to facilitate sleep. He is concerned about his family and has
difficulty focusing in school, frequently encountering disciplinary issues for his lack of
concentration and for throwing objects both at home and in school. He has been subjected to
bullying at school, being labeled "Mr. Smelly" because of his aversion to bathing and nocturnal
, enuresis. He experiences insomnia, frequent nocturnal awakenings, and diminished appetite and
has dropped three pounds over the past three weeks. He reports experiencing stomachaches and
headaches nearly every day. His challenges are exacerbated by sadness and trauma associated
with his father's loss; his father was deployed and died in combat when Dev was five, resulting
in uncertainty and feelings of abandonment, as his mother first informed him that his father was
on vacation. The patient refutes any suicidal or homicidal thoughts.
Past psychiatric history: No prior psychiatric evaluations or treatments were reported.
Medication trials and current medications: Pediatrician prescribed DDVAP (Desmopressin)
for bedwetting, though the dosage was not mentioned. but it has not been effective.
Psychotherapy or previous psychiatric diagnosis: No previous psychotherapy or psychiatric
diagnosis.
Substance use: None reported.
Family psychiatric/substance use history: No known family history of mental health or
substance abuse issues.
Social History: Dev resides with his mother and younger sibling. When Dev was five years old,
his father lost his life during a military deployment. Dev's mother originally informed him that
his father was on vacation, exacerbating his bewilderment and fear around abandonment.
Medical History: No notable medical concerns. The pediatrician has excluded physiological
causes for Dev's problems.
Allergies: None
Evaluation Template
Week 3 Assignment: Focused SOAP note on Anxiety, Obsessive-Compulsive and Related, and
Trauma and Stressor-Related Disorders
College Of Nursing-PMHNP, Walden University
NRNP 6675: PMHNP Care Across the Lifespan 11.
December 15, 2024
, This evaluation examines the case of Dev, a 7-year-old male exhibiting considerable
anxiety and associated symptoms. Dev's situation is intricate, characterized by a history of
extreme anxiety, sleep disruptions, somatic complaints, and behavioral problems intensified by
the stress and sorrow stemming from his father's absence. This evaluation seeks to elucidate
Dev's psychological condition, the influence of his familial and social context, and the
formulation of a suitable treatment strategy to meet his mental health requirements. The
assessment encompasses subjective and objective data, diagnostic evaluations, and an elaborate
case formulation, succeeded by an extensive treatment plan that incorporates both
pharmacological and non-pharmacological approaches. through aims to delineate effective ways
for controlling Dev's anxiety, treating his trauma, and enhancing his general well-being through a
comprehensive exploration of his situation.
Subjective:
CC: "My mum said you can help me get better."
History of Present Illness (HPI): Dev, a 7-year-old male, exhibits a notable history of anxiety
and apprehension, specifically concerning the welfare of his mother and brother, harboring fears
regarding their potential absence and a belief that his mother favors his brother. He recounts
recurrent nightmares concerning being lost and unable to locate his family. These nightmares
transpire nearly every night. Dev constantly has anxiety and articulates fears around his mother's
mortality or her failure to collect him from school. He has an aversion to darkness and requires a
nightlight and an open door to facilitate sleep. He is concerned about his family and has
difficulty focusing in school, frequently encountering disciplinary issues for his lack of
concentration and for throwing objects both at home and in school. He has been subjected to
bullying at school, being labeled "Mr. Smelly" because of his aversion to bathing and nocturnal
, enuresis. He experiences insomnia, frequent nocturnal awakenings, and diminished appetite and
has dropped three pounds over the past three weeks. He reports experiencing stomachaches and
headaches nearly every day. His challenges are exacerbated by sadness and trauma associated
with his father's loss; his father was deployed and died in combat when Dev was five, resulting
in uncertainty and feelings of abandonment, as his mother first informed him that his father was
on vacation. The patient refutes any suicidal or homicidal thoughts.
Past psychiatric history: No prior psychiatric evaluations or treatments were reported.
Medication trials and current medications: Pediatrician prescribed DDVAP (Desmopressin)
for bedwetting, though the dosage was not mentioned. but it has not been effective.
Psychotherapy or previous psychiatric diagnosis: No previous psychotherapy or psychiatric
diagnosis.
Substance use: None reported.
Family psychiatric/substance use history: No known family history of mental health or
substance abuse issues.
Social History: Dev resides with his mother and younger sibling. When Dev was five years old,
his father lost his life during a military deployment. Dev's mother originally informed him that
his father was on vacation, exacerbating his bewilderment and fear around abandonment.
Medical History: No notable medical concerns. The pediatrician has excluded physiological
causes for Dev's problems.
Allergies: None
