Week 8: Focused SOAP Note Complex Case Study Presentation
College of Nursing-PMHNP, Walden University
PRAC 6675: PMHNP Care Across the Lifespan I
Dr.Nataliya Ishkova
, NRNP/PRAC 6665 & 6675 Comprehensive Focused SOAP
Psychiatric Evaluation Template
Subjective:
CC (chief complaint): “I cannot sleep, and I do not see the point in getting out of bed anymore. It
has been getting worse since my wife died.”
HPI: M.H., a 74-year-old Caucasian retired machinist, presents for initial assessment with 4
months of persistent low mood, anhedonia, marked fatigue, early morning awakening (2–4 a.m.),
impaired concentration, psychomotor slowing noticed by family, and pervasive worry about
health and finances. Appetite is decreased with unintentional 10-lb weight loss over 3 months..
Denies current suicidal intent but endorses passive thoughts of “not wanting to wake up,”
without a plan or prior attempts; agrees to safety planning. Social history: Widowed 6 months;
lives alone in a rented apartment; two adult children live out of state. Fixed income; reports
difficulty paying for rides to appointments—former union machinist; high school education.
Church member but has not attended since spouse’s death. Limited social support locally.
Ambulates with a cane. Falls: one mechanical fall last month, no injury. Reports social
withdrawal, missed medical appointments, and decreased medication adherence following the
death of his spouse six months ago.
Anxiety is present most days, difficult to control, with restlessness and muscle tension—no panic
attacks. Symptoms occur most of the day, nearly every day, causing significant impairment—no
manic or hypomanic symptoms. Cognitive concerns include word-finding difficulty and
misplaced items, with the onset coinciding with mood decline. No psychotic symptoms. Pain
from chronic knee osteoarthritis flares, worsening with inactivity. No prior psychiatric diagnosis.
Received brief grief counseling after spouse’s death (3 sessions; discontinued due to
transportation issues). No history of self-harm, psychosis, or mania. Medical history:
College of Nursing-PMHNP, Walden University
PRAC 6675: PMHNP Care Across the Lifespan I
Dr.Nataliya Ishkova
, NRNP/PRAC 6665 & 6675 Comprehensive Focused SOAP
Psychiatric Evaluation Template
Subjective:
CC (chief complaint): “I cannot sleep, and I do not see the point in getting out of bed anymore. It
has been getting worse since my wife died.”
HPI: M.H., a 74-year-old Caucasian retired machinist, presents for initial assessment with 4
months of persistent low mood, anhedonia, marked fatigue, early morning awakening (2–4 a.m.),
impaired concentration, psychomotor slowing noticed by family, and pervasive worry about
health and finances. Appetite is decreased with unintentional 10-lb weight loss over 3 months..
Denies current suicidal intent but endorses passive thoughts of “not wanting to wake up,”
without a plan or prior attempts; agrees to safety planning. Social history: Widowed 6 months;
lives alone in a rented apartment; two adult children live out of state. Fixed income; reports
difficulty paying for rides to appointments—former union machinist; high school education.
Church member but has not attended since spouse’s death. Limited social support locally.
Ambulates with a cane. Falls: one mechanical fall last month, no injury. Reports social
withdrawal, missed medical appointments, and decreased medication adherence following the
death of his spouse six months ago.
Anxiety is present most days, difficult to control, with restlessness and muscle tension—no panic
attacks. Symptoms occur most of the day, nearly every day, causing significant impairment—no
manic or hypomanic symptoms. Cognitive concerns include word-finding difficulty and
misplaced items, with the onset coinciding with mood decline. No psychotic symptoms. Pain
from chronic knee osteoarthritis flares, worsening with inactivity. No prior psychiatric diagnosis.
Received brief grief counseling after spouse’s death (3 sessions; discontinued due to
transportation issues). No history of self-harm, psychosis, or mania. Medical history:
