Week 3: Focused SOAP Note and Patient Case Presentation
College of Nursing-PMHNP, Walden University
NRNP 6675: PMHNP Care Across the Lifespan 2 Practicum
September 19, 2021
Introduction
, Each mental intervention is based on the evidence gathered during the initial interview
with the patient; each patient's therapy begins with a thorough medical and mental health
evaluation, the incorporation of trust, and a dialogue of past mental health history, substance
misuse history, family mental health history, and so forth. The evaluation of the patient in this
case was documented, and a diagnostic impression was formed based on the information
obtained from the patient during the evaluation. A therapy strategy was devised when the case
was developed. The patient is a 7-year-old Caucasian boy who was scheduled for an initial
screening for a mood disorder after her pediatrician recommended that she consult a psychiatrist.
At this time, the patient is not taking any medications. DDAVP PO was given to the patient, but
it was stopped since it was ineffective.
Patient Initial: R.C Age: 7 Gender: Male
Subjective Data:
CC: "My mother said you will be able to help me with my mood problem"
HPI: R.C a 7-year-old White male who was referred to a psychiatrist for evaluation after several
treatments and efforts by his teacher to help him with his mood. According to patient's
mother during the interview, the mother said that the pediatrician placed patient on DDAVP
which did not help patient. Mother did not list dose of medication or frequency. During the
interview, patient states that he feels worried most time. Patient said " I am worried about
everything". Patient admits to bad dreams and that he dreams a lot that he can't find his brother
and mom. When asked if patient feels lost. Patient responding saying " I worry about my mom
and brother when I am alone". Patient went further to state "People in school don't like me. They
call me smelly and calls me names". Patient said that his mom said his school mates calls him
College of Nursing-PMHNP, Walden University
NRNP 6675: PMHNP Care Across the Lifespan 2 Practicum
September 19, 2021
Introduction
, Each mental intervention is based on the evidence gathered during the initial interview
with the patient; each patient's therapy begins with a thorough medical and mental health
evaluation, the incorporation of trust, and a dialogue of past mental health history, substance
misuse history, family mental health history, and so forth. The evaluation of the patient in this
case was documented, and a diagnostic impression was formed based on the information
obtained from the patient during the evaluation. A therapy strategy was devised when the case
was developed. The patient is a 7-year-old Caucasian boy who was scheduled for an initial
screening for a mood disorder after her pediatrician recommended that she consult a psychiatrist.
At this time, the patient is not taking any medications. DDAVP PO was given to the patient, but
it was stopped since it was ineffective.
Patient Initial: R.C Age: 7 Gender: Male
Subjective Data:
CC: "My mother said you will be able to help me with my mood problem"
HPI: R.C a 7-year-old White male who was referred to a psychiatrist for evaluation after several
treatments and efforts by his teacher to help him with his mood. According to patient's
mother during the interview, the mother said that the pediatrician placed patient on DDAVP
which did not help patient. Mother did not list dose of medication or frequency. During the
interview, patient states that he feels worried most time. Patient said " I am worried about
everything". Patient admits to bad dreams and that he dreams a lot that he can't find his brother
and mom. When asked if patient feels lost. Patient responding saying " I worry about my mom
and brother when I am alone". Patient went further to state "People in school don't like me. They
call me smelly and calls me names". Patient said that his mom said his school mates calls him
