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
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, Maternal Grandmother: Bipolar
Maternal Great-grandmother: committed suicide
Maternal Aunt: has schizophrenia
Paternal Cousin: committed suicide
Medical History: Normal blood tests and physical exam. She is a generally healthy 12-year-old
with no hospitalizations.
Allergies: None
Reproductive Hx: Normal no concerns, prepubescent.
ROS:
GENERAL: No fevers, sweats, shakes, chills or change in weight.
HEENT: Eyes: 20/20 vision no report of vision changes. No diplopia, amaurosis fugax
Ears, Nose, and Throat: No epistaxis or tinnitus.
SKIN: SP reported no rashes, eruptions or itching.
CARDIOVASCULAR: No edema, chest pain, or palpitations.
RESPIRATORY: JT denies shortness of breath, cough, wheezing, or sputum.
GASTROINTESTINAL: No anorexia, nausea, vomiting, or diarrhea. No abdominal pain
or blood.
GENITOURINARY: Denies frequency, nocturia, dysuria, or hematuria.
NEUROLOGICAL: Negative for any focal neurologic complaints.
MUSCULOSKELETAL: No joint swelling, stiffness, pain or myalgias.
HEMATOLOGIC: No abnormal prolonged bleeding or bruising.
LYMPHATICS: No enlarged nodes.
ENDOCRINOLOGIC: Negative for excessive thirst, urination, heat or cold intolerance,
diabetes or thyroid disease.
Objective:
General Appearance: JT appears her stated age, she is lean with a thin build but well nourished.
Diagnostic results: No labs, X-rays, or other diagnostics are needed to develop the differential
diagnoses at this time.
Mental Status Examination:
JT is 12-year-old Caucasian female presented for her initial assessment with her mother. She
complains of daily fears and anxieties. JT is polite and engaged in the session, maintaining good
eye contact and willing to communicate with the provider but is distracted by the alignment of
objects on the provider’s desk. JT appears to be her stated age; she is lean with a thin build but
well-nourished. JT shows no manifestations of suicidal ideation or homicidal ideation as well as
no obvious manifestations of ongoing or prevailing hallucinations, delusions or other indicators
of a psychotic process as her associations are intact, logical, and appropriate. JT has no history of
substance abuse. JT is casually and appropriately dressed, for situation and season. JT’s speech
was normal in rate, volume, and articulation that is coherent and spontaneous with no obvious
blocking or pressured speech. Language skills are intact and appropriate for age. Mood presented
This study source was downloaded by 100000850699744 from CourseHero.com on 08-17-2022 07:53:14 GMT -05:00
https://www.coursehero.com/file/101634071/Wk-7-Assign-2-Focused-SOAP-Note-and-Patient-Case-Presentationdocx/
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
This study source was downloaded by 100000850699744 from CourseHero.com on 08-17-2022 07:53:14 GMT -05:00
https://www.coursehero.com/file/101634071/Wk-7-Assign-2-Focused-SOAP-Note-and-Patient-Case-Presentationdocx/
, Maternal Grandmother: Bipolar
Maternal Great-grandmother: committed suicide
Maternal Aunt: has schizophrenia
Paternal Cousin: committed suicide
Medical History: Normal blood tests and physical exam. She is a generally healthy 12-year-old
with no hospitalizations.
Allergies: None
Reproductive Hx: Normal no concerns, prepubescent.
ROS:
GENERAL: No fevers, sweats, shakes, chills or change in weight.
HEENT: Eyes: 20/20 vision no report of vision changes. No diplopia, amaurosis fugax
Ears, Nose, and Throat: No epistaxis or tinnitus.
SKIN: SP reported no rashes, eruptions or itching.
CARDIOVASCULAR: No edema, chest pain, or palpitations.
RESPIRATORY: JT denies shortness of breath, cough, wheezing, or sputum.
GASTROINTESTINAL: No anorexia, nausea, vomiting, or diarrhea. No abdominal pain
or blood.
GENITOURINARY: Denies frequency, nocturia, dysuria, or hematuria.
NEUROLOGICAL: Negative for any focal neurologic complaints.
MUSCULOSKELETAL: No joint swelling, stiffness, pain or myalgias.
HEMATOLOGIC: No abnormal prolonged bleeding or bruising.
LYMPHATICS: No enlarged nodes.
ENDOCRINOLOGIC: Negative for excessive thirst, urination, heat or cold intolerance,
diabetes or thyroid disease.
Objective:
General Appearance: JT appears her stated age, she is lean with a thin build but well nourished.
Diagnostic results: No labs, X-rays, or other diagnostics are needed to develop the differential
diagnoses at this time.
Mental Status Examination:
JT is 12-year-old Caucasian female presented for her initial assessment with her mother. She
complains of daily fears and anxieties. JT is polite and engaged in the session, maintaining good
eye contact and willing to communicate with the provider but is distracted by the alignment of
objects on the provider’s desk. JT appears to be her stated age; she is lean with a thin build but
well-nourished. JT shows no manifestations of suicidal ideation or homicidal ideation as well as
no obvious manifestations of ongoing or prevailing hallucinations, delusions or other indicators
of a psychotic process as her associations are intact, logical, and appropriate. JT has no history of
substance abuse. JT is casually and appropriately dressed, for situation and season. JT’s speech
was normal in rate, volume, and articulation that is coherent and spontaneous with no obvious
blocking or pressured speech. Language skills are intact and appropriate for age. Mood presented
This study source was downloaded by 100000850699744 from CourseHero.com on 08-17-2022 07:53:14 GMT -05:00
https://www.coursehero.com/file/101634071/Wk-7-Assign-2-Focused-SOAP-Note-and-Patient-Case-Presentationdocx/
