NRNP 6665 Comprehensive Focused SOAP Psychiatric Evaluation Template

NRNP 6665 Comprehensive Focused SOAP Psychiatric Evaluation Template. Psychiatric Mental Health. The case involves a 17-year-old Asian American who is accompanied by the Guardian for psychiatric evaluation. She has been exhibiting symptoms of depression and sleep disorder which include loss of interest in school activities, lack of sleep, changes in appetite and weight, and feelings of sadness. Her diagnosis shows mood disorder- depression as she meets the DSM-5 diagnostic criteria for depression. She is placed under pharmacological treatment including SSRI and non –SSRI to help improve the symptoms. The follow up after 4 weeks shows the intervention was successful as the symproms had reduced . Subjective: CC (chief complaint): Mood disorder and Sleep disorder. HPI: RP is a 17 years old Asian American female presenting with a mood disorder and sleep disorder and has been experiencing symptoms for about a year. She is not currently prescribed psychotropic medication. RP shows less interest in school activities, cries a lot, especially at night, is always sad, lacks sleep, and is experiencing changes in appetite and weight. She denies any history of trauma to the head and suicidal thoughts. RP agrees to have been using illicit substances but claims she has stopped. Past Psychiatric History Hospitalizations: No history of hospitalization. Family Psychiatric/Substance Use History: There is no history of family mental health problems or substance abuse. NRNP/PRAC 6665 & 6675 Comprehensive Focused SOAP Psychiatric Evaluation Template © 2021 Walden University Page 3 of 8 Substance Current Use: The patient has a history of substance abuse. Trauma History: No history of childhood physical and sexual trauma. Violence Hx: No issues of safety. Medical History: Current Medications: Not currently under any medication. Allergies: No allergies. Reproductive Hx: No reproductive Hx issues. ROS:  GENERAL: Negative for fever, chills, weakness, or fatigue.  HEENT: Eyes: No visual loss, blurred vision, double vision, or yellow sclerae. Ears, Nose, No hearing loss, sneezing, congestion, runny nose, or sore throat.  SKIN: Negative for rash or itching.  CARDIOVASCULAR: Negative for chest pain, chest pressure, or chest discomfort. No palpitations or edema.  RESPIRATORY: No shortness of breath, cough, or sputum.  GASTROINTESTINAL: Negative for anorexia, nausea, vomiting, or diarrhea. No abdominal pain or blood.  GENITOURINARY: Negative for burning on urination, urgency. We offer online tutoring, help with assignments and essay writing for all Majors with a guaranteed pass. For assistance Contact Tutor Lucas: +1 (775) 766-9089 /