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Week 3: Assignment 2: FOCUSED SOAP NOTE AND
PATIENT CASE PRESENTATION PART 2
Judith Asika
College of Nursing-PMHNP, Walden University
PRAC 6665: PMHNP Care Across the Lifespan I
Professor LaTanya Battery-Wherry
06/16/25
, 2
Subjective:
Client Background: Patient’s Name: S.E. Age: 34 Race: Spanish Gender: Male
Diagnosis: MDD severe recurrent, GAD, Insomnia D/T Other Mental Conditions, and Panic
Attacks. CC: “ I need medication for depression and anxiety.”
HPI: S.E. is a 34-year-old Mexican male presenting for intake via Telehealth. He is currently
diagnosed with severe recurrent MDD, GAD, insomnia due to mental health conditions, and
panic attacks. He is actively seeing a therapist. Psychiatric history includes two hospitalizations
13 years ago and prior diagnoses of Bipolar Disorder, Anxiety Disorder, and PTSD. He has tried
multiple psychotropic medications, including Prozac, Zoloft, Lexapro, and Trazodone, with
limited effectiveness. Current medications include Mirtazapine 7.5 mg PO at bedtime, and may
increase to 15 mg PRN if needed for insomnia, and Xanax 0.5 mg PO PRN for panic attacks. He
reports depressive and anxious symptoms since childhood and experiences panic attacks about
twice a year, often triggered by stress-related. He is a veteran with a trauma history, with
stressors primarily related to work and personal life. He also has a history of hospitalization due
to insomnia and depression. In March 2025, a urologist consulted and underwent surgery for
varicocele. Last PCP unknown.
Client reports other symptoms of fatigue, insomnia, low confidence, anxiety, depression,
isolation, Trichotillomania, and distress over being the only veteran retained at work. Endorses
low energy, poor sleep, low motivation, mood/appetite fluctuations, and worsening anxiety due
© 2022 Walden University Page 2 of 19
, 3
to work stressors. Hx of substance use (alcohol, smoking, illicit drugs); sober from alcohol x2
months, smoking x 3 months. Insomnia exacerbates anxiety; sleep meds help briefly. Slept 3 hrs
last night. Reports family MH hx, past SI w/o attempt. Denied current SI but feels “drained.”
PHQ-9: 18, GAD-7: 19. Denies OTC med use. Recently started biking and gym. Reports positive
effects and a strong support system. Reports NKA, HT: 5'7", WT: 180 lbs. The MH consult form
for work is provided per request. Psychoeducation on diagnosis, meds, dosing, side effects, and
titration was provided, and the client verbalized understanding. Emergency protocols, treatment
adherence, cancellation policy, emergency contacts, and confidentiality were explained with
verbalized understanding. Possible med adjustments and alternatives for better symptom control
with fewer side effects are discussed. Past medical history, diagnoses, side effects, and preferred
pharmacy were reviewed. F/U scheduled in 4 weeks.
Past psychiatric history:
• Past psychiatric history: Psychiatric history includes two hospitalizations 13 years ago
and prior diagnoses of Bipolar Disorder, Anxiety Disorder, and PTSD. He has tried
multiple psychotropic medications. Reports lifelong depression and anxiety, with panic
attacks ~2x/year, typically triggered by stress. Veteran with trauma history; primary
stressors stem from work and personal life.
• Past Psychotropic Medication Trials: Psychotropic medications, including Prozac, Zoloft,
Lexapro, and Trazodone, with limited effectiveness.
• Current Psychotropic Medication: Mirtazapine 7.5 mg PO at bedtime and may increase to
15 mg PRN if needed for insomnia, and Xanax 0.5 mg PO PRN for panic attacks.
© 2022 Walden University Page 3 of 19
Week 3: Assignment 2: FOCUSED SOAP NOTE AND
PATIENT CASE PRESENTATION PART 2
Judith Asika
College of Nursing-PMHNP, Walden University
PRAC 6665: PMHNP Care Across the Lifespan I
Professor LaTanya Battery-Wherry
06/16/25
, 2
Subjective:
Client Background: Patient’s Name: S.E. Age: 34 Race: Spanish Gender: Male
Diagnosis: MDD severe recurrent, GAD, Insomnia D/T Other Mental Conditions, and Panic
Attacks. CC: “ I need medication for depression and anxiety.”
HPI: S.E. is a 34-year-old Mexican male presenting for intake via Telehealth. He is currently
diagnosed with severe recurrent MDD, GAD, insomnia due to mental health conditions, and
panic attacks. He is actively seeing a therapist. Psychiatric history includes two hospitalizations
13 years ago and prior diagnoses of Bipolar Disorder, Anxiety Disorder, and PTSD. He has tried
multiple psychotropic medications, including Prozac, Zoloft, Lexapro, and Trazodone, with
limited effectiveness. Current medications include Mirtazapine 7.5 mg PO at bedtime, and may
increase to 15 mg PRN if needed for insomnia, and Xanax 0.5 mg PO PRN for panic attacks. He
reports depressive and anxious symptoms since childhood and experiences panic attacks about
twice a year, often triggered by stress-related. He is a veteran with a trauma history, with
stressors primarily related to work and personal life. He also has a history of hospitalization due
to insomnia and depression. In March 2025, a urologist consulted and underwent surgery for
varicocele. Last PCP unknown.
Client reports other symptoms of fatigue, insomnia, low confidence, anxiety, depression,
isolation, Trichotillomania, and distress over being the only veteran retained at work. Endorses
low energy, poor sleep, low motivation, mood/appetite fluctuations, and worsening anxiety due
© 2022 Walden University Page 2 of 19
, 3
to work stressors. Hx of substance use (alcohol, smoking, illicit drugs); sober from alcohol x2
months, smoking x 3 months. Insomnia exacerbates anxiety; sleep meds help briefly. Slept 3 hrs
last night. Reports family MH hx, past SI w/o attempt. Denied current SI but feels “drained.”
PHQ-9: 18, GAD-7: 19. Denies OTC med use. Recently started biking and gym. Reports positive
effects and a strong support system. Reports NKA, HT: 5'7", WT: 180 lbs. The MH consult form
for work is provided per request. Psychoeducation on diagnosis, meds, dosing, side effects, and
titration was provided, and the client verbalized understanding. Emergency protocols, treatment
adherence, cancellation policy, emergency contacts, and confidentiality were explained with
verbalized understanding. Possible med adjustments and alternatives for better symptom control
with fewer side effects are discussed. Past medical history, diagnoses, side effects, and preferred
pharmacy were reviewed. F/U scheduled in 4 weeks.
Past psychiatric history:
• Past psychiatric history: Psychiatric history includes two hospitalizations 13 years ago
and prior diagnoses of Bipolar Disorder, Anxiety Disorder, and PTSD. He has tried
multiple psychotropic medications. Reports lifelong depression and anxiety, with panic
attacks ~2x/year, typically triggered by stress. Veteran with trauma history; primary
stressors stem from work and personal life.
• Past Psychotropic Medication Trials: Psychotropic medications, including Prozac, Zoloft,
Lexapro, and Trazodone, with limited effectiveness.
• Current Psychotropic Medication: Mirtazapine 7.5 mg PO at bedtime and may increase to
15 mg PRN if needed for insomnia, and Xanax 0.5 mg PO PRN for panic attacks.
© 2022 Walden University Page 3 of 19
