NRNP 6675 Week 3 Assignment; Focused SOAP Note for Anxiety, PTSD, and OCD
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Patient’s Initials D.C. Age: 7 years
Subjective:
CC (chief complaint): "My mum said you can help me get better."
HPI:
D.C. is a 7-year-old Caucasian male patient whose teacher referred him to a psychiatrist for examination on mood disorders. The patient's mother explained that his physician-administered DDAVP to help reduce his bedwetting, but it did not help. However, she did not provide the dose and frequency of DDAVP administration. The patient worries about everything and has terrible dreams about his brother and mother. He feels that people in school do not like him, calling him smelly and other names. He states that he has accidents at night and is worried that his father did not come home. The patient states that his schoolmates are unaware of how he feels about his father not coming back home and that his teacher appears to be picking on him. He has never attempted to harm himself, but the mother details that he worries about his mother's death, his mother abandoning him, and he has difficulty sleeping. He has lost weight (three pounds in three weeks) because of his poor eating. D.C.'s father was killed in the war, but his mother chose not to tell him about it, and now she feels guilty about what impact it might have caused on her son.
Substance Current Use: D.C has no substance use problems, and none has been abusing substances at home.
Medical History: The patient has no medical history.
Current Medications: The patient uses DDVP for his enuresis problems.
Allergies: D.C. has no allergies.......... Continue
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