NRNP 6675 Week 3 Assignment; SOAP Note

Course : Walden

Contributed : Latricia Gill

$20.00

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Subjective:

CC: “She thought you were going to help me be better.”

HPI: D.V 7yo Hispanic M. The patient is here for a psychiatric evaluation for increased anxiety and poor concentration at school. The patient has no previous psychiatric history and is currently not on any psychotropic medication. The patient reports that he “worries about everything.” He also notes that he hates sleeping in the dark and has nightmares of being lost almost every night. He states that his mother might not come home, just like his father. The patient’s mother reports that he always seems anxious and worried and has abandonment issues. His mother also states that she notices him getting jealous of his younger brother for getting more attention than him, so he throws tantrums at school. His mother also reports that he has a poor appetite and has lost 3 lbs. in the past week. The patient has also been complaining of stomachache and headaches almost every day. The mother reports that the patient's father passed when he was deployed but never told his son the truth and just told him his father left.

Substance Current Use: Denies

Medical History:

Current Medications: DDVAP
Allergies: NKDA
Reproductive Hx: Heterosexual

ROS:

GENERAL: Loss of 3 lbs. in the past week. No fevers, no chills, no weakness, no fatigue.
HEENT: Denies any visual changes. Denies any runny nose. Denies any sore throat or coughing.
SKIN: Denies any rashes or itching.
CARDIOVASCULAR: Denies any chest pain. Denies any heart palpitations. Denies any edema.
RESPIRATORY: Denies any shortness of breath or cough.
GASTROINTESTINAL: Reports abdominal pain.
GENITOURINARY: Reports nocturnal enuresis.
NEUROLOGICAL: Reports headaches almost every day.
MUSCULOSKELETAL: Denies any muscle or joint pain.
HEMATOLOGIC: Denies any bruising or bleeding.
LYMPHATICS: Denies any enlarged lymph nodes
ENDOCRINOLOGIC: Denies heat or cold intolerance.

Objective:

Diagnostic results: Besides a thorough physical examination, urinalysis, urine culture, and bladder scan should be done to eliminate any etiological causes of the patient wetting the bed (von Gontard & Kuwertz-Bröking, 2019).......... Continue