Week 7: Focused SOAP Note and Patient Case Presentation College of Nursing-PMHNP, Walden University PRAC 6665: PMHNP Care Across the Lifespan I Practicum Dr. Johnson April 18, 2022 Subjective: CC (chief complaint): “They’ve been following me”. HPI: The client is a 59-year-old female who presenting for an initial psychiatric evaluation. Client’s daughter was intermittently present for interview (ROI in file). Per chart review/records, client was admitted to mental health hospital for suicide attempt; walking into traffic. Client was discharged with a diagnosis of major depressive disorder, anxiety, insomnia, and post-traumatic stress disorder (PTSD). Today, client presents appropriately dressed, speech clear. However, client presents with child-like affect and is seemingly a poor historian. Client began experiencing auditory hallucination during session, placed both hands over her ears, became tearful and yelled, “ please stop, please stop.” Client’s daughter had to be summoned to the room to provide comfort. Client answered assessment questions but at times, became tearful and at other times could not provide meaningful answers to inquiries. Client could not discuss family history in detail, nor could she provide PMH diagnoses, dates of diagnoses, treatments and could not tell writer if she graduated from high school. Client further endorses delusional beliefs that she was being followed by unknown people. Client says these people steal her clothes and “ switch up,” making it difficult to identify the people that are following her. Client is unable to describe who is following her and why they are following her. Client believes they have been following her “ for a long time,” but could not relay specifics. Client says she figured if she died the people would stop following her and taking her clothes. This resulted in client trying to kill herself by walking into traffic which led to hospitalization at the end of March 2022. Client endorses visual and auditory hallucinations consisting of people calling her names. States it is multiple voices. Denies command hallucinations. Client says she can predict when some things happen. Onset: childhood. Client describes paranoid thoughts surrounding these hallucinations. Endorses past suicide attempts, three attempts total. The first attempt was at the age of 10 when she overdosed on pills and her last was recently trying to walk into traffic. She says the attempts were impulsive. Endorses history of self-harm. Reports history of head injury via abuse by past significant other. Endorses history of homicidal ideation only towards abusive husband, otherwise denies HI. Denies SI/HI at present. Client further endorses anxiety with panic and chronic bouts of depression with mood swings and mania. Social History: Born/Raised (B)North Carolina (R) Phoenix, AZ, Education: Does not recall, Occupation: Homemaker, Endorses three children and siblings. Legal: Endorses, resolved. Tobacco: Denies, Military: Denies, housing stable. Substance Use History: Client denies tobacco use. Endorses history of illicit drug use of cocaine in early 20s but has since resolved.......... Continue