Create a Focused SOAP Note on this patient using the

History 

You are asked to see a 69-year-old woman who complains of feeling constantly tired and not enjoying anything including her grandchildren. She sleeps for 8 hours or more but still never feels rested. She finds herself getting increasingly irritable and snappy with her 37-year-old daughter who is now living with her following the breakdown of her marriage. The daughter has two children ages 10 and 12 for whom the patient is having to provide care because her daughter is unable to manage this. The patient is finding the demands of her daughter, grandchildren and husband more and more difficult to cope with. She often forgets what needs to be done. Further questioning reveals that her daughter has agoraphobia and depression. She has no previous history of mental health problems. She has hypertension which is well controlled.

 Mental state examination

The woman looks tired and much older than her 69 years. She is obese and her dress is rather erratic. She has lots of layers of clothing and seems unaware that she has come in her slippers. She looks tired. Her speech is slow, flat and monosyllabic. She states she feels okay but she looks and sounds low. She does not have any active suicidal ideation but does question whether life is worth living. She feels hopeless about the circumstances she finds herself in. She has no hallucinations or formal thought disorder.

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Week (enter week #): (Enter assignment title)

Student Name

College of Nursing-PMHNP, Walden University

PRAC 6665: PMHNP Care Across the Lifespan I

Faculty Name

Assignment Due Date

Subjective:

CC (chief complaint):

HPI:

Substance Current Use:

Medical History:

· Current Medications:

· Allergies:

· Reproductive Hx:

ROS:

· GENERAL:

· HEENT:

· SKIN:

· CARDIOVASCULAR:

· RESPIRATORY:

· GASTROINTESTINAL:

· GENITOURINARY:

· NEUROLOGICAL:

· MUSCULOSKELETAL:

· HEMATOLOGIC:

· LYMPHATICS:

· ENDOCRINOLOGIC:

Objective:

Diagnostic results:

Assessment:

Mental Status Examination:

Diagnostic Impression:

Reflections:

Case Formulation and Treatment Plan: 

PRECEPTOR VERFICIATION:

I confirm the patient used for this assignment is a patient that was seen and managed by the student at their Meditrek approved clinical site during this quarter course of learning.

Preceptor signature: ________________________________________________________

Date: ________________________

References

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