nrnp 6665 26 pmhnp care across the lifespan i week seven focused soap note and patient case presentation 2022
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Running head: WEEK SEVEN FOCUSED SOAP NOTE. 1
Week Seven: Focused SOAP Note and Patient Case Presentation
Justina Awazi
College of Nursing-PMHNP, Walden University
NRNP 6665- 26 PMHNP Care Across the Lifespan I
Anna Lee Waldner
April 16, 2022
, WEEK SEVEN FOCUSED SOAP NOTE 2
Subjective:
Chief Complain: “My anxiety and depression are obstructing my interpersonal relationships and
education, I cannot keep on going like this. Sometimes I am manic and sometimes very
depressed.”
History of present illness: The patient is a 25 years old Caucasian male who presents in the clinic
asking for help with his manic and depressive symptoms that are obstructive to his education and
interpersonal relationship. The patient states, "I just need help because I have been trying to help
myself with marijuana and alcohol, but it's not working." The patient reports that he has been
struggling from one thing to another. He states it all started when his parents separated when he
was 12 years old; even though they came back together, the damage was done. He reports a
feeling of being abandoned by his dad, who left the house. He states that he noticed he was
hyper, talkative, had a hard time concentrating or sitting still when he was younger, and thinks
that it has carried on in his adult life. He reports being depressed starting at age 13. Report
symptoms of hopelessness, low motivation, not wanting to get out of bed, irritability at little
maters, sleeping 12 hours in 24 hours, waking up tired, and drinking alcohol to address his
depression. He reported that at age 16, he was placed in the juvenile hall where other kids
sexually abused him in there. At 17 years old, he was out of juvenile hall but engaged in using
methamphetamine and having multiple sex partners. He explained that his reason for having
multiple sex partners is to prevent one from breaking his heart. He states that he gets ashamed
and embarrassed when abandoned, and he will go into depression spirals.
He reports that his first manic episode occurred at the age of 19. He reports, "I felt I was
on top of the world, felt up". During this period, "I will have lots of energy, will go for five days
with two hours of sleep and sometimes with no sleep. He reported spending a lot of money on
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