Week 7: Focused Soap Note And Patient Case Presentation

Week 7: Assignment 2: Focused SOAP Note and Patient Case PresentationNameCollege of Nursing-PMHNP, Walden UniversityPRAC-6665F: Psychiatric Mental Health Nurse Practitioner Care Across the Lifespan I PracticumDr. DateAssignment 2: Focused SOAP Note and Patient Case PresentationClient Information: 12 yr old female with mom Chief Complaint: “I’m doing okay”-patient “She is doing better”- motherHistory of Illness: Dyslexia, Obsessive Compulsive Disorder, Attention Deficit Hyperactive Disorder, Intermittent Explosive Disorder and General Anxiety Disorder.Past Psychiatric: Obsessive Compulsive Disorder and General Anxiety Disorder.Current Medications: Fanapt decreased to 5mg from 6mg po at HS, Fluoxetine HCL 10mg 1 po in the morning. Lamictal 100mg in the morning 1 tablet pm, Lamictal 25 gm 2 tablets at HS. If the Fanapt can be weaned down. The patient will start Geodon. Past Medications: ZoloftPast Family Psychiatric/Medical History: ADHD runs into the family.Psychosocial History: Born and Raised: MotherMarital status & children: N/AStreet/Illicit drug use: Denies any street drug use.Smoking: DeniesAlcohol use: DeniesLegal or Pending Charge: DeniesH/O Abuse: NoJob: N/AEducation: Special education due to DyslexiaSocial Security benefits: YesFamily support / other supports in the community: YesLiving status: With familyMilitary H/O: N/ASubstance Abuse: noneMedical: