Psychiatric notes are a way to reflect on your practicum experiences and connect the experiences to the learning you gain from your weekly Learning Resources. Focused SOAP notes, such as the ones requ

Week 7: Focused SOAP Note

Shannon Pierce

College of Nursing-PMHNP, Walden University

PRAC 6665: PMHNP Care Across the Lifespan I

Dr. Judith Gichia-Waldrop

April 13, 2024

Subjective:

CC (chief complaint): alcohol detox. "Went to a friend house to social drink I was in a car accident (hit and run) then was charged with a DUI"

HPI:
The patient, a 23-year-old male engineer in the Navy from South Carolina, voluntarily presented for detoxification due to a history of alcohol use. He reports a pattern of consuming two to three beers daily, with increased intake during weekends in a social context, which he describes as casual drinking. The last alcohol consumption was about two days before the visit. Patient was in a MVA while under the influence. The patient denies experiencing any withdrawal symptoms, such as shakiness, and has been advised that detoxification is necessary before transitioning to an alcohol rehabilitation facility, as mandated by the Navy.

Substance Current Use: He reports consuming 2-3 beers daily, with increased intake during weekends spent with friends. Vape daily.

Medical History: Denies

• Current Medications: patient admitted with no home medications prescribed.

• Allergies: No Known Drug Allergies

• Reproductive Hx: N/A

ROS:

• GENERAL: no weight loss, fevers, or chills. Complaints of mild fatigue

• HEENT: eyes: no visual changes, PEARL wears readers. Ears, Nose, Throat: no hearing loss, sneezing, runny nose, or sore throat.

• SKIN: no rashes or open wounds. Dry skin with scars and tattoos

• CARDIOVASCULAR: no edema. No chest pain, pressure, or palpitations

• RESPIRATORY: No shortness of breath, cough, or difficulty breathing

• GASTROINTESTINAL: No nausea, vomiting, diarrhea. No abdominal pain

• GENITOURINARY: No burning on urination, urgency, or hesitancy. No odd color.

• NEUROLOGICAL: No headache, dizziness, ataxia. No reports of seizures, no tremors.

• MUSCULOSKELETAL: No muscle pain, joint pain, or stiffness

• HEMATOLOGIC: No abnormal bruising or bleeding

• LYMPHATICS: No enlarged nodes

• ENDOCRINOLOGIC: No reports of sweat or cold intolerance.

Objective:

Diagnostic results:

Assessment:

Mental Status Examination:23-year-old- black make who appears younger than his stated age. Behavior: Appropriate and Participating in Treatment. Thought Process: Normal. Perception: Hallucinations Denies. Orientation: Alert - Oriented to Time, Person, and Place. Attention Span Intact. Recent Memory Not Impaired. Abstract Reasoning Not Impaired. Vocabulary: normal. Thought content: Normal. Lethality: Denies suicidal or self-harm thoughts or plan and denies homicidal or aggressive ideation or plan Judgement: Impaired. Mood: Good Affect. Motor Activity: Normal Motor Activity. Speech: Normal General Appearance / Eye Contact: Neat Eye Contact: Normal

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