Focused Soap note and Patient Case Presentation Student Name Walden University N6665-Psychiatric Mental Health Nurse Practitioner Care Across the lifespan I Practicum

Focused Soap note and Patient Case Presentation Student Name Walden University N6665-Psychiatric Mental Health Nurse Practitioner Care Across the lifespan I Practicum

Subjective CC: Patient said he has been feeling suicidal with plan to take rat poison. Patient said “I do not need medication; I only need therapy” HPI: Patient is a 22-year-old Caucasian male voluntarily admit to the hospital for suicidal ideation with plan. Patient has been feeling suicidal for the past 3 weeks and depressed for the past 3-4 months. Patient has history of previous psychiatric hospital but was not taking any medication. Patient states “I took Prozac before, but I got more depressed and suicidal. Since then, I refused to take any medication”. Patient endorses mood swings, constant racing thoughts, negative thoughts. Patient feels worthless and hopeless. Patient has history of being sexually, physically, and emotionally abused by biological father. Recently, patient was molested by best friend. Patient’s triggers are work, family and “other things”. Patient has a job and lives with family Substance Current Use: Patient denies used of alcohol and illegal drugs. Medical History: Obese Current Medications: None Allergies: No known allergy Reproductive Hx: Male, no children ROS General: Patient has gained 15lbs in the past 3 months Head: normocephalic, denies any history of trauma, headaches EENT: Denies eyes, ear and nose pain. Denies gum bleeding and sore throat. Cardiovascular: denies irregular heartbeat, chest pain Respiratory: Denies cough, shortness of breath Gastrointestinal: denies heartburn, nausea, denies constipation and abdominal pain, last bowel movement was yesterday, Genitourinary: denies painful urination. Patient is not sexually active Neurological: Patient denies dizziness, unsteady feet, seizure, tics. Musculoskeletal: patient denies joint paint. Hematologic: no abnormal bleeding and bruising noted