NRNP/PRAC 6665 & 6675 Comprehensive Focused SOAP Psychiatric Evaluation Template

NRNP/PRAC 6665 & 6675 Comprehensive Focused SOAP Psychiatric Evaluation Template

College of Nursing-PMHNP, Walden University

NRNP 6675 PRAC: Care Across the Life Span II



At the end of this presentation, this class will be able to:

1. Distinguish anxiety disorders and their common symptoms, specifically panic disorder and generalized anxiety disorder

2. Identify screening instruments for anxiety and depression

3. Demonstrate understanding of the pharmacologic and nonpharmacologic treatments for panic and anxiety disorders


CC: “I am having panic attacks and can’t sleep; I’m just not right and I need help.”

HPI: S.A. is a 54-year-old white male who presents for initial psychiatric evaluation with complaint of panic attacks, anxiety and insomnia for the past two years. He reports one episode of psychosis two years ago while undergoing divorce. He was off his prescription opiods then. He married his wife for 26 years but got divorced in 2021. He was unexpectedly served with a divorce paper after returning from searching for a job in Los Angeles. He feels it’s difficult to get back to work. . He reports low self-esteem and self-doubts. He feels broken, hopeless, and helpless. He is positive for dysphoria and anhedonia. He reported recurrent panic attacks that occur 3-4 times daily, followed by shortness of breath, shaking, flushing, and fear of death. He previously visited the emergency department few times for help. He reports increased appetite, eating excessively, and insomnia. He worries a lot about work and finances, which worsens his insomnia. He reports feeling anxious, poor concentration, his mind going blank, and feeling restless and on the edge. His rates his anxiety level 7-9/10. He denies any suicidal or homicidal ideations stating “ I’m a spiritual person, I don’t believe in that.” After the divorce in 2021, he reports feeling the devil’s presence in the house, which continued for three months. He did not seek for help. He reports increased alcohol consumption during that time. Also, then, he talked much, became impulsive, had nervous twitching, and made poor decisions.

Past Psychiatric History: No impatient psych. Reported psychotherapy treatment due to his back injury, no longer attending.

Medication Trials: No psychotropic medication, reported he was prescribed opiods for back injury he sustained at work.

Substance Current Use and History: He reports increased alcohol consumption while undergoing divorce and after, but received no treatment. He usually drinks 2-3 drinks, three times a week. He is a non-smoker. He deniesr illicit substance use.

Psychosocial History: Patient is divorced white, heterosexual male who was born and raised in NY. He moved to San Diego at 8 y/o, parents were married, mom died in 2000, father in 2016, he has an older brother and a youger sister. He currently lives alone and is unemployed. He holds a graduate degree. He previously worked as an electrician. He denies any history of abuse. He denies current legal issues. He is obese, exercises 1-2 times per week. He consumes 1-2 caffeinated drinks a week.

Family Psychiatric/Substance Use History: Both his parents are deceased and no known psychiatric history reported. Reports sister has a hx of hallucination, brother with no known psychiatric history.

PMH: Ankylosing Spondylitis, chronic back pain, hip surgery

Current Medications: None reported

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