S.O.A.P Note for PTSD.edited (4) (1).docx - Running Head...

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Running Head: S.O.A.P NOTE FOR PTSD S.O.A.P Note for PTSD Student’s Name: Institution Affiliation: Date:
S.O.A.P NOTE FOR PTSD 2 Date and time: Feb 26 th , 2020 at 1630hrs Age: 16 CC: Patient says, "I have an ongoing problem of concentrating at school. I feel stressed, overwhelmed, and can barely sleep at night." Subjective COLDSPA : The patient is having signs of severe anxiety, loss of interest, social isolation. He complains of having nightmares. The symptoms started four weeks ago, five days after a senior schoolmate had sexually molested him. He says that he was abused in the school's hostels but never reported the case to the authorities. He has experienced severe symptoms for a week now. Pt has resulted in alcohol abuse, which "helps a little bit," but the symptoms become much worse when he gets sober. Course : Pt. says, "It all started with a mild feeling of anxiety and being disinterested in the stuff I love." Now, it has transposed to extreme physical reactions like sweating and increased heartbeat when he recalls the event. "It is uncontrollable." Stressors : Memories of the event. Staff observations : Pt is responsive to questions. No suicidal ideation/attempts Collateral information : No history of mental health disorders in the immediate family.

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