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Running Head: S.O.A.P NOTE FOR PTSDS.O.A.P Note for PTSDStudent’s Name:Institution Affiliation:Date:
S.O.A.P NOTE FOR PTSD2Date and time: Feb 26th, 2020 at 1630hrsAge: 16 CC: Patient says, "I have an ongoing problem of concentrating at school. I feel stressed, overwhelmed, and can barely sleep at night."SubjectiveCOLDSPA: 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 worsewhen 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/attemptsCollateral information: No history of mental health disorders in the immediate family.