Posted: September 4th, 2023

The patient is a 28-year-old male

NRNP PRAC 6665
Assignment
Select a patient of any age (either a child or an adult) that you examined during the last 3 weeks.
Create a Focused SOAP Note on this patient using the template provided in the Learning Resources. There is also a completed Focused SOAP Note Exemplar provided to serve as a guide to assignment expectations.

Patient
Patient is a 28-year-old male who walked into therapy due to substance abuse disorder. It is using alcohol and Heroin. Patient has history of depression. Pt was cooperative with staff. Patient states it stayed sober for one year and now he relapsed again by heroin/alcohol. He feels so lonely after his girlfriend cheated on him with his best friend. Patient was educated of how to cope with depression. At this visit, Cognitive Behavioral Therapy (CBT) techniques were used. Patient will see therapist every week for group cognitive behavioral therapy for 3 months.

Subjective:
The patient is a 28-year-old male who came into therapy seeking help for substance abuse disorder. He reported using both alcohol and heroin. The patient has a history of depression and reported feeling lonely after his girlfriend cheated on him with his best friend. The patient stated that he had previously been sober for one year but has now relapsed. He was cooperative with staff and was educated on how to cope with depression.

Objective:
The patient appeared to be in good physical health with no acute distress noted. Vital signs were within normal limits. The patient was alert and oriented to person, place, and time. The patient reported feeling sad and hopeless about his situation. During the session, cognitive-behavioral therapy (CBT) techniques were utilized. The patient has been scheduled to attend group CBT therapy once a week for three months.

Assessment:
The patient is a 28-year-old male with a history of depression and substance abuse disorder, who has relapsed after being sober for one year. The patient reported feelings of loneliness and hopelessness due to his recent break-up with his girlfriend. The patient was cooperative and willing to participate in therapy.

Plan:
The patient will attend group cognitive-behavioral therapy sessions once a week for three months. The therapist will work with the patient to develop coping strategies to deal with his depression and substance abuse disorder. The patient will be monitored for any signs of withdrawal or relapse. The therapist will also work with the patient to address the underlying issues that may have contributed to his substance abuse disorder. The patient will be encouraged to continue with his therapy and to seek support from friends and family. A follow-up appointment will be scheduled in one month.

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