Comprehensive Clinical Soap Note Nursing Paper Example

Comprehensive Clinical Soap Note Nursing Paper Example

Client ID: Initials: CH, AGE: 17, Demographic: African-American, Gender: F

(Comprehensive Clinical Soap Note Nursing Paper Example)


Chief complaint: CH’s chief complaint is, “I am constantly worried about my safety, and I experience bad dreams and nightmares about being abducted. Sometimes, I feel worthless and scared of becoming ill or dying.”

Source of reliability: Self-referred and reliable.(Comprehensive Clinical Soap Note Nursing Paper Example)

Present Illness: CH checks in for anxiety treatment. CH grew up with an abusive father, whom she describes as a “pathological drinker.” Her father consistently beat her and her mother when drunk, throwing them out of the house on several occasions despite her mother being sick. Sadly, her mother passed on while she was 6, and since then, she has been having worrying thoughts of becoming ill and dying. Although her father changed his behavior following prolonged therapy, she is still afraid of men. Every night, she locks her bedroom door with two padlocks and reinforces the door with a couch if any “man” wants to come in at night. Whether inside or outside the house, in school, or partying with friends, she is compelled to check whether there is any male adult around for her to feel safe. Five months ago, her friend’s brother physically and sexually abused her.(Comprehensive Clinical Soap Note Nursing Paper Example) Although she reported the matter to the police, the victim is still at large due to insufficient evidence.  Since then, she worries about something terrible happening to her, persistent thoughts of being abducted and physically abused, making her anxious and distressed. Every night, she gets out of bed at least three times to check if the door is appropriately locked despite using two padlocks and reinforcing using a couch even when in a friend or relative’s home. Following the sexual and physical abuse, she feels worthless and finds solace listening to music in her bedroom most of the time. She has an intense hatred towards men and fears having conversations with them. She has persistent dreams and sometimes nightmares from the event, making her sad and hungry most of the time.(Comprehensive Clinical Soap Note Nursing Paper Example)

Current psych meds:  Alprazolam 6mg PO QID for anxiety.

Past psychiatric history: None reported.

Past Medical Hx: None reported.

Allergies: NKFDA.

Substance use/abuse: Reports smoking and alcohol use to feel okay.

Past family, social history:

Family psych hx: Father diagnosed with alcohol use disorder.

Education/Employment/Disability: First-year undergraduate student of Information technology. Never worked. No disability.(Comprehensive Clinical Soap Note Nursing Paper Example)

Primary support system: Father.

Hobbies: Basketball.

Review of systems:

Constitutional: No weight loss, fever, or chills.

Eyes: Wear glasses for reading.(Comprehensive Clinical Soap Note Nursing Paper Example)

ENT: Reports no change in hearing and sense of smell. No sore throat.

Cardiac: No chest pains or discomfort.

Respiratory: Denies dyspnea. Reports no cough.

GI: No abdominal pain.

Skin: Normal skin turgor and moisture.

Neurologic: Reports blackout when drunk.

Endocrine: Reports no polydipsia or polyuria.

Musculoskeletal: Reports no joint pain or swelling.


Vitals: BP: 119/71 P: 71 Ht: 5”5” Wt: 135 BMI: 22.5 kg/m2

Appearance: Well-groomed. Eye contact avoidant.

Attitude/interaction: Interactive.

Activity level/behavior: Warm with comments and behavior.

Orientation: Alert and oriented × 4.

Speech: In-depth grammar and comprehension.

Thought content/process/perception: Past-oriented and somber. Negative perceptions about self were noted.

Mood/affect: Mood is normal.(Comprehensive Clinical Soap Note Nursing Paper Example)

Judgment/insight/cognitive/memory: Good judgement and insight. Normal ability to abstract.

Attention: Attentive.


UDS: positive for benzodiazepine.

Alcohol: Positive


  1. Obsessive-compulsive disorder (OCD). ICD-10 code F42. CH presents symptoms that meet OCD diagnostic criteria, including persistent thoughts most times a day attributed to childhood trauma (American Psychiatric Association, 2013). This is the primary diagnosis.(Comprehensive Clinical Soap Note Nursing Paper Example)
  2. Posttraumatic stress disorder (PSTD). ICD-10 code F43.10. CH presents symptoms associated with PSTD diagnosis, including exposure to sexual violence, recurrence of distressing memories, and avoidance of stimuli associated with the traumatic events (American Psychiatric Association, 2013). This diagnosis is refuted.
  3. Acute stress disorder (ASD). ICD-10 code F43.0. CH presents symptoms of ASD, including exposure to sexual violence, recurrent distressing memories, and negative mood that impairs social functioning (American Psychiatric Association, 2013). This diagnosis is refuted.(Comprehensive Clinical Soap Note Nursing Paper Example)
  4. Major depressive disorder (MDD). CH presents symptoms associated with moderate MDD, such as depressed mood, insomnia, and feelings of worthlessness (American Psychiatric Association, 2013). This diagnosis is refuted.
  5. Selective mutism (SM). ICD-10 code F94.0. CH presents symptoms associated with SM, such as consistent failure to speak in specific social situations, and the disturbance interferes with academic and social functioning (American Psychiatric Association, 2013). This diagnosis is refuted.(Comprehensive Clinical Soap Note Nursing Paper Example)

(Comprehensive Clinical Soap Note Nursing Paper Example)


Discontinue Alprazolam 6mg PO QID for anxiety due to addictions. Start 20 mg PO QID for anxiety. May gradually increase 20 mg/day after four weeks, depending on response. Fluoxetine is effective and well-tolerated in treating social anxiety among children and adolescents between 7 and 17 years (Amray et al., 2019). According to Boaden et al. (2020), Fluoxetine effectively treats OCD symptoms.  Start Zolpidem 5 mg PRN for insomnia. Zolpidem is a short-term treatment of insomnia, helping patients to get sleep and stay asleep (Bouchette, Akhondi & Quick, 2021). Watch out for misuse and side effects, including changes in behavior, withdrawal, dependency, and next-day impairment (Moore & Mattison, 2018).(Comprehensive Clinical Soap Note Nursing Paper Example)

Referral: Psychiatric therapist for Cognitive Behavioral Therapy (CBT). CBT helps treat OCD, teaching the client how to change thought patterns, react to and behave towards situations to help her manage the intrusive and compulsive thoughts, anxiety, and compulsive behavior.(Comprehensive Clinical Soap Note Nursing Paper Example)

Next Visit: After four weeks



Akhondi, H., & Quick, J. (2021). Zolpidem. StatPearls [Internet].

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). American Psychiatric Publishing, Inc.

Amray, A. N., Munir, K., Jahan, N., Motiwala, F. B., & Naveed, S. (2019). Psychopharmacology of pediatric anxiety disorders: a narrative review. Cureus11(8).

Boaden, K., Tomlinson, A., Cortese, S., & Cipriani, A. (2020). Antidepressants in children and adolescents: meta-review of efficacy, tolerability, and suicidality in acute treatment. Frontiers in psychiatry11, 717.

Moore, T. J., & Mattison, D. R. (2018). Assessment of patterns of potentially unsafe use of zolpidem. JAMA internal medicine178(9), 1275-1277. 10.1001/jamainternmed.2018.3031

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All the Best, 

Cathy, CS