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Original Question

Develop SOAP notes Substance Current Use: Medical History: Current Medications: Allergies: Reproductive Hx: Dr.Jenny: My name is Dr. Jenny. Can you tell me your name and how old you are? Dev Cordoba: My name is Dev, and I am 7 years old. Dr. Jenny: Wonderful. Can you tell me what month and date is? and where are we right now? Dev Cardoba: Today is St. Patrick’s Day. It’s March 17th Dr.Jenny: Do you know where we are? Dev: We’re at school. Dr. Jenny: Good. Did your mom tell you why you are here today to see me? Dev: She said you are going to help me better. Dr. Jenny: Yes, I am here to help you. Have you ever come to see someone like me before or talked to someone like me before to help you with your mood? Dev: No, never. Dr. Jenny: I would like to start by getting to know you a little better. If thats ok? What do you like to do for fun when you’re at home? Dev: I have a dog. His name is Sparky. We play policeman in my room. And I have Lego’s and I could build something if you want. Dr Jenny: I would love to see what you build with your Legos. May be you can bring that in for me at your next appointment. Who else lives in your home? Dev: My mom, my baby brother and Sparky Jenny:Do you help your mom with your brother? Dev: no, His breath smells like bad milk all the time. And he cries all the time and my mom spends more time with him. Jenny: So how do you feel most of the time? Do you feel sad or mad or worried or happy? Dev: worried Dr. jenny: What types of things do you worry about? Dev: I don’t know just everything. Dr. Jenny: Ok. So mom tells me you also have a lot of bad dreams. Can you say a little more about your bad dreams, like maybe what they are about. How many nights do you have them? Dev: I dream a lot that I’m lost, that I cant find my mom or my little brother. They seem like they happen almost every night, but maybe not some nights. Jenny: Now that must feel horrible. Have you ever been lost before when maybe you weren’t asleep? Dev: Oh No. And i don’t like the dark. My mom put me in a night light with the door open so I know she is really there. Jenny: That seems like that would probably help. Do you like to go to school or would you rather not go? Dev: I worry about my mom and brother when I’m at school. (Yawn) All I can think about is what they’re doing and if they are ok. And besides, nobody likes me there. They call me Mr.Smelly. Jenny: Well that’s not nice at all Jenny: Why do you feel they call you names? Dev: I don’t know. But my mom says I won’t take my baths like (Sigh) she tells me to and it….and I have night accidents. Jenny: How does that make you feel? Dev: Sad and really bad. They don’t know how it feels for their daddy to never come home. What if my mom never comes home too? Jenny: Yes you seem gto worry about that a lot. Does this worry stop you from being able to learn in school? Dev: Well (sighs)my teacher is all the time telling me to sit down and focus and I get in trouble for looking outside the window. And she moved my chair beside her desk, but I don’t mind because leaves me alone now. Jenny: Have you ever hit billy or someone else? Dev: But I did throw my book at him. Jenny: hmm Dev: (Chuckles) Jenny: What about yourself? Have you ever hit yourself or thought about doing something to hurt yourself? Dev: No Dev: Well, now I would like to talk to your mom now. We’re going to work together, and we’re going to help you feel happier and less worried and be able to enjoy school more. Is that ok? Dev: Yes. Thank you. Jenny: Hi Thank you, Miss. Cardoba for bringing in Dev. I feel we can help him. So tell me what are your main concerns for Dev? Miss Cardoba: He just seems so anxious and worried all the time. Silly things like I’m going to die or i won’t pick him up from school. He says I love his brother more than him. He’ll throw things around the house and get trouble in school for throwing things. He has a difficult time going to sleep. He wants his light on, doors open and gets up frequently. And he’s all the time wanting to come home from school, claims stomach aches and headaches almost daily. He won’t eat. He’s lost 3 pounds in the past 3 weeks. Our pediatrician sent us to you because he doesn’t believe anything is physically wrong. Oh!I almost forgot he still wets bed at night. Sighs we tried everything. His pediatrician did give him DDVAP but it does’t seem to help Jenny: Ok. Can you tell me if any blood relatives have any mental health or substance abuse issues? Cardoba: Not really. Jenny: What about his father, he said that he never came home. Cardoba: Oh yes. His father was deployed with the military when Dev was 5. I told Dev he was on vacation. I didn’t know what to tell him I thought he was too young to know about war and his father was killed, so Dev still doesn’t understand that his father didn’t just leave him. (Sighs) I just feel so guilty that it is all my fault. Jenny: Miss Cardoba, you did the right thing by bringing in Dev. We can help you with him. Cardoba: Oh, thank you

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