Write an Expanded SOAP Note on this patient. Guidelines and sample of an Expande

Write an Expanded SOAP Note on this patient. Guidelines and sample of an Expanded SOAP Note are attached
William is a 15-year-old Caucasian male, single, who presented to clinic along with his
mother to establish care and reports historical diagnoses of Major Depressive Disorder
and Generalized Anxiety Disorder and PTSD. His mother thinks he might have ADHD or
a mild form of autism spectrum disorder. He is currently symptomatic and reports feeling
down and depressed, anxious, feeling abandoned and guilty nearly every day as well as
problem with his focus and concentration, his energy level and his thought processes
nearly every day.
He denies any active legal issues or any previous engagement with law enforcement.
Reports a history of asthma and of Eustachian tubes and experiences when he eats
shrimp or spicy foods. He recently had surgery on his right hand. He denies a history of
seizures but reports “three to four concussions” in which he lost consciousness or any
other medical conditions.
William is the only child of his parents who separated when he was only 2 years old. His
father has three other children younger than he is. He denies any knowledge of his
father’s mental or medical history but states that his father “drinks a lot.” His mother has
mood and anxiety disorders and uses cannabis. William reports a history of physical
and emotional abuse mostly by his father and he currently has an estranged
relationship with his father and sates he does not feel safe around his dad. He reports
corporal punishment from his father, threatening behaviors and states his father pulled a
gun at his head when he was only 10 years old. He currently avoids his dad and his
“side of the family” because they remind him of how poorly he was treated by his father.
He currently experiences recurrent nightmares and “almost daily” flashbacks about
“watching my brother pass away.” His mother had a second child who died of SIDS at
age 32 days.
William denies any history of hospitalizations for psychiatric reasons. Denies any history
of suicide attempts but admitted coming “close to it” earlier this year. Denies any other
self-injurious behaviors. He denies a history of significant use of illicit substances or any
past treatment for alcohol or chemical dependency. He currently denies use if illicit
substances, drinking alcohol, smoking tobacco, or vaping nicotine. He also denies any
thought, intent or plans to harm himself or others.