SOAP PP

SI/HI: The patient denied having a history of suicide attempts or thoughts.

Sleep:  The patient admitted that he has trouble falling asleep or staying asleep due to his anxiety.

Appetite: He denied any changes in appetite or changes in weight.

Allergies (Drug/Food/Latex/Environmental/Herbal): ___He denied having any known allergies to drugs, food, latex, environment, or herbal.

Current perception of Health: Excellent Good Fair Poor

Psychiatric History:

Inpatient hospitalizations:

Outpatient psychiatric treatment:

Detox/Inpatient substance treatment:

History of suicide attempts and/or self-injurious behaviors: The patient denied having a history of any suicide attempts or self-injurious behaviors.

Past Medical History

· Major/Chronic Illnesses__ The patient admitted to having asthma which was diagnosed at age 5. The patient admitted the disease is active.

· Trauma/Injury __The patient denied a history of trauma or injury.

· Hospitalizations _The patient denied any history of hospitalizations.

· Past Surgical History___ The patient denied any surgical procedures performed on him._

Current psychotropic medications:  

____________None_____________________________ ________________________________

Current prescription medications:  

_________Inhaled fluticasone 100 mcg inhaler for asthma control_____________________________

_________________________________________

OTC/Nutritionals/Herbal/Complementary therapy:

_____________None____________________________ ________________________________

Substance use : (alcohol, marijuana, cocaine, caffeine, cigarettes)

Family Psychiatric History:

· The patient admitted that his mother who is currently 45 years old has a history of major depressive disorder which she manages with medication and occasional cognitive behavioral therapy.

· The patient admitted that his late father who died when he was 40 years old from suicide had a history of bipolar 1 disorder and major depressive disorder. The patient admitted that his father’s disorders were poorly managed.

· The patient admitted that his brother who is 34 years old was diagnosed with autism spectrum disorder when he was 2 years old. The patient admitted that his brother has been managing his condition with occasional psychotherapy.

· The patient admitted that his paternal grandfather who died when he was 76 years old was diagnosed with schizophrenia which he had managed well with medication and psychotherapy over the years.

Social History

Lives: Single-family House/Condo/ with stairs: _______2-bedroom apartment____ Marital Status: _____ Single___

Education: ___ Bachelor of Education__

Employment Status: __Employed part-time ____ Current/Previous occupation type: _____Part-time psychology teacher ____

Exposure to: ___Smoke__Denies__ ETOH _Admits to taking 3-4 bottles of beer on the weekends___ Recreational Drug Use: ________Denies__________

Sexual Orientation: _____Heterosexual__ Sexual Activity: __Active__ Contraception Use: ________Condom____

Family Composition: Family/Mother/Father/Alone : ____The patient’s mother, and older brother are alive. The patient leaves alone in a 2- bedroom apartment _____

Other: (Place of birth, childhood hx, legal, living situations, hobbies, abuse hx, trauma, violence, social network, marital hx): __The patient admitted to being born in Miami, Florida as the second born of two children. He admitted that his childhood was stable and he was a carefree and happy child. He denied being in any legal situation and admits to living alone in a 2- bedroom apartment. _ He admitted that he loves horse riding and playing basketball. He denied a history of abuse, trauma, or violence. He admitted that he has a lot of friends as he makes friends easily. He denied being married or ever being married.

Health Maintenance

Screening Tests (submit with SOAP note): Depression, Anxiety, ADHD, Autism, Psychosis, Dementia

· The patient denied having been screened for depression, anxiety, ADHD, autism, or psychosis. He admitted to having an annual checkup with the last results negative for any abnormality.

· He admitted that he receives a dental checkup every 6 months with the results being negative for any mouth/teeth diseases. He received education on proper teeth hygiene and flossing.

· He denied having an annual eye examination as required and does not recall the date of the last visit.

· He admitted to always wearing a seatbelt when he is in the car.

Exposures: He is exposed to ethanol from alcohol consumption

Immunization HX: The patient admitted that he is up to date with all his immunizations including the flu vaccine which he received on 10/05/2023.

Review of Systems (at least 3 areas per system):

General: The patient admitted to constant feelings of worry, lack of concentration and trouble falling or staying asleep. He denies fever, headaches, chills, or night sweats.

HEENT: The patient denied experiencing any headaches, head fractures, or hair loss. The patient denied having a history of eye injury, conjunctivitis, or abnormal eye discharge. The patient denied having a history of trauma to the ears, ear infections, or issues with hearing. The patient denied having any nose injury, current sneezing, allergies, or nasal congestion. The patient denied having a history of bad breath, oral snores, or history of gingivitis. The patient denied having issues with swallowing, swollen tonsils, or sore throat.

Neck: The patient denied having any neck pain, neck restrictions, or any history of swelling

Lungs: The patient denied any difficulties in breathing, shortness of breath, or recent respiratory illness.

Cardiovascular: The patient denied having any history of chest pain, chest injury, chest deformity, recent persistent coughing, or production of sputum.

Breast: The patient denied noticing any breast enlargement, breast deformity, nipple damage, or discharge.

GI: The patient denied having any recent stomach ache, diarrhea, constipation, nausea, or vomiting. He denied heartburn or bloating.

Male/female genital: The patient admitted that he has not had any history of penile discharge, sores on his penis, or itching.

GU: The patient denied having any frequent urination, a constant urge to urinate, urinary incontinence, or leakage.

Neuro: The patient denied having any history of seizures, tremors, or numbness. He admitted to occasional fainting but denied blackouts.

Musculoskeletal: The patient denied having a history of joint injury, joint pain, back pain, or muscle spasm.

Activity & Exercise: The patient admitted that he likes to keep fit and therefore goes to the gym every morning for 2 hours before going to school as he is a part-time student.

Psychosocial: The patient admitted to being constantly worried and having trouble concentrating, falling, or staying asleep.

Derm: The patient denied noticing any hyperpigmentation on his skin, and denies any scars, bruises, or blisters on his skin.

Nutrition: The patient admitted to being a vegetarian and therefore eats a diet of mostly vegetables and fruits.

Sleep/Rest: The patient admitted to having trouble sleeping, staying asleep, and waking up/ He denied having any trouble staying awake during the day.

LMP: Not applicable as the patient is male.

STI Hx: The patient denied having been diagnosed with STI. He denied a history of erectile dysfunction. He was admitted, however, to a history of urinary tract infection which was treated with antibiotics.

Physical Exam

BP___120/80 mmHg taken while patient was seated _____TPR_97.5F taken through the mouth____ HR: ___73__ RR: _20___Ht. ___5’9__ Wt. _70_____ BMI ( percentile) ___22.8 kg/m2  (60%, Healthy weight)

General: The patient is clean, wearing blue jeans and black t-shirt. His hair is well combed and he appears well-fed. He appears anxious and restless. He is able to maintain eye contact and respond appropriately.

HEENT: Head: No indications of injury, alopecia, or fractures, and no irregularities observed. Eye: Pupils are symmetrical, circular, and responsive to light. No redness or yellowing of the conjunctiva. No involuntary eye movements or unusual eye motions were detected. Ears: Both ear canals are open without wax or secretions. Eardrums are intact. No signs of ear infections were detected. No external abnormalities or sensitivity. Note: The nasal lining is rosy and moist. No bleeding or injury was noted. Throat: The oral cavity is clear. No swollen tonsils, discharge, or redness. The uvula is in the middle position.

Neck: No palpable swollen lymph nodes or enlargement in the neck. No signs of thyroid enlargement or sensitivity. The neck is flexible with a full range of motion.

Pulmonary: Clear breath sounds heard bilaterally. No wheezing, crackles, or abnormal lung sounds were noted. His breathing rate is regular and falls within the normal range at 20 breaths per minute.

Cardiovascular: Heart sounds are regular with no murmurs, irregular rhythms, or friction rubs. Radial and pedal pulses are equal and strong. No swelling in the extremities was observed.

Breast: No detectable masses or discharge from the nipples. No changes in the skin, indentations, or retractions. No sensitivity during the examination.

GI: Abdomen is soft and painless. Bowel sounds are present in all four quadrants. No enlarged organs or masses were noticed.

Male/female genital: Testicles are descended bilaterally without any masses or sensitivity. No hernias were observed, and no irregularities were noticed. External genitalia appear clean, normal, and without sores or discharge.

GU: No tenderness when palpating the area above the pubic bone. No abnormal masses or lesions. No sensitivity in the costovertebral angle.

Neuro: Neuro: Cranial nerves II-XII intact. No localized impairments were detected. Reflexes are symmetrical. No sensory abnormalities were detected. No shaking or involuntary movements.

Musculoskeletal: Full range of motion observed in all major joints. No joint swelling, deformities, or sensitivity. No muscle weakness or muscle wasting was observed.

Derm: Skin is intact without any rashes, sores, or bruising. No signs of infection or inflammation. No unusual pigmentation or swelling.

Psychosocial: The patient demonstrates a persistent state of unease and excessive worry. There is an evident presence of distress. The patient's emotional expression is characterized by heightened nervousness and restlessness. Positive report of constant difficulty in maintaining focus and concentration, often feeling overwhelmed by racing thoughts and an inability to relax. Motor function is observed to be hyperactive, with restlessness and fidgeting being prominent behaviors.

Misc. No additional data was collected.

Mental Status Exam

Appearance: The patient appears restless and exhibits signs of heightened nervousness. He displays fidgeting behaviors, such as tapping fingers and bouncing legs, indicating an underlying state of anxiety. However, he can maintain eye contact and does not demonstrate withdrawn behavior.

Behavior: The patient engages in frequent pacing and displays restless movements throughout the evaluation. He seems unable to sit still and often shifts positions in his seat. His body language suggests a state of hyperarousal and tension.

Speech: The patient's speech is rapid and pressured, reflecting his inner turmoil and anxiety. He spoke hastily, indicative of their racing thoughts.

Mood: The patient's mood is continuously anxious and apprehensive. He reports feeling on edge and describes a pervasive sense of worry. He expresses concerns about various aspects of his life and anticipates negative outcomes.

Affect: The patient's affect is predominantly tense and restless, reflecting his internal anxiety. He demonstrates the difficulty in modulating his emotions and often appears overwhelmed.

Thought Content: The patient's thought content revolves around worries, often related to everyday situations and potential threats. He expresses a preoccupation with potential negative outcomes.

Thought Process: The patient's thought process is characterized by excessive rumination and overthinking. He engages in catastrophic thinking, repeatedly focusing on worst-case scenarios.

Cognition/Intelligence: The patient demonstrates intact cognitive functioning and intellectual abilities. He engages in logical and coherent conversations, displays appropriate comprehension, and responds to questions with relevant information. There is no evidence of cognitive impairment or deficits.

Clinical Insight: The patient demonstrates awareness of his excessive worrying and admits that it interferes with his daily functioning. He recognizes that his anxiety is disproportionate to the actual threat level of the situations they encounter. This reflects a moderate level of clinical insight.

Clinical Judgment: The patient's clinical judgment appears compromised by his heightened anxiety. He tends to overestimate potential risks and struggles to make rational decisions due to his excessive worry.

Plan:

The GAD-7 is a self-report questionnaire that assesses the severity of Generalized Anxiety Disorder (GAD) symptoms and consists of seven items, each scored on a scale from 0 to 3, with a total possible score ranging from 0 to 21. The patient scored a total score of 20 suggestive of severe GAD symptoms. To help rule out other underlying conditions that might be causing the patient to experience these symptoms various additional tests were performed that included:

Complete Blood Count (CBC):

· Hemoglobin: 13.5 g/dL (normal range)

· White Blood Cell Count: 8,000 cells/mm³ (normal range)

· Platelet Count: 250,000/mm³ (normal range)

Thyroid Function Tests:

· Thyroid-Stimulating Hormone (TSH): 2.5 mIU/L (normal range)

· T4: 1.2 ng/dL (normal range)

Electrolyte Panel:

· Sodium: 140 mmol/L (normal range)

· Potassium: 4.0 mmol/L (normal range)

Liver Function Tests:

· Alanine Aminotransferase (ALT): 30 U/L (normal range)

· Aspartate Aminotransferase (AST): 25 U/L (normal range)

Differential Diagnoses

1. Major Depressive Disorder (MDD) with Anxiety Features: DSM-5 Code: 296.21 (F32.9)

Major Depressive Disorder can sometimes present with symptoms of anxiety, including excessive worry, restlessness, and irritability, which can overlap with GAD (Mullins et al., 2019). However, in MDD with anxiety features, the primary focus is on depressive symptoms such as persistent sadness, loss of interest, and changes in appetite or sleep patterns.

2. Panic Disorder: DSM-5 Code: 300.01 (F41.0)

A mental and behavioral disorder called panic disorder is characterized by recurrent, unprovoked panic attacks (Walter et al., 2020). Panic disorder focuses on recurrent panic attacks, which are sudden episodes of intense fear or discomfort accompanied by physical symptoms such as heart palpitations, shortness of breath, and dizziness.

Principal Diagnoses

1. Generalized Anxiety Disorder: DSM-5 Code 300.02 (F41.1)

Generalized Anxiety Disorder (GAD) is a mental health condition characterized by excessive and uncontrollable worry and anxiety about various aspects of life, including everyday situations and events (Kalin, 2020), The worry and anxiety experienced in GAD are persistent, lasting for at least six months, and are often disproportionate to the actual threat posed by the situation. It can significantly interfere with daily functioning, causing distress and impairment in various areas of life.

Plan:

The patient was prescribed Sertraline 50 mg, taken orally (tablet), once daily, preferably in the morning. The patient was educated to strictly follow the prescribed dosage and frequency as instructed and to void skipping or doubling doses without medical guidance. The price of 30 tablets of sertraline 50 mg is approximately $7.

Non-pharmacological

Cognitive behavioral therapy was recommended to the patient to help him identify and modify the dysfunctional thoughts, beliefs, and behaviors that contribute to his excessive worry and anxiety.

Diagnosis #1 Generalized anxiety disorder

Diagnostic Testing/Screening: GAD-7 screening tool with a score of 20 for severe GAD.

Pharmacological Treatment:

Medication : Sertraline

Dosage : 50 mg

Route : Oral (tablet)

Frequency : Once daily, preferably in the morning;

Estimated Price: The price of 30 tablets of sertraline 50 mg is approximately $7.

Non-Pharmacological Treatment: Cognitive Behavioral Therapy.

Patient/Family Education:

1. Pay attention to situations, thoughts, or events that tend to trigger your anxiety, and keep a journal to track and identify patterns.

2. Challenge negative thoughts and replace them with more balanced and realistic thoughts.

3. Learn and regularly practice relaxation techniques such as deep breathing, progressive muscle relaxation, or mindfulness meditation to help manage anxiety symptoms.

4. Designate a specific time each day to worry and focus on your anxious thoughts.

5. Prioritize self-care activities that promote physical and emotional well-being, such as regular exercise, maintaining a balanced diet, getting enough sleep, and engaging in activities you enjoy.

6. Because exercise has been shown to reduce anxiety symptoms, aim for at least 30 minutes of moderate-intensity exercise most days of the week.

Referrals: Psychotherapist

Follow-up: 2 weeks to check on improvement or progression of symptoms

Anticipatory Guidance:

1. Create a calming bedtime routine and ensure you get enough sleep each night.

2. Avoid caffeine and electronic devices close to bedtime.

3. Limit Alcohol as alcohol can exacerbate anxiety symptoms.

4. Connect with supportive friends, family members, or support groups.

5. Develop effective time management skills to reduce feelings of overwhelm such as breaking tasks into smaller, manageable steps and prioritize based on importance and urgency.

6. Practice assertiveness by learning to express your needs, setting boundaries, and communicating effectively.

Signature (with appropriate credentials): __________________________________________

Cite current evidenced based guideline(s) used to guide care (Mandatory)_______________

References

Kalin, N. H. (2020). The critical relationship between anxiety and depression. American Journal of Psychiatry, 177(5), 365-367. https://doi.org/10.1176/appi.ajp.2020.20030305

Mullins, N., Bigdeli, T. B., Børglum, A. D., Coleman, J. R., Demontis, D., Mehta, D., ... & Lewis, C. M. (2019). GWAS of suicide attempt in psychiatric disorders and association with major depression polygenic risk scores. American Journal of Psychiatry, 176(8), 651-660. https://doi.org/10.1176/appi.ajp.2019.18080957

Walter, H. J., Bukstein, O. G., Abright, A. R., Keable, H., Ramtekkar, U., Ripperger-Suhler, J., & Rockhill, C. (2020). Clinical practice guideline for the assessment and treatment of children and adolescents with anxiety disorders. Journal of the American Academy of Child & Adolescent Psychiatry, 59(10), 1107-1124. https://doi.org/10.1016/j.jaac.2020.05.005

DEA#: 101010101 STU Clinic LIC# 10000000

Tel: (000) 555-1234 FAX: (000) 555-12222

Patient Name: (Initials)___________W.W.___________________ Age _______18____

Date: ______06/09/2023_________

RX _______ Sertraline _______________________________

SIG: Dosage: 50 mg Route: Oral Frequency: Once daily, preferably in the morning. The price of 30 tablets of sertraline 50 mg is approximately $7.

Dispense: _______30____ Refill: ___0______________

No Substitution

Signature: ____________________________________________________________

Rev. 2272022 LM