NSG 535 Soap note

K.W is a 29 yr old female telehealth intake visit; CC “I have dealt with panic disorder, severe depression, and anxiety as a child. Patient felt hopelessness a month ago: Hx of cutting wrist when she was 11 years. Denies pain, NKA. Rollover car MVA (8years ago), few minor accidents, Psychiatric visit due to postpartum depression, was assessed and d/c.

Reports anxiety as child at age 9-10. Most felt sad 9/10 of the time. Wakes up racing heart rate, “nightmares” thinks she is more anxious than depressed. Anxious today 6/10, depression today 5/10 but other others can more.

Triggers: Everything likes to be perfect, gets angry when anxious. Likes things her way, fight at times. Denies thoughts of suicide or hallucinations/delusions.

No anxiety coping skills. (Educate on coping skills) has ADHD can’t meditate.

Father has anxiety, ADHD (undiagnosed)

Maternal uncle has mental illness on and off and some arrest by police.

Has a 6year old daughter (c-section) full custody

Currently dating. Weight 180, ht 5’11.

LMP 12/20/22-reports irregular menses (will see Gynecologist soon).

Patient is an Office manager at grocery story

Appears normal, Mood; anxious, sleep-nightmares 6 months ago-no triggers, sleeps on and off, low energy, trouble concentrations. Has healthy relationship (sometimes anxiety affects it), enjoys work, loves to write

EDUCATION.

Continue Effexor 225 mg PO daily, monitor s/sx of buspirone 7.5 mg Po TID

ADHD online information

PLAN

Neuropsychologic testing? ADHD, borderline personal) F/U in two weeks

Call with any questions