SOAP Note For Anxiety Assignment Paper

Patient initials: G.R Age:26 Gender: female Race: Caucasian DOB; 2006
S:
CC: “Fatigue, inability to sleep, and extreme irritability.”
HPI: G.R, a 26-year-old Caucasian woman, presented at the clinic complaining of being weary, unable to sleep, and irritated. He mentioned that the symptoms began 9 months ago when she discovered that his coworkers were ganging against her. They intend to fire her since she is immensely smarter than them. She also complains of recurrent stomach cramps, dizziness, and back pain. She reported the symptoms to have impeded her ability do her daily chores and her duties at her workplace. She is constantly anxious and irritated for no apparent reason, and she avoids her three-year-old daughter because she sees her as a threat to her. She has not yet sought treatment. She denies feeling depressed.
Medication; None SOAP Note For Anxiety Assignment Paper

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PMH: none
Allergies: NKDA
SHx: G.R, a 26-year-old woman, works as a full-time paralegal at a nearby law firm. She is married to a single man, with whom she has a three-year-old daughter. She denies smoking but confesses to drinking heavily to unwind. She is financially stable and is insured. She used to attend to gymnastics twice a week but has quit since she feels she is becoming thin. The patient lives in a secure neighbourhood, regularly wears a seatbelt when driving, and eschewed using a phone and drive. She has been eating well-balanced diet but she has ended up losing her appetite and is eating less often than usual.
Family history: father (63 y/o): diabetes. Mother (57 y/o): hyperlipidaemia. Maternal grandmother (deceased): hypertension. Maternal grandfather (89 y/o): diabetes. Paternal grandmother (deceased): bipolar disorder. Elder bother: Asthma SOAP Note For Anxiety Assignment Paper
ROS
General: Denies fevers, chills, but reported significant weight loss.
HEENT: Negative for loss of vision, and hearing, nosebleed, and post nasal drip.
Cardiovascular: Negative for chest pain, heart murmur or galops.
Respiratory: Denies SOB, and chronic cough
GI: Reported decrease in appetite and nausea. Denies heartburn, vomiting, or diarrhea.
Msk: Reported instances of back pain.
Neurologic: Denies headache, dizziness, muscle spasm, and fainting.
Psychiatric: Denies homicidal ideation, and depression. Reported issue with sleep, irritability, social withdrawal and excessive worry.
Endocrine: Denies heat or cold intolerances.
Skin/lymph/heme: Denies changes in skin color or, rash.
O.
PE
VTS: BP 198/66 left arm, sitting using regular adult cuff. Wt.: 146lb Ht.: 5’4 T.: 37.4 RR: 20 P: 80 Sp02: 98%
General: A&Ox3, appear mildly distress.
HEENT; normocephalic and atraumatic. Visual acuity 20/20. EOMI, PERRLA.
Cardiovascular: irregular heart beat noted, no murmur, SI and S2 heard.
Respiratory: Chest wall is symmetric and nontender. Lung sound clear to auscultation. Resonance is normal upon percussion.
MSK: Full range of motion noted in all joints.
Skin: Intact without rashes. Normal texture.
Abdomen: Soft and symmetrical without distention. Bowel sounds are normoactive.
Extremities: Atraumatic without tenderness.
Neuro: Sensation intact bilaterally. Memory and thought process intact.
Psychiatric: Oriented to place and time, no abnormal affect noted. Appear paranoid. Her insight and judgement are fair.
Assessment: SOAP Note For Anxiety Assignment Paper
Diagnostic test and result
GAD-7: scored 14
Differential diagnoses:
Generalized anxiety disorder
This is a mental disorder characterized by excessive, persistent, and unjustified anxiety over everyday events. It can also produce agitation, nervousness, difficulty concentrating, fatigue, irregular pulse, and difficulties controlling anxiety (Strawn et al.,2018). Patients suffering with this condition may feel threatened at times and may isolate themselves from friends or family. His has an effect on their work performance. This illness can only be identified once symptoms have been present for at least 6 months. This is the most likely diagnosis for the client based on the clinical presentation and results of the diagnostic tests. SOAP Note For Anxiety Assignment Paper

Major depressive disorder
This is a mental illness that affects mood, behaviour, and overall health. It is distinguished by prolonged sadness, general weariness, irritability, changes in food, sleep habits, considerable weight loss, and difficulties focusing (Sanada et al.,2020). People with this illness also have inexplicable physical aches and pains, such as back discomfort, which was evident in the case scenario. Nonetheless, patients with this illness are unlikely to report of excessive worry.
Social anxiety disorder
This is a psychiatric condition marked by an extreme and persistent dread of being evaluated by others. This can have an impact on one’s work or school performance, as well as other everyday activities. People who suffer from this illness are extremely uneasy, self-conscious in public, and shun social situations (Leigh et al.,2018). This diagnostic is ruled out since anticipated anxiety associated with social environment were not evident.
Primary diagnoses: generalized anxiety disorder.
P.
Lab test: CBC is necessary to rule out other potential causes of the patient clinical presentation.
Pharmacological management: Administer Escitalopram 10mg po QD to the patient. I recommend this medicine since, in addition to being used as a first-line therapy for GAD, it is well tolerated and effective for managing GAD symptoms (McClelland et al.,2021)SOAP Note For Anxiety Assignment Paper. Furthermore, its negative consequences are limited.
Non-pharmacological: Initiate cognitive behavioral therapy with the patient. CBT is encouraged because, in addition to assisting with GAD symptoms, therapy can be tailored to each person’s unique set of destabilizing beliefs and inappropriate cognition, resulting in long-term benefits.
Patient education: Patient education entails teaching the patient about the condition, the need of following the doctor’s recommendation, the necessity of medicine and its adverse effects, and the need to stop drinking heavily. She needs to be counseled on coping methods and adequate sleep hygiene.
Follow-up: The patient to return to the clinic after four weeks of therapy for further assessment.

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References

Strawn, J. R., Geracioti, L., Rajdev, N., Clemenza, K., & Levine, A. (2018). Pharmacotherapy for generalized anxiety disorder in adult and pediatric patients: an evidence-based treatment review. Expert opinion on pharmacotherapy, 19(10), 1057-1070.
Sanada, K., Nakajima, S., Kurokawa, S., Barceló-Soler, A., Ikuse, D., Hirata, A., … & Kishimoto, T. (2020). Gut microbiota and major depressive disorder: A systematic review and meta-analysis. Journal of Affective Disorders, 266, 1-13.
Leigh, E., & Clark, D. M. (2018). Understanding social anxiety disorder in adolescents and improving treatment outcomes: Applying the cognitive model of Clark and Wells (1995). Clinical child and family psychology review, 21(3), 388-414.
McClelland, M., & McClelland, S. (2021). Case of a 21-year-old man with persistent lung collapse leading to a pericardiectomy linked to vape use. Heart & Lung, 50(2), 262-267. SOAP Note For Anxiety Assignment Paper