SOAP Note: Anxiety Disorder Example Subjective:
Presenting Complaint:
Feelings of excessive anxiety. HPI:
M.P is a 32-year-old Hispanic female who was well until about seven months ago when she started experiencing anxiety. At first, she would worry that she had left her door unlocked while she was at her workplace. Gradually, the feelings of anxiety became more intense, greatly affecting her performance at work. She also noticed that she began feeling quite fatigued most of the time. She also became irritable, lost concentration easily, and had difficulty sleeping.
These symptoms have become more severe over the past seven months. The patient insists that nothing is wrong, saying that it may be a result of being stressed out and fatigued, and is only here because her co-workers insisted that she seek some help.
Drug And Substance Use:
Patient does not use tobacco or any other substances. Says that she is a social drinker who takes a glass of wine with her food on the weekends.
Medical History:
The patient has no known chronic illnesses. No surgical history. No previous hospital admissions.
■ Current Medications: Currently not on any medication.
■ Allergies: NKFDA.
■ Reproductive Hx:
LMP 29/05/2022. Cycle is 28 days and lasts 3 days. Regular flow. G0T0P0A0L0. No contraceptive. Has one sexual partner currently. Uses condoms as a mode of contraception.
ROS:
■ GENERAL: Denies any other concerns, fever, or body aches.
■ HEENT: Patient does not complain of any headaches. She reports no history of trauma.
There are no complaints regarding her throat, nose or ears.
■ SKIN: No complaints of any lesions or rashes. The patient reports no eczema.
■ CARDIOVASCULAR: Patient reports no chest pain, no cough, no palpitations, no cyanosis, no orthopnea, no fatigability.
■ RESPIRATORY: No cough, no difficulty breathing, no wheezing.
■ GASTROINTESTINAL: The patient reports no vomiting, no abnormal bowel movements, no loss of appetite.
■ GENITOURINARY: No dysuria, no hematuria, no urgency, no frequency.
■ NEUROLOGICAL: No visual disturbances, no headaches, no loss of consciousness.
■ MUSCULOSKELETAL: The patient does not complain of any joint pain. No muscle pains.
■ HEMATOLOGIC: No history of easy bruisability or bleeding.
■ LYMPHATICS: Denies any lymph node swelling.
■ ENDOCRINOLOGIC: No heat or cold intolerances, no polyphagia, no polydipsia, no polyuria.
Objective: VS: Temp: 98.4 F, BP: 110/75, HR: 82, RR: 16, 100% on RA, Height: 5ft, 6in Wt.: 147 lbs.
BMI: 23.7. It is within the normal range.
General: Patient is of good nutritional status. No signs of dehydration. Not in any obvious pain or distress. Appropriately dressed.
Skin: Warm and moist. Appropriate hair distribution. No ulcers or rashes. Head: Normocephalic.
Eyes: No conjunctival pallor. No scleral jaundice. Eyelids are normal. Examination reveals normal pupils and irises.
ENT: Appearance of the external ears and nose is normal. No abnormalities in the external auditory canal and eardrum. Unimpaired hearing. NRNP 6675 Week 3 Assignment Soap Note
Neck: Supple and no lymphadenopathy.
CV: Chest wall is normal. No parasternal heaves or thrills. No cardiac dullness. Normal heart sounds (S1, S2) heard with no additional sounds. No murmurs.
RS: Chest wall is normal. Movement with respiration. Trachea and apex beats are not displaced. Vesicular and bronchial breath sounds heard. No additional sounds. No wheeze, no grunting, no stridor.
Abdomen: Normal shape. Movement with respiration. No tenderness or organomegaly elicited. Bowel sounds present and normal.
Musculoskeletal: No skeletal deformities or point tenderness. No joint pain or swelling. Range of movement in the joints is not impaired. Appropriate muscle strength and tone.
To rule out underlying conditions that may be the cause of the patient’s presenting complaint, it is important to perform a complete blood count (CBC). Reduced RBC and hemoglobin levels may cause increased fatigability, and it is important to rule this out. A random blood sugar (RBS) is important to rule out hypoglycemia. Thyroid function tests (TFTs) are vital in ruling out thyroid dysfunction, which may be the cause of the presenting complaints. A CT scan or an MRI can also be performed to rule out any abnormalities or brain injuries that may cause the current presentation.
Assessment:
Mental Status Examination (MSE):
The patient is a 32-year-old Hispanic female. She looks appropriate for her stated age. She is appropriately dressed, c
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