Generalized Anxiety Disorder SOAP Note

Generalized Anxiety Disorder SOAP Note

Comprehensive Essay on Generalized Anxiety Disorder SOAP Note

Comprehensive Essay on Generalized Anxiety Disorder SOAP Note

CriteriaClinical Notes
  
Informed ConsentInformed Consent  The patient responds to and appears to understand the Informed consent given about the psychiatric interview process and psychiatric/psychotherapy treatment. The patient is informed of the benefits and drawbacks of the psychiatric evaluation process and the expected psychotherapeutic/psychiatric therapy. As an adult, she gives her verbal and written approval.(Comprehensive Essay on Generalized Anxiety Disorder SOAP Note)
SubjectiveVerify Patient Name D.P. Demographic: Middle-aged female. Gender Identifier Note: Female CC: “I am worried about everything, I have trouble controlling my worries, I have trouble falling asleep, and I frequently become irritable.”   HPI: D.P. is a 34-year-old Caucasian woman who presents to the clinic complaining of being ‘worried about everything. She is having trouble falling asleep and managing her anxiety because she is unable to regulate her worries. The patient claims she has had invitations to several events and gatherings, but she cannot attend most of them because she experiences anxiety when she is away from home and feels driven to come back(Comprehensive Essay on Generalized Anxiety Disorder SOAP Note). The patient claims that although she has experienced anxiety for a significant portion of her life, her symptoms have a detrimental impact on her employment, social life, and self-care. The patient has been diagnosed with Psoriasis in the past. She is married and has a daughter who is five years old. She regularly takes over-the-counter medications and a B-12 supplement for stress reduction due to marital conflict and childcare concerns(Comprehensive Essay on Generalized Anxiety Disorder SOAP Note). Three weeks have passed since the patient’s last menstrual cycle.   Patient self-esteem is fair, with feelings of excessive loss of control, no reported anhedonia. She reports sleeping difficulties and trouble controlling her anxiety, changes in appetite, and changes in concentration. No reported libido disturbances. SI/ HI/ AV: D.P. denies suicidal ideation, denies SIBx, denies homicidal ideation, denies violent behavior, and denies inappropriate/illegal behaviors.  
Allergies: None Reported.   (Comprehensive Essay on Generalized Anxiety Disorder SOAP Note)
Past Medical Hx: Medical history: None Patient denies history of chronic infection, including MRSA, T.B., HIV and Hep C.
Surgical Hx: No surgical history reported  
Past Psychiatric Hx: Previous psychiatric diagnoses: Patient has history of anxiety(Comprehensive Essay on Generalized Anxiety Disorder SOAP Note). Denied family history of mental illness.  
Previous medication trials: no reported medication trials
Current Medications: Patient reports she initiated 5-HTP, L-Tryptophan in 2021 to help her with anxiety. The medication was recommended by a friend and not prescribed by a mental health practitioner. She takes over-the-counter medication routinely and B-12 vitamin for stress management from marital struggles and childcare issues.            (Contraceptives): N/A
Safety Concerns: History of Violence to Self:  negative History of Violence to Others: negative     Auditory Hallucinations: negative Visual Hallucinations: negative Mental Health Treatment History discussed: (Comprehensive Essay on Generalized Anxiety Disorder SOAP Note)
History Of Outpatient Treatment: none reported
Previous Psychiatric Hospitalizations: none reported Prior Substance Abuse Treatment: none reported  
Trauma history: Client  denies any history of trauma including abuse, domestic violence, witnessing disturbing events.  (Comprehensive Essay on Generalized Anxiety Disorder SOAP Note)
Substance Use: Client denies use or dependence on nicotine/tobacco products or any illicit drugs. (Comprehensive Essay on Generalized Anxiety Disorder SOAP Note)          
  Family Medical Hx: None reported
Family Psychiatric Hx:           Substance use: Negative           Suicides: Negative           Psychiatric diagnoses/hospitalization: Negative           Developmental diagnoses: Normal developmental milestones were reported.  
Social History: (Comprehensive Essay on Generalized Anxiety Disorder SOAP Note)
Occupational History: currently employed, working as an accountant Marital Status: She is married and has a five-year-old son Education history:  Completed college and graduated with a B.S. in accounting. She has a master’s degree in accounting. Developmental History: Reports normal development patterns.                ROS: General: Denies weight loss, fever, chills, weakness, or fatigue. HEENT: Eyes denies visual loss, blurred vision, double vision, or yellow sclerae. Ears, Nose, Throat: No hearing loss, sneezing, congestion, runny nose, or sore throat. Skin: No rash or itching. Cardiovascular: Denies chest pain, chest pressure, or chest discomfort. No palpitations or edema. Respiratory: Denies wheezes, shortness of breath, consistent coughs, and breathing difficulties while resting. Gastrointestinal: No anorexia, nausea, vomiting, or diarrhea. No abdominal pain or blood. Genitourinary: Denies burning on urination, urgency, hesitancy, odor, odd color Neurological: Reports headache, denies dizziness, syncope, paralysis, ataxia, numbness, or tingling in the extremities. No change in bowel or bladder control. Denies difficulties concentrating and paying attention. Reports constant worries she cannot control.   Musculoskeletal: Denies muscle, back pain, joint pain, or stiffness. Hematologic: Denies anemia, bleeding, or bruising. Lymphatics: Denies enlarged nodes. No history of splenectomy. Endocrinologic: reports random sweating, No reports of cold or heat intolerance. No polyuria or polydipsia.(Comprehensive Essay on Generalized Anxiety Disorder SOAP Note)
Verify Patient: Name, Assigned identification number (e.g., medical record number), Date of birth, Phone number, social security number, Address, Photo.   Include demographics, chief complaint, subjective information from the patient, and names and relations of others present in the interview.   HPI:           , Past Medical and Psychiatric History, Current Medications, Previous Psych Med trials, Allergies.  Social History, Family History. Review of Systems (ROS) – if ROS is negative, “ROS noncontributory,” or “ROS negative except for…”
Objective                 Vital Signs: Stable Temp:98.7F             BP: 100/58             H.R.: 70              RR:18              O2: Room air              Pain:2/10              Ht: 65 inches              Wt.: 150 lbs.              BMI: 24.96              BMI Range: Healthy range              LABS: Lab findings WNL Tox screen: Negative Alcohol: Negative HCG: N/A     Physical Exam General appearance: The patient looks well-fed and in good health. She converses and regularly engages with the medical staff. She is cooperative and maintained calm throughout the process. HEENT: Normocephalic and atraumatic. Sclera anicteric, No conjunctival erythema, PERRLA, oropharynx red, moist mucous membranes. Neck: Supple. No JVD. Trachea midline. No pain, swelling or palpable nodules. Heart/Peripheral Vascular: Regular rate and rhythm noted. No murmurs. No palpitation. No peripheral edema to palpation bilaterally. Cardiovascular: Patient’s heartbeat and rhythm are regular. The patient’s heart rate is constant and capillaries refill in two seconds.   Musculoskeletal: Normal range of motion. Regular muscle mass for age. No signs of swelling or joint deformities. Respiratory: No wheezes and respirations are easy and regular. Neurological: Balance is stable, gait is normal, posture is erect, tone is good, and speech is clear. Psychiatric: The patient is attentive and cooperative. Patient is easily distracted, yet occasionally appears to pay attention to the caregiver. Neuropsychological testing: Patient has difficulties executing work and house functions. Social-emotional functioning was limited. Behavior/motor activity: Patient behavior was appropriate and constant throughout the assessment Gait/station: Stable. Mood: The patient exhibited an anxious mood. Affect The patient’s mood was worried and anxious Thought process/associations: comparatively linear and goal directed. Thought content: Noted some signs of paranoia Attitude: Patient was cooperative throughout the assessment Orientation: Oriented to self, place, situation, and general timeframe. Attention/concentration: Good Insight: Good Judgment: Good. Remote memory: considered good Short term memory: considered excellent Intellectual /cognitive function: considered good Language: clear speech, with a tone assessed to be normal Fund of knowledge: Good. Suicidal ideation: Patient denies any suicidal ideation, is negative for active plans or intent. Homicide ideation: Negative. GAD-7 Screening Tool scores   Feeling nervous, anxious, or on edge- 3   Not being able to stop or control worries- 3   Worrying too much about different things- 3   Trouble relaxing- 2   Being so restless that it is hard to sit still- 2   Becoming easily annoyed or irritable- 2   Feeling afraid as if something awful might happen- 1   Total score out of 21- 16 Impression: severe case of anxiety(Comprehensive Essay on Generalized Anxiety Disorder SOAP Note)
This is where the “facts” are located. Vitals, **Physical Exam (if performed, will not be performed every visit in every setting) Include relevant labs, test results, and Include MSE, risk assessment here, and psychiatric screening measure results.
AssessmentThe patient, a 34-year-old Caucasian woman, states always worried and this has a significant effect on her work and life. She has trouble falling asleep, and she gets frustrated easily. During the physical examination, a sizable elevated silvery-white scaly patch on the scalp area of the occipital was noted. The patient underwent a second test using the GAD-7 Screening tool, and received a score of 16 out of 21, indicating a severe case of anxiety.   DSM5 Diagnosis: with ICD-10 codes F41.1 Generalized Anxiety Disorder (GAD) (Confirmed Diagnosis): GAD symptoms include worry, fear, and a sense powerlessness. It is characterized by irrational, excessive, and persistent concern for trivial matters. Patient presents with excessive anxiety and worry, occurring continuous for the past few months (Munir et al., 2022). Patient worries constantly about going to work and leaving the house or going in social events. Diagnosis was done based on the patient subjective data, physical evaluation, and the GAD-7 screening tool scores. F41. 9 Anxiety (Comprehensive Essay on Generalized Anxiety Disorder SOAP Note)Anxiety/fear a future-focused emotional state. Anxiety/fear is characterized by complex, affective, behavioral and physiological response to impending situations or events perceived as threats. Patients present with feeling nervous, restless, or tense, have a sense of impeding danger (Chand & Marwaha, 2022). Physical symptoms include rapid breaths, sweat, trembles, weakness or tiredness, and trouble with concentration. The diagnosis was refuted because the patient does not report such physical symptoms. GAD-7 scores confirmed generalized anxiety disorder.  F40. 10 Social Anxiety Disorder (SAD)(Comprehensive Essay on Generalized Anxiety Disorder SOAP Note) The primary symptoms of SAD include anxiety, intense or strong fear in social situations. The person worries that in such situations, others would have a poor opinion of him or her. Additionally, he or she worries about offending, humiliating, or being rejected by others (Chand & Marwaha, 2022). These events are always accompanied by tremendous fear and anxiety, and they are avoided whenever possible. This diagnosis was refuted because the patient worries generally about everything, not only social events. GAD-7 scores confirmed generalized anxiety disorder. F32.9 Depression Depression is a mood illness. Depression is characterized by loss of interest and constant melancholic feelings. Sadness, emptiness, or irritability are common characteristics of all depressive disorders, along with physical and cognitive alterations that have a substantial impact on the person’s ability to function (Chand et al., 2021). Patient experiencing depression present with diminished interest/pleasure in daily activities, almost every day. This diagnosis is refuted because the patient does not report excessive sadness. GAD-7 scores confirmed generalized anxiety disorder.   (Comprehensive Essay on Generalized Anxiety Disorder SOAP Note)
Include your findings, diagnosis, and differentials (DSM-5 and any other medical diagnosis) along with ICD-10 codes, treatment options, and patient input regarding treatment options (if possible), including obstacles to treatment.   Informed Consent Ability
Plan   (Note some items may only be applicable in the inpatient environment)  The patient would benefit from a combination of psychotherapy and medication. Safety Risk/Plan(Comprehensive Essay on Generalized Anxiety Disorder SOAP Note): Risk for harm to others is deemed low, the risk for suicide in the current setting nonexistent, as do risk for self-harm or self-mutilation. The medications included in the treatment plan were duly discussed, and informed consent was given. The assessment does not indicate hospitalization necessity. The patient should continue with her stress management medication. Family care would be fundamental, and patient should seek constant engagement with family.    Pharmacologic interventions: #90862(Comprehensive Essay on Generalized Anxiety Disorder SOAP Note) Selective serotonin reuptake inhibitors: Paxil 20 mg P.O. qDay initially, may increase by 10 mg qWeek: Can be taken daily to reduce the symptoms of discomfort and sleep disturbance (Arcangelo & Peterson, 2017). Can be taken daily with minimal adverse effects than tricyclic(Comprehensive Essay on Generalized Anxiety Disorder SOAP Note) antidepressants. Zoloft 5 mg P.O. qDay. May be increased weekly by 25 mg. Dosage should not exceed 200 mg qDay to minimize anxiety effects (Singh & Saadabadi, 2021). Calcipotriene (Davonex) twice daily for 6-8 weeks for Psoriasis. A topical Vitamin D relieves mild Psoriasis (Patel et al., 2017). Psychotherapy: #90834 Cognitive Behavioral Therapy: (Comprehensive Essay on Generalized Anxiety Disorder SOAP Note)CBT is recommended to address GAD by stopping negative behavior cycles. It involves providing information via psychoeducation, changing maladaptive thought patterns, gradually exposing anxiety-provoking situations, and experimentation with new behavior and emotions, including (Comprehensive Essay on Generalized Anxiety Disorder SOAP Note)exposition and relaxation (Munir et al., 2022). Education: #98960 Educate about potential side effects of medication therapy and when to report any complications or undesired effects. Educate the patient about when the medication will work and the need to adhere to prescription guidelines. Advise patient to join a support group or group therapy to help deal with anxiety Further assessment is advised after a score of 16 to develop a more detailed care plan. Referrals: Dermatologist for Psoriasis Consultation/follow-up: The patient needs to see a psychologist and occupational psychologist for cognitive behavioral therapy to address her anxiety. A dermatologist can help address her Psoriasis further.   ☒ > 50%-time spent counseling/coordination of care. Time spent in Psychotherapy  45 minutes Visit lasted 100  minutes(Comprehensive Essay on Generalized Anxiety Disorder SOAP Note)       
ReferencesArcangelo, V. P., & Peterson, A. M. (Eds.). (2017). Pharmacotherapeutics for advanced practice: a practical approach (Vol. 536). Lippincott Williams & Wilkins. Retrieved from vbk://9781496374066 Chand, S. P., & Marwaha, R. (2022). Anxiety. StatPearls(Comprehensive Essay on Generalized Anxiety Disorder SOAP Note) [Internet]. Chand, S. P., Arif, H., & Kutlenios, R. M. (2021). Depression (Nursing). Munir, S., Takov, V., & Coletti, V. A. (2022). Generalized anxiety disorder (nursing). In StatPearls [Internet]. StatPearls Publishing. Patel, N. U., Felix, K., Reimer, D., & Feldman, S. R. (2017). Calcipotriene/betamethasone dipropionate for the treatment of psoriasis vulgaris: an evidence-based review. Clinical, cosmetic, and investigational dermatology10, 385–391. https://doi.org/10.2147/CCID.S131727 Singh, H. K., & Saadabadi, A. (2021). Sertraline. StatPearls [Internet].
https://www.ncbi.nlm.nih.gov/(Comprehensive Essay on Generalized Anxiety Disorder SOAP Note)

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