SOAP Note & Reflection
Subjective
Chief complaint (CC): The chief complaint of the client is uncontrollable anger. S.K came to the
facility after her mother suggested that he see a health professional for an evaluation. He gets
agitated for no reason when he argues with another person over a small matter. He feels isolated
in school but very engaging while playing basketball.
HPI: S.K, a 15-year old male, is of Mexican descent as his mother is White while his father is a
Mexican who was deported back to his home country for lacking appropriate immigration
documents. The purpose of an evaluation is to identify the cause of the client’s anger
management problem.
Substance Current Use: The client does not use any sense or drugs.
Medical History:
• Current Medications: Escitalopram (Lexapro), Fluoxetine (Prozac), Sertraline (Zoloft),
Clomipramine (Anafranil), and Fluvoxamine.
• Allergies: Allergies for wheat, soy, peanuts, pollen, and pet fur.
• Reproductive Hx: Not sexually active.
ROS:
• GENERAL: Fatigued, significant weight loss, withdrawn.
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