Week 3: Assignment 2: Focused SOAP Note and Patient Case Presentation

Subjective:

CC (chief complaint): “I have excessive fear and worry that have affected my health and wellbeing.”

HPI: A.K is a 24-year-old female that came to the clinic with complaints of excessive fear of unknown outcomes that may occur in her family and her academic performance. The client reported that the symptoms have persisted for the last six months. She was worried that the symptoms had increased in frequency and intensity, affecting her academic and social performance. She also reported that the symptoms were difficult for her to control. The accompanying symptoms of excessive worry and anxiety included restlessness, insomnia, easy fatigability, muscle pain, and impaired or difficulty in concentration. She could not attribute the symptoms to any medical problem, medication use, or psychiatric condition.

Substance Current Use: The client denies any current use of substances

Medical History:

  • Current Medications: She is on Tylenol to manage pain in her left arm, which she hurt two days ago.
  • Allergies: She reports allergic reaction to pollen.
  • Reproductive Hx: She is single, with no pregnancy or pregnancy loss history. Her last menstrual period was 12/12/2021. The menstrual period is regular, without any abnormal symptoms. Her last gynecological examination was six months ago, which was normal. She denies an increase in urinary frequency and urgency. She denies any history of sexually transmitted diseases.

ROS:

  • GENERAL: The client has dressed appropriately for the occasion. She has weight normal for her age. There is no evidence of fever or fatigue.
  • HEENT:  Eyes:  The patient denies visual loss, blurred vision, double vision, or yellow sclera. Ears, Nose, Throat:  The patient denies hearing loss, sneezing, congestion, runny nose, or sore throat.
  • SKIN:  The client denies rash or itching.
  • CARDIOVASCULAR:  The client denies chest pain, chest pressure, or chest discomfort. No palpitations or edema.
  • RESPIRATORY:  The client denies shortness of breath, cough, or sputum.
  • GASTROINTESTINAL:  The patient denies anorexia, nausea, vomiting, or diarrhea. No abdominal pain or blood.
  • GENITOURINARY:  The patient denies burning on urination and a history of sexually transmitted infections
  • NEUROLOGICAL:  The patient denies headache, dizziness, syncope, paralysis, ataxia, numbness, or tingling in the extremities. No change in bowel or bladder control.
  • MUSCULOSKELETAL:  The client denies muscle or joint pain, joint rigidity, tenders, and difficulty in movement. He also denies fractures.
  • HEMATOLOGIC:  The patient denies anemia, bleeding, or bruising.
  • LYMPHATICS:  The patient denies enlarged nodes. No history of splenectomy.
  • PSYCHIATRIC:  The patient denies any history of depression or anxiety.
  • ENDOCRINOLOGIC:  The patient denies sweating, cold, or heat intolerance reports. No polyuria or polydipsia.
  • ALLERGIES:  The patient reports allergic reactions to pollen. She denies any other history of allergies.

Objective:

Diagnostic results: Laboratory and imaging studies should be performed to develop accurate diagnoses of the client’s problems. The studies help rule out other potential causes that could contribute to symptom development. One of the diagnostic investigations requested for the client is laboratory work for blood analysis. A complete blood count was ordered to determine if she had any other existing problems that required the attention of the healthcare providers. The other diagnostic investigation undertaken was the administration of psychological questionnaires. The General Anxiety Disorder-7 questionnaire was administered to determine if the client was suffering from an anxiety disorder. Severity Measure for Panic Disorder was also used to determine if she had a panic attack (Mossman et al., 2017). The diagnostic investigation was remarkable for the General Anxiety Disorder-7 tool.

Assessment:

Mental Status Examination: The patient appears well-groomed for the occasion. She is oriented to self, others, time, and events. Her thought content is future-oriented. She maintains normal eye contact during the assessment. She denies illusions, delusions, and hallucinations. Her self-reported mood is ‘anxious.’ Her speech is of normal rate, tone

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