NRNP 6675 Week 3 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 lasting 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 complain 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 fatiguability.
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. NRNP 6675 Week 3 SOAP Note: Anxiety Disorder Example

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.

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 beat 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 fatiguability, 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, clean and her hair well-kempt. She sits quietly and is co-operative during the whole session. She, however, does not maintain eye contact during the interview. She does not display any tics or any other abnormal physical movements. She communicates clearly projecting her voice in a normal tone and volume.

She presents her thoughts clearly and answers the questions posed appropriately. The patient does not display any flight of ideas or loosening of associations. She reports to be in a euthymic mood. Her affect is appropriate for her mood meaning that there is congruency between her mood and affect. M.P denies any hallucinations or delusions. The patient reports that she has not had any thoughts of inflicting self-harm or harm to others. Patient is alert and well-oriented to time, place and person. Memory and concentration are unaffected. Has impaired insight into her condition.

Diagnostic Impression:

Diagnosis in this case scenario is generalized anxiety disorder (GAD). This is a condition marked by generalized excessive anxiety and worry about everyday life events. The worry reaches extreme levels where it affects an individual’s day-to-day activities by impairing concentration, causing insomnia, irritability, fatigue, restlessness, and an unrealistic view towards everyday challenges (DeMartini et al., 2019).

Our patient presented with anxiety for the last seven months. In addition, she complained of impaired concentration, irritability, insomnia, and fatigue. These symptoms are in line with GAD. Differential diagnoses include hyperthyroidism and depression. Normal thyroid hormone levels rule out hyperthyroidism. Depression, on the other hand, presents with prolonged periods of low mood and loss of interest in previously pleasurable activities.

Reflections:

The diagnosis of generalized anxiety disorder (GAD) is in line with my thinking. I have learned about the important features that I need to pick up in my history and MSE to make a diagnosis of GAD. What I would do differently is to inquire further about any history of mental illness or similar episodes in the past and the interventions provided, if any. Legal/ethical considerations to take into account include informed consent, confidentiality, therapeutic misconception, placebo related, vulnerability, exploitation, and operational challenges (Brown et al., 2020).

Plan Of Management:

The first line drug of choice for GAD are Selective Serotonin Reuptake Inhibitors (SSRIs). Continuous use of the medication for 12 months before tapering off should be encouraged to reduce the risk of relapse. SSRIs greatly minimize the physiological symptoms of anxiety, including muscle tension and headaches (Slee et al., 2019).
Psychotherapy is another option that has been proven to be as effective as medication, with CBT having the best results in reference to available evidence.
Provide emergency numbers such as 911 and suicide hotlines in case the patient contemplates harm to self or others at any time.
Educate patient on the importance of compliance to medication.
Follow up and review any arising issues with the patient.
Refer to a psychiatrist if patient is not improving.