This is a sample of my Soap note #2 for you guide if you consider convenient. The topic for the new soap note will be
Autism Spectrum Disorder
Soap Note Anxiety Disorder
Miguel A Prado Gomez
Dr. Jessica Sonnier
CC (chief complaint): “Since I started my cancer treatment, I have been anxious about chemotherapy and the upcoming surgery. Also, I have trouble sleeping at night due to worrying about the overall prognosis. Besides, I have chronic fatigue after the chemotherapy.”
The patient is a 60-year-old African American Man who was presented to the clinic with complaints of anxiety because of his overall prognosis. Also, the patient reported trouble sleeping and chronic fatigue. The patient has a history of hyperlipidemia and diabetes. The patient manages these conditions through exercise and eating a balanced diet. Besides, the patient was diagnosed with pancreatic cancer four months ago. Correspondingly, the patient is a Christian who goes to Jehovah’s Witness; their church they don’t believe in blood transfusions. He stated that he would refuse the process if it will be needed.
The patient stated that she awaits surgery to remove the tumor, and he is worried about the whole process. He mentioned that the feeling of anxiety interferes with his daily functioning. For instance, he mentioned that he no longer enjoys hanging out with friends and feels tired most of the time. The patient mentioned that after starting chemotherapy, he is not experiencing abdominal pain. Further, the patient reported that he has been experiencing brain fog and is constantly thinking about his future, which causes anxiety. The patient denies experiencing suicidal or homicidal ideation.
Past Medical History
The patient has the following medical history:
– Pancreatic Cancer
– Type 2 diabetes
The patient is awaiting surgery to remove the tumor.
In 2015 the patient had undergone surgery for Hernia Repair
The patient has a history of hospitalization; this was a result of Hernia Repair.
The patient has no known drug allergies
The patient has no known food allergies
The patient has no known environmental allergies.
The patient is under the following medications.
– Lyumjev 100 units/mL solution, four units
– Novolog Mix 70/30 100 unit/mL suspension, 35 units
The patient comes from a family with a history of substance abuse and mental health disorder. His father died because of excessive consumption of alcohol; his mother died from a stroke, and she was diagnosed with type 2 diabetes. The patient has two siblings, one brother, and a sister. His sister is alive with an unknown health history. His brother is living, and he has hyperattention and diabetes. The patient has two draughts working miles away, who visit often.
The patient lives with his wife, who is very supportive; they regularly go to church together. The patient is a retired bus driver; he is now staying at home with his wife. The patient denies using tobacco or illicit drugs. The patient mentioned that he drinks two beers a month. He mentioned that he drinks caffeine often. The patient reported that he walks for 20 minutes two days a week.
• GENERAL: The patient’s general appearance is good; he is oriented to time, place, and situation. The patient has dressed appropriately to age. The patient reported fatigue and brain fog.
• HEENT: The patient is using spectacle; his vision is not good. His hearing is good; he is not using any hearing aid. The patient is not experiencing a good sore throat.
• SKIN: The patient skin is in good condition; the patient does not have rushes or wounds.
• CARDIOVASCULAR: The patient does not experience chest pain. However, he reported intermittent tachycardia.
• RESPIRATORY: The patient denies shortness of breath, cough, and wheezing.
• GASTROINTESTINAL: The patient denies experiencing abdominal pain.
• MUSCULOSKELETAL: The patient does not have joint or back pain.
• HEMATOLOGIC: The patient does not have anemia or bleeding problems.
BMI 30.18 (this indicates that the patient is obese)
At 66 inches
Wt 187 lbs
The patient was evaluated for anxiety disorder. Several screening tools can be used to evaluate for mental health disorders. as it relates to this case, the Generalized Anxiety Disorder 7-item scale (GAD-7) was used to evaluate for the severity of anxiety disorder. There is substantial literature that supports the validity and reliability of GAD-7. This tool has seven items with a score of 0 to 3 and a total score of 21 (Pérez-Pedrogo et al., 2022). The cut points of GAD-7 are 5, 10, and 15; A score of 0 to 5 indicates mild anxiety; a score of 10 and above indicates moderate anxiety. A score of 15 and above indicate severe anxiety. The patient scored 11, which means that
he has moderate anxiety. Psychotherapy needs to be started to help the patient manage his condition.
Mental Status Examination:
The patient is well-dressed and appropriate for his age. The patient is alert and oriented to time, place, and situation. The patient does not have an odor. The patient was cooperative throughout the sessions; he answered all questions as asked. The patient did not have abnormal mortar activities like tremors. The patient’s speech was clear and soft. He appeared anxious, and his affect was appropriate to his mood. His thought process is linear and goal-oriented. The patient thought the content was good; he does not have suicidal or homicidal ideation. The patient’s memory is good, as he can recall past events. Also, his judgment and insight are good.
F41.8 Anxiety Disorder: Anxiety is a common mental health disorder characterized by intense feelings, worries, or fear that interfere with a person’s daily functioning. According to the DSM-5 criteria, for a person to be diagnosed with anxiety disorder, he must meet the following criteria a person must have excessive worry or fear that occurs almost every day for at least six months; the anxiety should be associated with a number of things such as school and work (American Psychiatric Association. 2018). The patients fit into this diagnosis as he reported excessive worry over his prognosis and condition. Also, the patient reported trouble sleeping.
F41.0 Panic Attack: This is a serious disorder characterized by sudden episodes of intense fear or worry over something (American Psychiatric Association. 2018). This disorder has symptoms that mimic anxiety disorder. The patient did not fit into this diagnosis as he did not sadden episodes of intense fear over something.
E 05 Hyperthyroidism: This disorder is characterized by feelings of anxiety, tremors, and increased sweating (Ross, 2022). The patient did not fit into this diagnosis
Plan of Care
The plan of care is to continue with previous medications Lyumjev 100 units/mL solution, four units, and Novolog Mix 70/30 100 unit/mL suspension, 35 units; this will help the patient to manage his condition. I will start B12 Fast dissolve tablet disintegrating, 5000mcg once daily by mouth; this medication will help the patient with fatigue and brain fog.
Also, I will start psychotherapy to help the client manage anxiety symptoms. I will use cognitive-behavioral therapy to help the client’s anxiety related to his prognosis. Through this approach, the patient will learn how negative thinking patterns influence our behavior and emotions.
I will encourage the patient to reduce caffeine intake; this will help to address the issue of insomnia.
I will encourage the patient to reduce alcohol intake
I will encourage the patient to continue engaging in physical activities
Also, I will encourage the patient to practice yoga and meditation; literature asserts that medication and yoga help relieve anxiety symptoms (Craske & Bystritsky, 2022).
The patient will come for a follow-up after two weeks.
American Psychiatric Association. (2018). Diagnostic and statistical manual of mental disorders (5th ed.). American Psychiatric Association.
Craske, M., & Bystritsky, A. (2022). Generalized anxiety disorder in adults: Management. UpToDate. Accessed September 8. https://www.medilib.ir/uptodate/show/101879
Pérez-Pedrogo, C., Sánchez-Cardona, I., Castro-Díaz, B., & López-Torres, S. (2022). Psychometric properties of the Generalized Anxiety Disorder 7-item scale in adolescents: An effective screening tool for school and community settings. Puerto Rico Health Sciences Journal, 41(4), 226. https://prhsj.rcm.upr.edu/index.php/prhsj/article/view/2775
Ross, D. S. (2022). Treating hypothyroidism is not always easy: When to treat subclinical hypothyroidism, TSH goals in the elderly, and alternatives to levothyroxine monotherapy. Journal of Internal Medicine, 291(2), 128–140. https://doi.org/10.1111/joim.13410
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