Focused SOAP Note – Patient with Generalized Anxiety Disorder

Subjective:

CC (chief complaint): The patient presents with a chief complaint of extreme anxiety, restlessness, apprehension, trouble concentrating, hyperventilation, heart palpitations, racing heart, sweating, and dizziness, and notes that all of these symptoms began this morning after opening up about his sex change and taking hormone pills.

Age: 22

Gender: Male/Transgender

Diagnosis: GAD

A 22-year-old transgender male came into the office and reported feeling extremely anxious, restless, apprehensive, having trouble concentrating, hyperventilating, having heart palpitations, racing, sweating, and dizziness. The patient reported that he started feeling the symptoms after waking up this morning. He reported that he started noticing these symptoms since being open about his sex change and taking hormone pills. The patient reported that he has trouble sleeping at times. He states that his symptoms occur out of nowhere. He reports overall being a happy young man and rarely feels sad. He reports a good support system and a close-knit family with friends.

HPI: The 22-year-old transgender male patient presented to the office and stated that he started feeling extremely anxious, restless, apprehensive, had trouble concentrating, hyperventilating, had heart palpitations, racing, sweating, and dizziness. He notes these symptoms started this morning. He notes that he has occasionally experienced sleeplessness. He reports that these symptoms seemingly come on out of nowhere. He notes that these symptoms appeared when he opened up about his sex change and took hormone pills. He generally describes himself as a happy individual, rarely experiencing persistent sadness, as he has good social support from a close-knit family and friends.

Substance Current Use: The patient has no reported history of substance use.

Medical History:

Current Medications: The 22-year-old patient is currently on hormone therapy. He takes hormone pills after undergoing sex change. The current hormone pills, dosage, and period the patient has been taking and is expected to take the pills have not been specified during this assessment.
Allergies: The patient has no reported known allergies in the past or currently during his sex change hormone therapy.

Reproductive Hx: The 22-year-old patient was born with feminine sex and gender, has undergone a transgender sex change, and currently identifies as a transgender male. He is currently under hormone therapy. The patient has no known history of his previous menstrual patterns, contraceptive use, or his previous and current preferred types of sexual intercourse or sexual activity. He also has no current sexual concerns.

ROS:

GENERAL: The patient denies any fever, chills, fatigue, or unintentional weight loss. However, he reports feeling dizzy with increased sweating.
HEENT: The patient does not report any headaches but notes he feels dizzy. He has visual disturbances, hearing loss, or a sore throat. He does not report nasal congestion or any nose-related issues in recent times. He does not report any smell issues. He does not report issues when swallowing.
SKIN: No rash or scratches on the skin. Denies any itchiness.
CARDIOVASCULAR: The patient complains he experiences irregular and fast heartbeats. The patient does not report any history of chest issues.
RESPIRATORY: The patient does not report any breathing issues, including shortness of breath. The patient does not report having chest pain.
GASTROINTESTINAL: The patient does not complain or report any gastrointestinal issues such as nausea, vomiting, abdominal pain, or changes in bowel movements.
GENITOURINARY: The patient does not report any genitourinary issues, including burning on urination, urgency to go, hesitancy to go, odor, or odd urine color.
NEUROLOGICAL: The patient complains of dizziness and feeling extremely anxious. He denies any focal neurological symptoms. No change in bowel or bladder control.
MUSCULOSKELETAL: The patient does not report any issues, including pain or limitations in movement.
HEMATOLOGIC: The patient reports no blood or bleeding issues and bruising.
LYMPHATICS: The patient does not report any swollen or enlarged lymph nodes.
ENDOCRINOLOGIC: The patient reports of sweating. He denies feeling cold, polyuria, or polydipsia.

Objective:

Diagnostic results: No diagnostic tests were carried out on the patient

Assessment:

Mental Status Examination:

The 22-year-old transgender male patient presents with complaints of feeling extremely anxious, restless, and apprehensive, with trouble concentrating and hyperventilating. He also reports having abnormal and racing heartbeats, with a lot of sweating and feeling dizzy. The patient appears well-groomed and is well dressed for age and gender he identifies with and to the occasion and current weather. The patient was cooperative throughout the assessment. However, from time to time, he got distracted and stopped concentrating on the assessment. He also physically appears anxious and restless and exhibits visible signs of hyperventilation, sweating, and palpitations. The patient’s mood is anxious, with an effect that is congruent with their anxious presentation. He has a well-organized and coherent thought, and there is no evidence of having any thought disorder. According to the presented history, his insight and judgment are sound, as evidenced by his presentation to the clinic to seek health care. The patient’s cognitive functions appear intact as he has been able to provide a detailed history of his symptoms and account for the time they occurred and events like opening up about his sex change and using hormone pills. His thought content and perception are intact. He denies having any suicidal, self-harming thoughts or homicidal ideation. Most of his thought process, content, and perception are related to his current gender change process and the use of hormone pills. He denies any hallucinations or delusions.

Diagnostic Impression:

Based on the patient’s information and symptoms, the three major differential diagnoses are generalized anxiety disorder (GAD), adjustment disorder with anxiety, and panic disorder.

Generalized anxiety disorder (GAD) is the preliminary diagnosis. The rationale for this diagnostic impression is that the patient reports experiencing excessive anxiety as evidenced by restlessness, trouble concentrating, hyperventilation, and sweating. The symptoms are consistent with the diagnostic guidelines provided by the Centers for Disease Control and Prevention (CDC) (Terlizzi & Villarroel, 2019). It further includes being easily fatigued, irritable, and with sleep disturbances (DeMartini et al., 2019). However, more objective tests, including urine and blood tests, are needed.

The second differential diagnosis is adjustment disorder with anxiety. Adjustment disorder is a type of anxiety disorder that majorly develops due to adaptation to a stressful event (O’Donnell et al., 2019). It is characterized by stress responses such as anxiety due to the event. The rationale for this diagnostic impression is linked to the fact that the patient has undergone a major gender change and is using hormone pills. However, it can be ruled out due to the symptoms related to GAD that the patient presents.

The third diagnostic impression is panic disorder. The rationale for this diagnostic impression is due to the patient’s reported symptoms, such as hyperventilation, heart palpitations, sweating, and dizziness. However, panic disorder can be ruled out, as the symptoms have presented for a while, and the patient does not report experiencing any sudden and episodic feelings of intense fear.

Reflections:

Managing this particular case has been a learning moment. First, I agree with the preceptor’s assessment and diagnostic impression of the patient due to the symptoms presented by the patient as well as the current condition of the patient. I have had multiple learning points during the delivery of care for the client. These include applying nursing knowledge to assess, diagnose, and plan the care for a patient with mental health issues. I have ended up learning how to develop cultural competencies and professionalism in care delivery after caring for a transgender patient. I have also learned how to uphold ethical principles in patient care, including the ethical principles of autonomy, safety, confidentiality, and beneficence (Behavior Analyst Certification Board, 2020).

Case Formulation and Treatment Plan:

The care plan for the patient will first develop deeper insights into the patient’s problem through objective evaluation. The patient will also be evaluated by other behavioral analysts available at the facility. The patient will also be assessed for mental stability and any thoughts of suicide, self-harm, or harming others. After all evaluations have been completed, the current and previous medications will be analyzed to understand their effectiveness and side effects. The patient will be provided psychoeducation to help him deal with anxiety as well as adjust to his new gender. The management of the GAD will include the use of psychotherapeutic approaches, especially cognitive-behavioral therapy (CBT), to address anxiety and develop coping strategies. CBT can support the provision of culturally competent care that meets the needs of the patient (Naz et al., 2019). The final steps include setting up a support system for the patient and scheduling follow-up to ensure the patient adheres to the care provided.

PRECEPTOR VERIFICATION:

I confirm the patient used for this assignment is a patient that was seen and managed by the student at their Meditrek approved clinical site during this quarter course of learning.

Preceptor signature: ________________________________________________________

Date: ________________________

References

Behavior Analyst Certification Board. (2020). Ethics code for behavior analysts. BACB. https://bacb.com/wp-content/ethics-code-for-behavior-analysts/

DeMartini, J., Patel, G., & Fancher, T. L. (2019). Generalized anxiety disorder. Annals of Internal Medicine, 170(7), ITC49–ITC64. https://doi.org/10.7326/AITC201904020

Naz, S., Gregory, R., & Bahu, M. (2019). Addressing issues of race, ethnicity, and culture in CBT to support therapists and service managers to deliver culturally competent therapy and reduce inequalities in mental health provision for BAME service users. The Cognitive Behaviour Therapist, 12, e22. https://doi.org/10.1017/S1754470X19000060

O’Donnell, M. L., Agathos, J. A., Metcalf, O., Gibson, K., & Lau, W. (2019). Adjustment disorder: Current developments and future directions. International Journal of Environmental Research and Public Health 2019, Vol. 16, Page 2537, 16(14), 2537. https://doi.org/10.3390/IJERPH16142537

Terlizzi, E. P., & Villarroel, M. A. (2019). Symptoms of generalized anxiety disorder among adults: United States, 2019. https://www.cdc.gov/nchs/products/index.htm.

ORDER A PLAGIARISM-FREE PAPER HERE

We’ll write everything from scratch

Question

Focused SOAP Note – Patient with Generalized Anxiety Disorder

Subjective:

CC (chief complaint):

Age: 22

Gender: Male/Transgender

Diagnosis: GAD

A 22-year-old transgender male came into the office and reported feeling extremely anxious, restless, apprehensive, having trouble concentrating, hyperventilating, having heart palpitations, racing, sweating, and dizziness. The patient reported that he started feeling the symptoms after waking up this morning. He reported that he started noticing these symptoms since being open about his sex change and taking hormone pills. The patient reported that he has trouble sleeping at times. He states that his symptoms occur out of nowhere. He reports that, overall, he is a happy young man and rarely feels sad. He reports a good support system and a close-knit family with friends.

HPI:

Substance Current Use:

Medical History:

Current Medications:
Allergies:

Reproductive Hx:

ROS:

GENERAL:
HEENT:
SKIN:
CARDIOVASCULAR:
RESPIRATORY:
GASTROINTESTINAL:
GENITOURINARY:
NEUROLOGICAL:
MUSCULOSKELETAL:
HEMATOLOGIC:
LYMPHATICS:
ENDOCRINOLOGIC:

Objective:

Diagnostic results:

Assessment:

Mental Status Examination:

Diagnostic Impression:

Reflections:

Case Formulation and Treatment Plan:

PRECEPTOR VERIFICATION:

I confirm the patient used for this assignment is a patient who was seen and managed by the student at their Meditrek-approved clinical site during this quarter’s course of learning.