SOAP NOTE: Anxiety

“I’ve been feeling constantly anxious and restless, and it’s getting harder to focus at work.”

Amanda Brooks is a 27-year-old female who presents with a 6-month history of persistent anxiety. She describes experiencing excessive worry, restlessness, irritability, muscle tension, and difficulty concentrating. These symptoms occur daily and are impacting her ability to function at work. She complains that she has trouble falling asleep, and it takes her more than an hour to fall asleep most nights. Denies chest discomfort, palpitation, panic attacks, hallucinations, suicidal thoughts. She remembers having the same symptoms in college and sought no medical attention at that time. The latest episode was provoked by career pressure. There is no recent trauma, drug use, or medical changes noticed

 Melatonin 5 mg PO at bedtime as needed for sleep disturbances (Savage et al., 2020)

The patient reports overall good health with no chronic medical conditions, except for a past appendectomy at age 15 and a history of untreated anxiety symptoms during college.

Allergies:

No known drug allergies (NKDA)

Medication Intolerances:

Patient denies any known medication intolerances. She does not have any history of negative reactions to prescription or over-the-counter medication.

Chronic Illnesses/Major traumas

No medical history of chronic illness including diabetes, hypertension, asthma, or thyroid problems. The patient suffered periodic anxiety when in college, which was never specifically diagnosed or treated. No significant history of traumatic events.

Hospitalizations/Surgeries

The patient does not have any previous hospitalizations and claims that she was hospitalized only once with appendectomy at the age of 15 years. It was not complicated in any way and led to her recovery. She denies any further hospital, surgical, or emergency room admissions. No obstetric, orthopedic, or gynecologic surgery history.

The patient states that her mother was diagnosed with generalized anxiety disorder late in her 30s and is doing well on a combination of cognitive behavioral therapy and pharmacologic management. Her father has a long history of essential hypertension that was diagnosed at the age of early 40s and managed through lifestyle changes and antihypertensive drug therapy. No family history of diabetes mellitus, cancer, tuberculosis (TB), kidney disease, lung disease, or heart disease is known. The patient has no siblings or known hereditary or genetic diseases in her extended family. There is no family history of psychotic disorders, bipolar disorder, or substance use disorders.

The patient has a Bachelor’s degree in Marketing and is employed full-time as a marketing assistant at a mid-sized digital advertising firm. She describes her job as stressful but rewarding and experiences good attendance and performance. Amanda is single, has never been married, and lives alone in a one-bedroom apartment in a safe urban neighborhood. She denies having any children or dependents.

She does not use tobacco, alcohol, or recreational drugs, and reports no past substance use or abuse. She maintains a healthy lifestyle, engages in occasional yoga, and walks regularly. There is no history of domestic violence or safety concerns in her current living or working environments. She identifies a strong support system consisting of close friends and her mother.

Denies weight changes, fever, chills, or night sweats. Reports mild fatigue and low daytime energy due to poor sleep.

Denies chest pain, palpitations, orthopnea, PND, or edema.

No rashes, delayed healing, bruising, or skin changes noted.

Denies cough, wheezing, hemoptysis, dyspnea, or history of pneumonia or TB.

Uses corrective lenses. Denies blurring or other visual changes.

Occasional nausea related to anxiety. Denies vomiting, diarrhea, constipation, black stools, or abdominal pain.

No ear pain, hearing loss, tinnitus, or discharge.

No urinary urgency, burning, or color change. Sexually active, on oral contraceptives. Last Pap smear 10 months ago—normal. No vaginal discharge or menstrual complaints. No history of STIs or pregnancy.

Denies sinus issues, sore throat, dysphagia, nosebleeds, or dental problems.

Reports neck and shoulder tension. No joint pain, swelling, or fractures.

No breast lumps, tenderness, or changes reported. Performs monthly self-exams.

Denies syncope, seizures, weakness, or paresthesias. No blackout episodes.

Denies abnormal bleeding, swollen glands, heat/cold intolerance, or increased thirst/hunger. HIV status unknown.

Reports daily anxiety, sleep disturbances, and restlessness. Denies depression, suicidal ideation, hallucinations, or past psychiatric hospitalizations.

Healthy-appearing adult female in no acute distress. Alert and oriented ×3. Initially, the somber affect gradually became more engaging during the encounter.

Warm, dry, intact. No rashes, lesions, or discoloration noted.

Head is normocephalic, atraumatic, and without lesions; hair evenly distributed. Eyes: Normocephalic and atraumatic. Eyes PERRLA, EOMI, no conjunctival or scleral injection. Ears clear, TMs pearly gray with intact landmarks. Nasal mucosa pink, no septal deviation. Throat non-erythematous, moist oral mucosa. Teeth in good repair. Neck supple, no lymphadenopathy or thyromegaly.

Regular rate and rhythm. No murmurs, rubs, or gallops. Pulses 3+ bilaterally. Capillary refill <2 seconds. No peripheral edema.

Breath sounds clear bilaterally. Symmetric chest wall movement. No respiratory distress.

Obese abdomen, soft, non-tender, non-distended. Bowel sounds active in all quadrants. No hepatosplenomegaly.

No palpable masses, tenderness, discharge, or visible skin changes.

Bladder non-distended. External genitalia normal. Vaginal walls are pink and rugated. No lesions or CMT. Cervix pink, firm, nulliparous. Scant clear-to-cloudy discharge present. Uterus is anteverted and non-tender, with no adnexal masses. Ovaries non-palpable.

Full active range of motion in all extremities. No joint swelling or deformities observed.

Speech clear and fluent. Normal tone and coordination. Gait steady. No focal deficits.

Alert, oriented, well-groomed. Maintains eye contact. Mood mildly anxious, affect congruent. Speech soft but clear and coherent. No psychomotor agitation or retardation.

Urinalysis: Pending

Urine Culture: Pending

Wet Prep: Not indicated at this time

GAD-7 Anxiety Screening Tool: Score of 14, indicating moderate anxiety

TSH, CBC, CMP ordered to rule out medical contributors to symptoms (e.g., hyperthyroidism, anemia, metabolic imbalance)

o    1-Generalized Anxiety Disorder (F41.1) – Considered due to persistent worry, restlessness, fatigue, and poor sleep; symptom duration exceeds six months and impacts functioning (Munir & Takov, 2022).

o    2-Hyperthyroidism, unspecified (E05.90) – May present with anxiety, tremors, and fatigue; though not evident clinically, labs ordered to rule out endocrine etiology (Mathew & Rawla, 2023).

o    3-Adjustment Disorder with Anxiety (F43.22) – Considered due to recent work-related stress; however, symptom persistence and severity suggest a more chronic anxiety disorder (Substance Abuse and Mental Health Services Administration, 2020).

Diagnosis

o    Anxiety Disorder, Unspecified (F41.9) – Diagnosis is based on persistent worry, restlessness, fatigue, and poor sleep lasting over six months. Symptoms suggest generalized anxiety but lack full DSM-5-TR criteria. GAD-7 score of 14 indicates moderate severity. No depression, panic, or suicidal ideation noted. Medical causes under evaluation (Munir & Takov, 2022).

Plan/Therapeutics

§   Further Testing: Order CBC, CMP, and TSH to rule out medical causes of anxiety.

§   Medication: Start Sertraline 25 mg PO daily, increase to 50 mg after one week.
Prescribe Hydroxyzine 25 mg PO PRN for acute anxiety.

§   Education: Reviewed SSRI use, side effects, delayed onset, and adherence. Provided tips on sleep and anxiety management.

§   Non-Medication Treatments: Referred to CBT. Advised daily mindfulness, journaling, and relaxation exercises.

§   Follow-Up: Return in 4 weeks to evaluate progress and lab results. Call sooner if symptoms worsen.

The patient was cooperative and engaged and understood her diagnosis and treatment. No safety concerns noted. Follow-up arranged to assess response to therapy and monitor symptom progression.