SOAP NOTE - Generalized Anxiety Disorder

SOAP NOTE – Generalized Anxiety Disorder

ID:

Client’s Initials: C.O. Age: 37 Race: Caucasian: Gender: Female Date of Birth: January 1, 1987 Insurance: Kaiser Permanente | Marital Status: Married |

Subjective:

CC: “I have been feeling more tensed and worried lately.”

HPI: C.O. is a 37-year-old Caucasian female presenting with complaints of a heightened state of tension and worry. The symptoms began over a year ago but have worsened progressively over the past six months. The patient worries about all aspects of her daily living and social engagement, such as work, health, and interpersonal relationships. The symptoms are present daily and often last several hours. They are usually accompanied by restlessness, sleep disturbances, difficulty concentrating, and muscle tension. They are aggravated by daily stressors such as work, caffeine intake, and interpersonal conflicts in her relationship and improved, albeit temporarily, by talking to friends and engaging in mindfulness activities such as yoga. The anxiety affects her mental well-being and ability to perform optimally in her social activities. They are especially more intense before important social activities, such as office meetings and in the morning. The symptoms also increase in severity as the week progresses and the work pressure increases. The patient rates her anxiety as a 7/10. She also reports frequent GI disturbances, episodic sweating, and headaches that mostly coincide with anxiety.

Past Medical History:

Medical problem list

The patient has no known physical or psychiatric illness.

Surgical:

– The patient has never had any surgical procedures.

Preventive Care:

-The patient had a breast examination last month. The breast exam was negative for any breast anomalies. She also had a cervical cancer screening in January. The screening was negative for any cervical anomalies. She is due for a dental checkup.

Allergies:

– The patient is allergic to animal dander. She denies having any other allergies.

Medications:

– Tylenol 1g, taken every 8 hours for the management of her headaches.

Immunizations:

– The patient is up to date with all her childhood and adulthood vaccines. She recently received her second booster dose for the Pfizer Covid vaccine. She has also received her annual influenza vaccine.

Social History:

Chemical history: The patient is a frequent cigarette smoker. She notes that she smokes up to two cigarettes every weekend to “calm” her. She also notes that she has been having a preference for vaping. She is a social drinker. She drinks occasionally at social events. She has a preference for wine but is comfortable taking other alcoholic drinks. She denies taking any illicit substances or narcotics.
Sexual history and contraception/protection: The client is a single mother of one daughter. She is, however, in a monogamous relationship with her boyfriend. She is also sexually active and frequently indulges in sexual intercourse with her boyfriend. She denies using any form of contraceptive.
Other:

C.O. works as a financial adviser for one of the local companies. She is a caffeine lover, noting that she takes at least one glass of coffee to remain active and prevent her from dozing off during the day. She exercises regularly and attends yoga classes to help her address her anxiety. She also does random walks in the park during her stressful days. C.O. lives in a rented apartment with her 10-year-old daughter. C.O. was brought up in a well-off family. She denies having had any developmental concerns during her early childhood. She also denies having experienced any form of violence from her parents. She has had a positive relationship with her parents, all of whom are still alive. She also noted that her parents have been her leading source of social and emotional wellness.

Safety:

The client denies owning a gun. She notes that her current residence is safe as she has not experienced any form of violence or crime. She also notes that she has not had any change in residence recently. She practices safety behaviors, such as wearing safety belts when driving.

Family History:

Both of her parents are still alive. Her father has been battling generalized anxiety disorder since his early childhood and has been on medication. Her mother has no history of any psychiatric illness.

Review of Systems

Constitutional: The client denies experiencing any recent changes in her weight. She also denies fever or chills. She, however, notes that she is fatigued and attributes her fatigue to poor night sleep.

Eyes: Denies visual loss or any changes in her visual acuity. She also denies double vision or eye discharge.

Ears/Nose/Mouth/Throat: Denies any auditory loss, ear discharge, or tinnitus. She also denies experiencing any nasal congestion, or discharge, mouth sores, gum swelling or bleeding, sore throat, or pain during swallowing.

Cardiovascular: Denies palpitations, irregular heart rhythms, chest pain, or swelling in the extremities.

Pulmonary: Denies wheezing, labored breathing shortness of breath, or coughs. She also denies hemoptysis or pleuritic pain.

Gastrointestinal: Denies abdominal discomfort, pain, tenderness, or distension. She, however, reports experiencing frequent GI disturbances with alternating episodes of diarrhea and constipation. She experiences diarrhea mostly on the days when she is most tense and anxious.

Genitourinary: Denies experiencing any urinary urgency, frequency, or dysuria. She also denies experiencing pain during coitus.

Musculoskeletal: The client experiences episodes of muscle tension frequently. The tension often accompanies the anxiety and often manifests as muscle stiffness, especially in the lower and upper limbs, muscle aches, especially in the morning, and muscle pain. The muscle pain is often intermittent and lasts only a few minutes. They are relieved by exercise. She, however, denies experiencing any pain in her joints or having any limitations in the range of motion of her joints.

Integumentary & breast: The client reports experiencing sweats when she is anxious and tense. She denies having any skin color changes, hyper-pigmentation, skin rashes, or abnormal skin swellings. The color of her skin is also consistent. She also denies experiencing any breast anomalies, such as pain and tenderness.

Neurological: The client reports experiencing sporadic headaches. The headaches often accompany the anxiety. She also experiences occasional dizziness. She, however, denies syncope.

Psychiatric: The patient has generalized anxiety disorder for the past year.

Endocrine: Denies any recent weight changes. She also denies having heat or cold intolerance.

Hematologic/Lymphatic: Denies splenomegaly, or lymph node swelling. She also denies ease of bruising or excessive bleeding.

Allergic/Immunologic: The patient is allergic to animal dander.

Objective

Height 5’11 | Weight 180 lbs. | BMI 25.1

Labs, radiology, or other pertinent studies:

Thyroid function tests revealed a TSH level of 3.3 (mIU/L).

Complete Blood Count for P.B.: This test was necessitated to rule out any possible infection or inflammatory processes that may potentiate anxiety manifestations (Vedhara et al., 2022).

Hematology	Result	Normal range
Red cell count	5.5 x 10¹²/L	4.5–5.7
White cell count	8 x 10⁹/L	4.0–10.0
Hemoglobin	160 g/L	133–167
Hematocrit	0.50	0.35–0.53
MCV	80 fL	77–98
MCH	27 pg	26–33
MCHC	332 g/L	330–370
RDW	10.5%	10.3–15.3

Physical Exam

General Survey: The client seems restless and is notably sweating. She also appeared fatigued. There are, however, no signs of weight loss or chills.

HEENT: The head is normocephalic. The hair is evenly distributed on the scalp, with no signs of hair loss or abnormal hair thickening. There are no signs of swelling or scars on the client’s head. The eyes are symmetrical and well-positioned on the head. No sign of eye discharge, corneal dystrophy, bloodshot, or astigmatism. The visual acuity is 20/20. The ears are symmetrical and consistent in coloration with other parts of the head. They are lined with hair. The tympanic membrane is clear, with no exudate or discharge noted. No sign of uvula deviation.

Neck: The neck is symmetrical. The trachea is midline on the neck. There is no sign of swelling or nodular enlargement on the neck. No sign of jugular venous distension.

CVS: The heart rate is rhythmic. No gallop or pericardial friction rub sounds were heard on auscultation.

Chest/Thorax: The chest wall is symmetrical. No signs of labored breathing or use of accessory muscles of inspiration. The respiratory rate was rhythmic.

Abdominal: The abdomen is well-rounded and symmetrical. There are no signs of abdominal distension, scars, or skin color inconsistencies. There is also no sign of vein engorgement, striae, or abdominal masses. Abdominal sounds were heard in all four quadrants.

Musculoskeletal: The joints were symmetrical. No signs of joint stiffness of active and passive motion. There were also no signs of joint swelling, skin color changes on the joints, or scars on the joint area. There were also no signs of muscle stiffness or pain in active and passive movements.

Integumentary: There was notable sweating on the palms. However, there were no signs of skin color changes, scars, swellings, or rash. There were also no signs of finger clubbing or cyanosis. The capillary refill time on the upper and lower limbs was 2 seconds.

Neurological Examination

Cognition: The patient is cooperative and alert. She answers the interview questions asked appropriately. She can follow a three-step contra-lateral localization command. She can also name objects, as well as follow written commands.

Orientation: C.O. is fully aware of her surroundings. She is dressed appropriately for the event, time, and weather of the day. She verbalizes the reason for her seeking healthcare interventions and expresses her desire to get well.

Speech: The client has a normative speech. Her speech has normal intonation. No signs of shouting or slurred speech. Her speech is also goal-directed and logical.

Memory and reasoning: C.O.’s memory is intact. She can recall all the events of the interview, including questions asked in the last five minutes. Her reasoning is also logical.

Cerebellum

Balance: C.O. has a normal gait. She could easily make ten consecutive walking steps, in a heel-to-toe manner in a straight line with her eyes open for over 15 feet. She could also make five consecutive steps when walking on her toes. The patient could also maintain an upright position after 60 seconds of closing her eyes.

Sensory: The patient could determine the positions of her joints with her eyes closed. She could also distinguish two nearby objects at distinct points on her skin, as well as discern the symbols scribbled on her skin with her eyes closed. She could also detect different sensations including a cotton rub, vibrations, and pinpricks on her extremities.

determine the joint position sense while maintaining a closed

Motor System: C.O. could resist pressure applied bilaterally to her deltoids, triceps, and biceps. Her hand grip was also excellent. She could easily make squat and jump movements.

Reflexes: Bilateral deep tendon reflexes were noted on the Achilles, biceps, triceps, and patellar

Assessment

Differential Diagnoses

Generalized Anxiety Disorder (GAD) ICD-10 Code F41.1: GAD is a mental health illness characterized by intense worry and a persistent feeling of being overwhelmed. According to the fifth edition Diagnostic and Statistical Manual for Mental Health Disorders (DSM-V), GAD presents with unrealistic worry about things others consider normal. A positive diagnosis for GAD is made in the presence of anxiety exceeding six months. The patients must be having difficulty controlling the worry, and the anxiety must have been causing significant social and occupational distress. Likewise, the anxiety must be accompanied by a constellation of symptoms such as restlessness, muscle tension, difficulty concentrating, fatiguability, irritability, and sleep disturbance (Mishra & Varma, 2023). The patient in the case presented had been experiencing anxiety for the past year. The anxiety has been affecting her mental wellness, work, and relationships. The anxiety was also accompanied by symptoms of muscle tension, fatiguability, sleep disturbance, and difficulty concentrating. These manifestations are consistent with those of GAD, warranting the inclusion of this differential.
Bipolar Disorder ICD-10 Code F30.9: Bipolar disorder is a psychiatric illness characterized by alternating episodes of depression and mania. In the depressive phase, the patient will manifest with classical depressive symptoms such as hopelessness and depressed mood. In the manic phase, patients with bipolar will manifest with an irritable mood, decreased need for sleep, grandiosity, distractibility, and a flight of ideas, among others. Likewise, symptoms of sweating may be apparent (Goes, 2023). The patient in the case presented was restless and had difficulty concentrating. These manifestations are similar to those of mania, warranting the inclusion of this differential. A comprehensive history is necessary to rule out manifestations of the depressive episodes of bipolar disorder.
Hyperthyroidism ICD-10 Code E05: Hyperthyroidism is a medical condition characterized by excessive production of the thyroid hormone. It has a multifactorial etiology, with Graves’ disease, toxic multinodular goiter, and toxic adenoma being implicated in the majority of the cases. Persons with hyperthyroidism will commonly manifest with symptoms of unintentional weight loss, increased anxiety, muscle weakness, increased frequency of bowel movements with subsequent diarrhea, and hair loss, among other symptoms. Physical exam reveals sweating, restlessness, and an anxious appearance (Wiersinga et al., 2023). The patient in the case presented had anxiety and diarrhea. Assessment findings also revealed restlessness and moist skin. These symptoms are consistent with those of hyperthyroidism. A thyroid function test is necessary to rule out this diagnosis.

Diagnosis: The presumptive diagnosis in the case presented is generalized anxiety disorder. The symptoms of anxiety for more than six months, patient difficulty in controlling the anxiety, and the anxiety symptoms causing social and occupational distress, coupled with the symptoms of muscle tension, sleep disturbances, restlessness, and sweating, are consistent with those of GAD per the DSM-V criteria for diagnosing GAD. Additionally, the thyroid function tests ruled out hyperthyroidism,m and the assessment findings from the case were negative for depressive manifestations ruling out bipolar disorder.

Plan

Generalized Anxiety Disorder

Diagnostics:

Thyroid function tests to rule out hyperthyroidism. Hyperthyroidism often presents with manifestations of increased anxiety, moist skin, restlessness, and insomnia that could be confused with GAD (Wiersinga et al., 2023).
Toxicological screen to rule out substance abuse as the likely cause of the anxiety. Prolonged use of alcohol and other substances of abuse can increase the risk of developing anxiety attacks. Likewise, anxiety has been associated with alcohol withdrawal (Mohamed et al., 2020).
Blood glucose level to rule out hypoglycemia, as low blood sugar can mirror anxiety manifestations (Wu et al., 2023).

Treatment

The patient will be initiated on 10mg of escitalopram administered in a once-daily dosing. Escitalopram belongs to the class of selective serotonin reuptake inhibitors. Along with SNRIs, these agents are the first line in the management of anxiety. They are highly effective in lowering anxiety symptoms and are fairly tolerable (Edinoff et al., 2021).
Pharmacotherapy in anxiety disorders is only recommended in moderate to severe disease and when non-pharmacotherapy fails to calm the patients. The patient in the case presented may benefit from these medications as she has a severe disease (Mishra & Varma, 2023).
The patient will also be scheduled for a cognitive behavioral therapy session to help address her worries. Combination therapy involving pharmacotherapeutic and non-pharmacotherapeutic measures maintains superiority over either agent used alone in addressing anxiety symptoms (Mishra & Varma, 2023). Their combined use is, therefore, likely to produce maximal benefits in calming the patient.

Education:

The patient will be educated on the disease process and the available therapeutic options for GAD. She will be told that GAD is a chronic mental health illness if left unmanaged, can result in significant disease complications. Some of the possible complications of unmanaged GAD include depression and substance use disorder. These illnesses are common comorbidities in GAD that become apparent when the primary disease is under-addressed (Mishra & Varma, 2023).
The patient will also be educated on the significance of pharmacotherapy and CBT in managing GAD. She will be told of the importance of adhering to the prescribed medications and attending her CBT sessions to lower anxiety manifestations. She will also be educated on the likely side effects of escitalopram, such as nausea, dry mouth, and headaches, and be advised to visit the clinic if she develops the side effects (Edinoff et al., 2021).
The patient will also be educated on lifestyle modifications that may help in lowering the frequency of her anxiety attacks. She should be advised to minimize caffeine intake. Caffeine and other stimulants are known triggers for anxiety attacks. They may also lower the effectiveness of therapy in addressing anxiety manifestations (Mishra & Varma, 2023).
Likewise, she will be encouraged to minimize alcohol consumption and cigarette smoking as alcohol use may increase her chances of developing substance use and anxiety disorder comorbidity (Mishra & Varma, 2023).

Follow-Up:

The patient should return for follow whenever she experiences any side effects that may be affecting her ability to perform her activities of daily living. She is also expected to return for a follow-up clinic after two weeks to enable the assessment of her response to the prescribed medications. A referral to a psychiatrist may be necessary when the response to the prescribed therapy is suboptimal.

References

Edinoff, A. N., Akuly, H. A., Hanna, T. A., Ochoa, C. O., Patti, S. J., Ghaffar, Y. A., Kaye, A. D., Viswanath, O., Urits, I., Boyer, A. G., Cornett, E. M., & Kaye, A. M. (2021). Selective serotonin reuptake inhibitors and adverse effects: A narrative review. Neurology International, 13(3), 387–401. https://doi.org/10.3390/neurolint13030038

Goes, F. S. (2023). Diagnosis and management of Bipolar Disorders. BMJ. https://doi.org/10.1136/bmj-2022-073591

Mishra, A. K., & Varma, A. R. (2023). A comprehensive review of Generalized Anxiety Disorder. Cureus. https://doi.org/10.7759/cureus.46115

Mohamed, I. I., Ahmad, H. E., Hassaan, S. H., & Hassan, S. M. (2020). Assessment of anxiety and depression among substance use disorder patients: A case-control study. Middle East Current Psychiatry, 27(1). https://doi.org/10.1186/s43045-020-00029-w

Vedhara, K., Ayling, K., Jia, R., Fairclough, L., Morling, J. R., Ball, J. K., Knight, H., Blake, H., Corner, J., Denning, C., Bolton, K., Jackson, H., Coupland, C., & Tighe, P. (2022). Relationship between anxiety, depression, and susceptibility to severe acute respiratory syndrome coronavirus 2 infection: Proof of concept. The Journal of Infectious Diseases, 225(12), 2137–2141. https://doi.org/10.1093/infdis/jiac006

Wiersinga, W. M., Poppe, K. G., & Effraimidis, G. (2023). Hyperthyroidism: Aetiology, pathogenesis, diagnosis, management, complications, and prognosis. The Lancet Diabetes & Endocrinology, 11(4), 282–298. https://doi.org/10.1016/s2213-8587(23)00005-0

Wu, C., Wang, W., Cheng, S., Zhang, H., Li, L., Tian, C., Zhang, L., Chen, N., Du, J., Ren, L., & Lang, H. (2023). The relationship between components of hypoglycemia worries and avoiding hypoglycemia behavior in type 2 diabetes mellitus with hypoglycemia: A network analysis. BMC Psychiatry, 23(1). https://doi.org/10.1186/s12888-023-04698-9

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Create a pretend SOAP NOTE GENERALIZED ANXIETY DISORDER. I ATTACHED some details. Please DO NOT use the textbook as a reference. We need to use the Clinical Guidelines. You can also use my up-to-date account to find clinical guidelines and treatments

SOAP NOTE – Generalized Anxiety Disorder

This is a SOAP NOTE on Generalized Anxiety Disorder, so please only include what is pertinent on ROS and Physical exam based on the complaint. You can use our SOAP NOTE TEMPLATE
On the Assessment part, put rationale why it is your main diagnosis and also rationales for the two differentials on why it is not the main diagnosis.
Please make sure to put in-text citations on assessment, treatment, diagnostics, etc. that need references.
Please use a Clinical Guidelines reference within the last 5 years,
Make sure the correct spelling, grammar, and abbreviation rules are correct too.
PLEASE MAKE SURE IT’S PLAGIARISM FREE.

Some pretend details, but please rewrite it to be more plagiarism-free

E.B. is a 34-year-old female presenting with a one-year history of generalized anxiety that has progressively worsened over the past six months. She describes her anxiety as constant, with a heightened state of worry and tension that affects her overall mental well-being. The anxiety is pervasive and not localized, leading her to worry about various aspects of her life, including work, relationships, and health. E.B. experiences these symptoms daily, with episodes lasting several hours and presenting “almost every day.”
The characteristics of her anxiety include restlessness, muscle tension, difficulty concentrating, irritability, and frequent sleep disturbances, such as trouble falling asleep and waking up multiple times during the night. Factors that aggravate her anxiety include stress at work, conflicts in personal relationships, and caffeine intake. E.B. finds temporary relief from her symptoms by talking to friends and family and engaging in activities like yoga and mindfulness exercises, although the relief is often short-lived.
E.B.’s anxiety is most intense in the morning when she wakes up and remains elevated throughout the day, especially increasing before important meetings at work or social gatherings. She notices a significant escalation of symptoms towards the end of the week. E.B. rates her anxiety severity as a 7 out of 10 on most days, indicating a substantial impact on her ability to focus on her job and maintain relationships. Additionally, she reports frequent headaches, gastrointestinal discomfort, and episodes of sweating, which she attributes to her anxiety. Overall, her symptoms have significantly affected her quality of life and meet the diagnostic criteria for Generalized Anxiety Disorder (GAD) according to the DSM-5 (American Psychiatric Association, 2023).

SOAP NOTE – Generalized Anxiety Disorder