Submit 1 Mini-SOAP note on a patient

Posted: August 7th, 2024

Submit 1 Mini-SOAP note on a patient that you saw in clinic this week. Submit as a Word Document. See example template below for required format.
Review the rubric for more information on how your assignment will be graded.
Demographic Data
• Patient initial (one initial only), age, and gender must be Health Insurance Portability and Accountability (HIPPA) compliant.
Subjective
• Chief Complaint (CC)
• History of Present Illness (HPI) (symptoms) in paragraph format
• Past Medical History (PMH): Current problem-focused and document pertinent information only.
• Current Medications:
• Medication Allergies:
• Social History: For current problem-focused and document only pertinent information only.
• Family History: For current problem-focused and document only pertinent information only.
• Review of Systems (ROS) as appropriate:
Objective
• Vital signs
• Mental Status Exam
• Physical findings listed by body systems, not paragraph form.
• Patient Health Questionnaires, Screenings, and the results (PHQ-9, GAD 7, suicidal)
Assessment (Diagnosis/ICD10 Code)
• Include all diagnoses that apply to this visit.
• Include one differential diagnosis.
Plan
• Dx Plan (lab, x-ray)
• Tx Plan: (meds)
• Pt. Education, including specific medication teaching points.   
• Safety Plan       
• Referral/Follow-up
*Based on population focus, some additional details may be required by faculty Top of Form
==============
Mini-SOAP note:
Demographic Data:
Patient: L.P, 28, Female
Subjective:
Chief Complaint (CC): “I can’t focus and feel anxious all the time.”
History of Present Illness (HPI): Patient reports a 3-month history of increasing difficulty concentrating at work and persistent feelings of worry. She describes feeling restless, irritable, and on edge most days. Sleep has been disrupted, with trouble falling and staying asleep. These symptoms have begun to affect her job performance and relationships.
Past Medical History (PMH): No significant medical history.
Current Medications: None.
Medication Allergies: None known.
Social History: Works as a marketing executive. Reports high stress levels at work. Non-smoker, social drinker (1-2 drinks/week). Lives alone, single.
Family History: Mother with history of depression.
Review of Systems (ROS): Positive for fatigue and muscle tension. Negative for weight changes, appetite changes, or suicidal ideation.
Objective:
Vital signs: BP 118/76 mmHg, HR 82 bpm, RR 16 breaths/min, Temp 98.2°F (36.8°C)
Mental Status Exam: Alert and oriented x3. Appears anxious with restless movements. Speech is rapid but coherent. Mood anxious, affect congruent. Thought process logical. No evidence of delusions or hallucinations.
Physical findings:

General: Well-groomed, appears stated age
HEENT: Normocephalic, atraumatic
Cardiovascular: Regular rate and rhythm, no murmurs
Respiratory: Clear to auscultation bilaterally
Neurological: Cranial nerves II-XII intact, no focal deficits

Patient Health Questionnaires:

GAD-7 score: 16 (Severe anxiety)
PHQ-9 score: 8 (Mild depression)
Columbia-Suicide Severity Rating Scale: Negative for current suicidal ideation

Assessment:

Generalized Anxiety Disorder (F41.1)
Differential Diagnosis: Adjustment Disorder with Anxiety

Plan:
Dx Plan: No additional diagnostic tests indicated at this time.
Tx Plan:

Start Sertraline 50 mg PO daily, to be increased to 100 mg after 1 week if tolerated
Refer to cognitive-behavioral therapy (CBT)

Pt. Education:

Explained nature of generalized anxiety disorder and treatment options
Discussed potential side effects of Sertraline, including initial increase in anxiety, nausea, and sleep disturbances
Emphasized importance of consistent medication use and follow-up appointments
Recommended stress reduction techniques: deep breathing exercises, progressive muscle relaxation, and mindfulness meditation

Safety Plan:

Provided crisis hotline number
Instructed to seek immediate care if suicidal thoughts develop

Referral/Follow-up:

Referral to therapist for CBT
Follow-up appointment in 2 weeks to assess medication response and side effects
Encouraged to call if symptoms worsen or side effects become intolerable

References

Bandelow, B., Michaelis, S., & Wedekind, D. (2017). Treatment of anxiety disorders. Dialogues in Clinical Neuroscience, 19(2), 93-107. https://doi.org/10.31887/DCNS.2017.19.2/bbandelow
Craske, M. G., & Stein, M. B. (2022). Anxiety. The Lancet, 399(10345), 2138-2151. https://doi.org/10.1016/S0140-6736(22)00136-5
Driot, D., Ouhayoun, S., Perinelli, F., Grézy-Chabardès, C., Birebent, J., & Bismuth, M. (2019). Non-drug and drug alternatives to benzodiazepines for insomnia in primary care: Study among GPs and pharmacists of Toulouse. Therapies, 74(5), 537-546. https://doi.org/10.1016/j.therap.2019.03.002
Slee, A., Nazareth, I., Freemantle, N., & Horsfall, L. (2021). Pharmacological treatments for generalised anxiety disorder: A systematic review and network meta-analysis. The Lancet, 397(10277), 867-877. https://doi.org/10.1016/S0140-6736(21)00475-4
Zhu, Y., Wang, Y., Wang, P., & Wang, H. (2023). The efficacy of cognitive behavioral therapy for generalized anxiety disorder: A systematic review and meta-analysis. Frontiers in Psychiatry, 14, 1135793. https://doi.org/10.3389/fpsyt.2023.1135793