Panic disorder SOAP
Criteria Clinical Notes
Subjective Patient information: Susan 45-year-old Caucasian female .
Include chief CC: “I’ve been having trouble sleeping”
complaint, subjective HPI:
information from the Susan is a 45-year-old Caucasian female who visited the
clinic with
patient, names and complaints of sleep disturbances for last three months. She
recently
relations of others underwent a hysterectomy due to uterine fibroids. Her
OBGYN
present in the physician, Dr. Ferris, prescribed hormone replace therapy
(HRT) but
interview, and basic patient, after doing some of her own research, decided to
demographic discontinue treatment because of concerns about potential
cancer
information of the risks, especially due to her mother’s history of cancer. After
her
patient. HPI, Past decision to stop HRT, Susan had experienced sleeping
disturbances
Medical and such as tossing and turning, inability to achieve deep sleep,
and
Psychiatric History, sleeping only 2-3 hours per night. She reported feeling
anxious and
Social History. desperate to sleep, and increase in stress levels due to her
inability
to focus during the day on her work. Susan reported that her
job
performance is negatively impacted by her lack of sleep, and
also
social interactions with her friends. She stated that she
needs to take
naps during the day whenever possible, and that disrupts her
daily
life and schedule. Also, reported that over-the-counter sleep
aids are
not helping much.
Past Psychiatric History
General statement: Denies history of mental illness.
Caregiver: none
Hospitalizations: none
Allergies: NKDA
Medications: D.C. does not currently take any medication.
Was
prescribed HRT but does not take anymore.
Pychotherapy or prior psychiatric diagnosis: Denies.
, Substance abuse history: patient denies taking any drugs or
smoking, or drinking alcohol.
Family Psychiatric history: Mother was diagnosed with GAD
after
her cancer diagnosis. Denies any suicides, or any other
known
psychiatric conditions in the family.
Social history: D.C. has an older sister, who is married and
moved
to North Carolina. They were raised by both parents, who still
live in
Castro Valley, CA where they grew up. D.C. moved to L.A. a
year
and a half ago to attend school full-time at UCLA for a degree
in
Chemistry. He is not married or have any children. He is not
currently dating anyone since his studies and friends take
most of
his time. He likes to swim, run, and hang out with his
friends in his free time. He has never experienced trauma
or violence, and he has no past legal issues.
Medical History: History of benign uterine fibroids, recent
hysterectomy.
Reproductive history: currently abstinent
ROS
General: Denies chills, fatigue, or recent weight changes.
Only brief episodes of diaphoresis.
HEENT: Head – denies headaches, or lightheadness, or
trauma. Eye – denies blurry vision, or photophobia or pain.
Ear – denies pain or discharge, or hearing loss. Nose and
Throat: denies any pain/soreness or other issues.
Skin: denies jaundice, itchiness, or rashes.
Cardiovascular: Reports palpitations, chest
thightness, and shortness of breath. Denies any
edema, but states he has orthopnea.
Respiratory: Denies cough, wheezing, phlegm but
reports chest discomfort, shortness of breath without
exertion, and orthopnea. GI: Denies N/V/D/C. Denies
acid reflux.
Neurological: Denies numbness, tingling, headaches,
dizziness, or syncope.
Objective
Criteria Clinical Notes
Subjective Patient information: Susan 45-year-old Caucasian female .
Include chief CC: “I’ve been having trouble sleeping”
complaint, subjective HPI:
information from the Susan is a 45-year-old Caucasian female who visited the
clinic with
patient, names and complaints of sleep disturbances for last three months. She
recently
relations of others underwent a hysterectomy due to uterine fibroids. Her
OBGYN
present in the physician, Dr. Ferris, prescribed hormone replace therapy
(HRT) but
interview, and basic patient, after doing some of her own research, decided to
demographic discontinue treatment because of concerns about potential
cancer
information of the risks, especially due to her mother’s history of cancer. After
her
patient. HPI, Past decision to stop HRT, Susan had experienced sleeping
disturbances
Medical and such as tossing and turning, inability to achieve deep sleep,
and
Psychiatric History, sleeping only 2-3 hours per night. She reported feeling
anxious and
Social History. desperate to sleep, and increase in stress levels due to her
inability
to focus during the day on her work. Susan reported that her
job
performance is negatively impacted by her lack of sleep, and
also
social interactions with her friends. She stated that she
needs to take
naps during the day whenever possible, and that disrupts her
daily
life and schedule. Also, reported that over-the-counter sleep
aids are
not helping much.
Past Psychiatric History
General statement: Denies history of mental illness.
Caregiver: none
Hospitalizations: none
Allergies: NKDA
Medications: D.C. does not currently take any medication.
Was
prescribed HRT but does not take anymore.
Pychotherapy or prior psychiatric diagnosis: Denies.
, Substance abuse history: patient denies taking any drugs or
smoking, or drinking alcohol.
Family Psychiatric history: Mother was diagnosed with GAD
after
her cancer diagnosis. Denies any suicides, or any other
known
psychiatric conditions in the family.
Social history: D.C. has an older sister, who is married and
moved
to North Carolina. They were raised by both parents, who still
live in
Castro Valley, CA where they grew up. D.C. moved to L.A. a
year
and a half ago to attend school full-time at UCLA for a degree
in
Chemistry. He is not married or have any children. He is not
currently dating anyone since his studies and friends take
most of
his time. He likes to swim, run, and hang out with his
friends in his free time. He has never experienced trauma
or violence, and he has no past legal issues.
Medical History: History of benign uterine fibroids, recent
hysterectomy.
Reproductive history: currently abstinent
ROS
General: Denies chills, fatigue, or recent weight changes.
Only brief episodes of diaphoresis.
HEENT: Head – denies headaches, or lightheadness, or
trauma. Eye – denies blurry vision, or photophobia or pain.
Ear – denies pain or discharge, or hearing loss. Nose and
Throat: denies any pain/soreness or other issues.
Skin: denies jaundice, itchiness, or rashes.
Cardiovascular: Reports palpitations, chest
thightness, and shortness of breath. Denies any
edema, but states he has orthopnea.
Respiratory: Denies cough, wheezing, phlegm but
reports chest discomfort, shortness of breath without
exertion, and orthopnea. GI: Denies N/V/D/C. Denies
acid reflux.
Neurological: Denies numbness, tingling, headaches,
dizziness, or syncope.
Objective
