Panic disorder
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
This study source was downloaded by 100000897906157 from CourseHero.com on 07-01-2025 15:09:09 GMT -05:00
https://www.coursehero.com/file/243867344/Panic-disorder-SOAPdocx/
, 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 ROS: see above
This is where the Objective data
“facts” are located. Vital Signs
Include relevant labs, BP: 120/76 HR: 83 RR: 18 SPO2: 97% T: 98.5
test results, vitals, and Pain: 0/10
Height: 5’10 Weight: 170 BMI: 24.4 normal
Review of Systems
Diagnostic results:
(ROS) – if ROS is
GAD-7 : score 10, which indicates moderate anxiety
negative, “ROS
Panic Disorder Severity Scale: score 11 this is not a diagnostic tool
noncontributory,” or
but a score of 9 and above suggest the need for a formal diagnostic
“ROS negative with
assessment.
the exception of…”
Thyroid function test, CBC, CMP, Troponin: Normal
Include MSE, risk
Toxicology screening: negative
assessment here, and
BAC level: normal
psychiatric screening
ECG: Normal
measure results.
Mental status examination
He is a 20-year-old Caucasian man who is in decent physical shape,
walks regularly, dresses appropriately, has a clean appearance, and
overall seems his age. He cooperates, maintains eye contact,
remains attentive, and exhibits strong communication skills
throughout the assessment. Although his affect is normal, his mood
This study source was downloaded by 100000897906157 from CourseHero.com on 07-01-2025 15:09:09 GMT -05:00
https://www.coursehero.com/file/243867344/Panic-disorder-SOAPdocx/
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
This study source was downloaded by 100000897906157 from CourseHero.com on 07-01-2025 15:09:09 GMT -05:00
https://www.coursehero.com/file/243867344/Panic-disorder-SOAPdocx/
, 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 ROS: see above
This is where the Objective data
“facts” are located. Vital Signs
Include relevant labs, BP: 120/76 HR: 83 RR: 18 SPO2: 97% T: 98.5
test results, vitals, and Pain: 0/10
Height: 5’10 Weight: 170 BMI: 24.4 normal
Review of Systems
Diagnostic results:
(ROS) – if ROS is
GAD-7 : score 10, which indicates moderate anxiety
negative, “ROS
Panic Disorder Severity Scale: score 11 this is not a diagnostic tool
noncontributory,” or
but a score of 9 and above suggest the need for a formal diagnostic
“ROS negative with
assessment.
the exception of…”
Thyroid function test, CBC, CMP, Troponin: Normal
Include MSE, risk
Toxicology screening: negative
assessment here, and
BAC level: normal
psychiatric screening
ECG: Normal
measure results.
Mental status examination
He is a 20-year-old Caucasian man who is in decent physical shape,
walks regularly, dresses appropriately, has a clean appearance, and
overall seems his age. He cooperates, maintains eye contact,
remains attentive, and exhibits strong communication skills
throughout the assessment. Although his affect is normal, his mood
This study source was downloaded by 100000897906157 from CourseHero.com on 07-01-2025 15:09:09 GMT -05:00
https://www.coursehero.com/file/243867344/Panic-disorder-SOAPdocx/
