SOAP NOTES (1).docx - SUBJECTIVE Chief Complaint u201cI am...

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SUBJECTIVE Chief Complaint: “I am always anxious" History of presenting illness: 25 year old African American female presents to the clinic for been too anxious and needs psychotherapy. she complains she has seek medical advice and has been referred to the psychiatrist and psychotherapist denies SI, HI, VH, AH. She believes with appropriate help she will get relieved of her anxiety. she sometimes get anxious for no reason. she has tries to control it but she can't help it . Past psychiatric hx:None Medical Hx: None Legal History: None Social/Development History: single OBJECTIVE Mental Status Exam Appearance: thin appearing, appears older stated age, good hygiene, Behavior: Calm, cooperative, engaged, pleasant, appropriate eye contact Motor: Normal (no psychomotor retardation/agitation) Speech: Fluent, coherent, Normal tone, rate and volume Mood: no disturbance Affect: congruent Thought Process: linear, coherent. Thought Content: No SI/HI no delusions, Perception disturbance: No AH/VH Orientation: Awake and alert x 4 Cognition: Memory, concentration, attention, abstraction, fund of knowledge, language grossly intact Insight/ Judgement: full/ good Impulse Control: Good Review of Systems General: No acute distress, well appearing Constitutional: No fever, No chills.
Respiratory: No shortness of breath, No cough, No wheezing. Cardiovascular: No chest pain, No palpitations. Gastrointestinal: No nausea, No vomiting, No diarrhea, No heartburn. Genitourinary: No dysuria, No urinary frequency, No urinary urgency. Musculoskeletal: No joint pain, No muscle pain. Neurologic: Alert and oriented X4. VS:WNL ASSESSMENT DSM-5 Diagnoses 1. F064 - Anxiety disorder due to known unknown physiological condition PLAN AND RECOMMENDATION 1) Initial cognitive behavioral therapy Cognitive Pie Chart Exercise Investigating Thoughts Cognitive Techniques to Reduce Worry Treating Thoughts as Guesses Constructive Worry Acceptance Exercises Identifying Cognitive Distortions a. Catastrophizing b. Fortune-telling c. Mind reading d. Negative filtering e. Labeling f. Overgeneralizing g. All-or-nothing thinking Cognitive Behavioral Therapy Exercises: Activity Scheduling • Identifying Behavioral Causes of Depression
• Behavioral Activation Problem Solving Relaxation Breathing Training 2) Safety plan discussed 3) Medication: Zoloft 50 mg PO QDAY 4) Follow up in 1 week. CASE 2 Patient Information ? Gender: Male ? Height and Weight:6'2 190lbs ? Marital status: Married. ? Occupation: store worker ? Current medication: None ? Past Psychiatric medication: None ? Allergies: None ? Chief complaint: Patient stated “i don't understand myself anymore, things no longer interest me, after my divorce i became moody,I seem to loose concentration very often, I feel so hopeless, I don’t feel like getting out of bed or talking to anyone, I don’t eat normal, and I seem to loose concentration, I need help” ? Medical history: None ? Psychiatric history: None Family history: Uncle diagnosed with depression ? Psychosocial/Developmental History: within normal limit. He met all developmental milestones growing up. just went through a divorce ?

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