SOAP Note Essay Assignment Discussions

SOAP Note Essay Assignment Discussions

Hello! You helped me in the past with my SOAP notes. Thank you! I need few more, please. 1.Birth Control Method for a young woman, 2. Hypertension patient, 3. Diabetic patient, 4.Lower back pain patient, 5. COPD patient, 6. Anxiety patient. There is no need for references, my teacher likes lots of detail about presentation and both non pharmacological and pharmacological approach to everything. Thank you so much!

ORDER A PLAGIARISM-FREE PAPER HERE

SOAP Note

Patient information

Patient initials: M.K Age: 53 Race: Hispanic Gender: male

CC:” Can I have my blood pressure checked?”

HPI: M.K, a 53-year-old Hispanic male, stepped in to get his blood pressure checked. He added that he had checked his blood pressure two weeks before to his visit in a mall near his office, and the measurement of 144/105 mmHg really startled him. He has been having inexplicable headaches and chest discomfort for the past 8 weeks, which he rates as a 7/10, and the pain intensifies when he falls asleep. He had presumed the symptoms were typical and had not sought medical attention. He denies having history of syncope, dyspnea, or edema, but admit to having nosebleeds and fatigue in the last month.

Medication: Metformin HCL 850 P0 taken once daily.

Allergies: no known drug or food allergies

PMHX: Diabetes, well managed by Glucophage XR

Past surgical history: none reported.

Family history: Father (83-y/o): diabetes type 2. Mother (77 y/o): hypertension. Maternal grandfather (deceased): hypertension. Maternal grandmother (deceased): breast cancer. Maternal grandfather (deceased): stroke. Elder brother (59 y/o): Asthma.

Social history: M.K, a Hispanic patient, was born in the Georgian city of Macon at the age of 53. He’s a full-time instructor at a local college. He is married to a single lady who works as a nurse, and they have three college-age children. He reported smoking more frequently and drinking alcohol on weekends. He reported going to gymnastics twice a week with his wife for fitness. He is financially secure and has insurance. Reported living in a safe neighborhood, wearing a seat belt, and never using a phone or driving while under the influence of alcohol. Consumes a nutritious diet high in fruits and vegetables.

ROS

General: No fevers, chills, but significant weight gain reported.

HEENT: Reported severe headache and dizziness. Denies loss of hearing, and sinusitis. Reported frequent nosebleed, denies sinusitis, and frequent sore throat.

Cardiovascular: Reported chest pain and dyspnea. Denies irregular heartbeats, heart murmur, and pain in the feet.

Respiratory: Denies SOB, and chronic cough

GI: Denies decrease in appetite, heartburn, nausea, vomiting, or diarrhea.

GU: Denies pain, or burning with urination, urinary urgency and frequency.

Msk: Denies muscle weakness, joint swelling, or any orthopedic injuries.

Neurologic: Reported unexplained headache, and dizziness, denies muscle spasm, and fainting.

Psychiatric: Denies depression or anxiety. Denies homicidal ideation.

Endocrine: Denies heat or cold intolerances, increases in thirst, and decreases in sexual desire.

Skin/lymph/heme: Denies skin redness, rash, or changes in skin color.

VTS: BP 154/105 left arm, sitting using regular adult cuff. Wt.: 203lb Ht.: 5’6 T.: 37.8 RR: 20 P: 80 Sp02: 98%

General: A&Ox3, appear mildly distress. Well-nourished. Appear his stated age.

HEENT; normocephalic and atraumatic. Hair is normal in texture; visual acuity 20/20, sclera non-icteric. EOMI, PERRLA, no sign of nystagmus. Snares patent bilaterally. Hearing intact with good acuity. No buccal nodule noted. Carotid pulse 2+ bilaterally without bruit.

Cardiovascular: Heartbeat irregular, no murmur, SI and S2 heard and are of normal intensity.

Respiratory: Chest wall is symmetric and non-tender. No signs of respiratory distress noted., lungs sound is clear without rales. Resonance is normal upon percussion.

Skin: Warm and dry. Normal texture

Abdomen: Soft and symmetrical without distention. Bowel sounds are normoactive. No masses noted.

Extremities: Atraumatic with tenderness. No swelling noted. Muscle strength 5/5 bilaterally. Capillary refill >3sec.

Neuro: Cranial nerve intact. Sensation intact bilaterally. Memory and thought process intact.

Psychiatric: He is oriented to place and time, no abnormal affect noted.

Assessment:

Lab test and result

CBC: result pending

TSH test: result pending

Chest Xray: result pending

Diagnosis

Differential diagnosis

Essential Hypertension

This is the most common type of hypertension, affecting millions of people worldwide. This condition often develops gradually over time and is more common in men than in women. While its etiology is unknown, genetic and environmental factors are thought to play a role in its pathogenesis. Essential hypertension causes blood pressure to rise significantly above normal levels (Saxena et al.,2018). Common symptoms of essential hypertension include headaches, dizziness, fatigue, and difficulty breathing, all of which were present in the patient’s case. Furthermore, the patient’s ancestry and lifestyle may be factors in this diagnosis.

Congestive heart Failure

This is a complicated clinical condition in which the heart is unable to fully pump to suit the body’s metabolic demands. This condition can be caused by coronary artery disease, hypertension, vulvar heart disease, or cardiomyopathies (Porumbs et al.,2020). CHF symptoms include overall weariness, hard breathing, and chest discomfort. It was also linked to right hypochondrial discomfort, persistent cough, weight gain, loss of appetite, and edema, none of which were present in the case scenario.

Chronic Kidney Disease

Chronic kidney failure (CKF) is a long-term gradual reduction in kidney function. It can be caused by a variety of diseases, including diabetes, hypertension, and glomerulonephritis. CKF can cause a variety of major health issues, including anemia, bone disease, and cardiovascular disease. CKF normally develops over time, however it can emerge unexpectedly in persons who have never had any previous kidney issues (Gichoni et al.,2018). It is characterized by weariness, chest discomfort, elevated blood pressure, headache, and dizziness. This might be a diagnosis since the patient has high blood pressure and is diabetes. However, this condition is also accompanied with additional symptoms such as shortness of breath, weight loss, and unconsciousness, which were not present in the M.K clinical presentation.

Primary diagnoses: Essential hypertension

Lab test: Patient cholesterol and creatinine levels need to be tested.

Medication: Give Prinivil 10mg PO to be taken once daily for six weeks more so before bedtime (Gujjarlamudi et al.,2018).

Patient education: The patient must be thoroughly counselled on lifestyle changes including avoiding alcohol intake, minimizing salt intake, and using DAS diet on consistent basis. He must be advised on monitoring his blood pressure on a regular. The patient must be encouraged to adhere to prescription for better result.

Follow-up: After 6 weeks of therapy, the patient must report back to the clinic for further assessment.

Referral: in case of any complication, the patient should be referred to the cardiologist, and nephrologist for further intervention.

References

Saxena, T., Ali, A. O., & Saxena, M. (2018). Pathophysiology of essential hypertension: an update. Expert review of cardiovascular therapy, 16(12), 879-887.

Porumb, M., Iadanza, E., Massaro, S., & Pecchia, L. (2020). A convolutional neural network approach to detect congestive heart failure. Biomedical Signal Processing and Control, 55, 101597.

Gichoni, P. (2018). Evaluation of Therapy Adherence Among Patients With End Stage Renal Disease at Kenyatta National Hospital (Doctoral dissertation, University of Nairobi).

Gujjarlamudi, H. B., Jose, A., & Dupaguntla, R. (2018). Cost analysis of ACE inhibitors and ARBs used in essential hypertension. Asian Journal of Pharmacy and Pharmacology, 4(3), 275-279.

SOAP Note

Patient information

Patient initials: G.F Age: 46 Race: Caucasian Gender: male

CC:” Persistent cough and yellowish sputum.”

HPI: G.F, a 46-year-old Caucasian male, presented to the clinic with a chief complaint of chronic cough and yellowish sputum. He also reported shortness of breath, chest tightness, and wheezing that exacerbated with exertion. He indicated that these sensations are interfering with his day-to-day activities and that he frequently used a mixture of hot water, ginger, and honey to calm them, but this only provided minor relief. The patient stated that he began having these symptoms 6 months ago. Denies nausea, vomiting, and diarrhea.

Medication: none

Allergies: Allergy: allergic to pollen grain, and Sulphur containing drugs

PMHX: Sinusitis and pneumonia that prompted hospitalizations but was successful managed.

Immunization: up-to-date. Last receive flu vaccine 4/2/22

Past surgical history: none reported.

Family history: Family history: mother (72. Y/o): hypertension, father (deceased): stroke maternal grandfather (deceased): COPD. Paternal grandfather(deceased): Hypertension. Paternal grandmother (deceased): Asthma.

Social history: G.F is a part-time lecturer at a nearby institution. He is married to a single woman, and they have a 24-year-old son. He denies using alcohol but confesses to smoking two cartons of cigarettes daily. He stated that he spent the most of his time operating his business in a nearby local market. Exercise once in a while. He is financially secure and has insurance for his family. He always wears his seat belt and avoids using phone while driving. Eat a well-balanced diet that is high in fruits and vegetables.

ROS

General: No fevers, chills, or significant changes in energy level reported.

HEENT: Denies loss of hearing vision, frequent nosebleed, and sore throat.

Cardiovascular: Denies chest pain and dyspnea

Respiratory: Reports chronic cough with yellow sputum, SOB, and wheezes

GI: Denies decrease in appetite, nausea, vomiting, or diarrhea.

GU: Denies urinary urgency and frequency.

Msk: Denies muscle weakness, joint swelling.

Neurologic: stable balance and gait.

Psychiatric: Denies depression or anxiety. Denies homicidal ideation.

Endocrine: Denies heat or cold intolerances

Skin/lymph/heme: Denies skin rash or significant changes in skin color.

VTS: BP 124/88 left arm, sitting using regular adult cuff. Wt.: 296lb Ht.: 5’6 T.: 37.8 RR: 20 P: 80 Sp02: 98%

General: A&Ox3, appear mildly distress. Well-nourished. Appear his stated age.

HEENT; normocephalic and atraumatic. Visual acuity 20/20, sclera non-icteric. EOMI, PERRLA, no sign of nystagmus. Snares patent bilaterally. Hearing intact with good acuity. No buccal nodule noted. Carotid pulse 2+ bilaterally without bruit.

Cardiovascular: Heartbeat irregular, no murmur, SI and S2 heard and are of normal intensity.

Respiratory: Chest wall is symmetric and non-tender. Yellowish sputum with chronic cough noted.

Skin: Warm and dry. Normal texture

Abdomen: Soft and symmetrical without distention. Bowel sounds are normoactive. No masses noted.

Extremities: Atraumatic with tenderness. No swelling noted. Muscle strength 5/5 bilaterally.

Neuro: Cranial nerve intact. Sensation intact bilaterally. Memory and thought process intact.

Psychiatric: He is oriented to place and time, no abnormal affect noted.

Assessment:

Lab test and result

Chest x-ray: hyperinflated lungs noted.

Spirometry: result pending

CBC: result pending.

Diagnosis

Differential diagnoses

Chronic obstructive pulmonary disease (COPD)

Chronic obstructive pulmonary disease (COPD) is a kind of obstructive lung disease characterized by long-term breathing issues and decreased airflow. Shortness of breath, wheezing, coughing, and chest tightness are the most prevalent symptoms. COPD is associated to a history of smoking, exposure to environmental pollutants, and genetic variables such as age (Hikichi et al.,2019). The illness is distinguished by sputum that may be clear but is commonly yellowish or greenish in color, and the predominant clinical manifestation is shortness of breath after activity. Based on clinical complaints and laboratory testing that confirmed hyperinflated lungs, this is the most likely diagnosis for the client.

ORDER HERE

Pneumonia

Pneumonia is a catastrophic lung infection that causes fluid to accumulate in the air sacs. This can make breathing difficult and even deadly. Pneumonia is a common complication of COPD that can be hard to identify from COPD exacerbations (Varshni et al.,2019). Coughing up green or yellow mucus and shortness of breath that worsens with activity are also symptoms of pneumonia. It has also been related to unexplained shivering chills, intense perspiration, severe stabbing chest discomfort, and fever that were not evident.

Acute sinusitis

Acute sinusitis is a disorder in which the sinuses become inflamed. This illness is generally brought on by an infection, although it can also be brought on by allergies or other irritants (Wyler et al.,2019). It is distinguished by nasal congestion that makes breathing difficult, thick, yellow or greenish mucus, facial pain, fever, and hyposmia, none of which were present in the client’s instance.

Primary diagnoses: COPD

Lab test: no further lab test is needed.

Medication: Give Ventolin HFA (2 puffs) to be inhaled after every 6 hours to relieve the symptoms.

Patient education: To get the greatest outcomes, the client should be properly instructed on how to use this inhaler. He must be educated of the importance and potential effects of such treatment. He should be advised on the need of stopping smoking because it adds to the progression of COPD. To help manage COPD symptoms, he should be encouraged to get the pneumococcal vaccine (Ignatova et al.,2021). He should be encouraged to eat more fruits and vegetables and to drink plenty of water.

Follow-up: After 6 weeks of therapy, the patient must report back to the clinic for further assessment.

Referral: in case of any complication, the patient should be referred to the pulmonologist for further intervention.

References

Hikichi, M., Mizumura, K., Maruoka, S., & Gon, Y. (2019). Pathogenesis of chronic obstructive pulmonary disease (COPD) induced by cigarette smoke. Journal of thoracic disease, 11(Suppl 17), S2129.

Varshni, D., Thakral, K., Agarwal, L., Nijhawan, R., & Mittal, A. (2019, February). Pneumonia detection using CNN based feature extraction. In 2019 IEEE international conference on electrical, computer and communication technologies (ICECCT) (pp. 1-7). IEEE.

Wyler, B., & Mallon, W. K. (2019). Sinusitis update. Emergency Medicine Clinics, 37(1), 41-54

Ignatova, G. L., Avdeev, S. N., & Antonov, V. N. (2021). Comparative effectiveness of pneumococcal vaccination with PPV23 and PCV13 in COPD patients over a 5-year follow-up cohort study. Scientific Reports, 11(1), 1-1

SOAP Note

Patient information

Patient initials: J.F Age: 62 Race: Caucasian Gender: male

CC:” Lower back pain”

HPI: J.F, a 62-year-old Caucasian man, presented to the clinic with the primary complaint of chronic lower back pain that began 8 weeks ago and has been radiating to the hip. The patient reported the pain as a dull throbbing ache, giving it a score of 7/10. He further reported the pain to increase with activity but lessened with rest. He further claimed that the ache becomes worse at night, disrupting his sleep. This prompted him to start using Tylenol 500mg OTC for pain relief, despite the fact that the improvement has been minimal. He also claimed to be fatigued. The patient indicated that his issues began a day after he was involved in a car accident wherein, he slammed his back severely on the curb, leaving him with bruises that have since disappeared but the ache has persisted. He claims he has no fever, nausea, vomiting, or diarrhea.

Medication: Tylenol 500mg 2tab P0 PRN, and Synthroid 50mcg 1tab QD for managing pain, and hypothyroidism respectively.

Allergies: no known drug or food allergies

PMHX: Diabetes which were well managed by lifestyle modification and hypothyroidism managed by mediation.

Immunization: up to date. Last received his MMR 7/3/2022, and HEP B vaccine 6/1/2022

Past surgical history: none reported.

Family history: Father (85-y/o): hypothyroidism. Mother (81 y/o): Breast cancer. Maternal grandfather (deceased): diabetes. Maternal grandmother (deceased): hypertension. Maternal grandfather (deceased): COPD.

Social history: J.F, a 62-year-old Caucasian patient, works as a professor at a nearby technical university full-time. He is married to a single woman and has two children, ages 23 and 28 years old. Denies smoking but concedes to occasionally drinking alcohol. He doesn’t have time to exercise since he spends so much time gardening. He is financially solvent, and his family’s health is covered by insurance. He claimed that he lived in a safe neighborhood, that he always wears his seat belt, and that he never uses his phone while driving. Eats a well-balanced diet rich in fruits and vegetables.

ROS

General: Denies fevers, chills, or significant changes in weight.

HEENT: Denies loss of vision, and hearing, nosebleed, sinusitis, and post nasal drip.

Cardiovascular: Denies chest pain, irregular heartbeats, heart murmur, and pain in the feet.

Respiratory: Denies SOB, night sweat and chronic cough

GI: Denies decrease in appetite, heartburn, frequent belching nausea, vomiting, or diarrhea.

GU: Denies pain, or burning with urination, urinary urgency and frequency.

Msk: Reported chronic back pain that radiates to the hip.

Neurologic: Reported unexplained headache, and dizziness, denies muscle spasm, and fainting.

Psychiatric: Denies depression or anxiety. Denies homicidal ideation.

Endocrine: Denies heat or cold intolerances.

Skin/lymph/heme: Denies skin redness, rash, or changes in skin color.

VTS: BP 128/66 left arm, sitting using regular adult cuff. Wt.: 201lb Ht.: 5’7 T.: 37.4 RR: 20 P: 80 Sp02: 98%

General: A&Ox3, no acute distress except for his chronic pain in his lower back. Well-nourished. Appear his stated age.

HEENT; normocephalic and atraumatic. Visual acuity 20/20. EOMI, PERRLA. Snares patent bilaterally. Hearing intact with good acuity. Carotid pulse 2+ bilaterally without bruit.

Cardiovascular: RRR, no murmur, gallops or rubs, SI and S2 heard and are of normal intensity.

Respiratory: Chest wall is symmetric and non-tender. Lung sound clear without rales. No signs of respiratory distress noted. Resonance is normal upon percussion.

MSK: Full range of motion noted in all joints. Pulses palpable. Lower back pain noted with flexion.

Skin: Warm and dry. Intact without rashes. Normal texture. appropriate color for ethnicity.

Abdomen: Soft and symmetrical without distention. Bowel sounds are normoactive. No masses noted.

Extremities: Atraumatic without tenderness. Muscle strength 5/5 bilaterally.

Neuro: Sensation intact bilaterally. Memory and thought process intact.

Psychiatric: Oriented to place and time, no abnormal affect noted.

Assessment:

Chronic lower back pain

Lab test and result

Lasegue test to asses lumbosacral nerve root irritation: positive

CBC to point out infection or inflammation: result pending

Erythrocyte sedimentation rate: result pending

Diagnosis

Sciatica

Sciatica is a medical disorder that causes pain to radiate from the lower back down the hip, buttocks, and leg. The sciatic nerve, the body’s biggest nerve, is squeezed, causing this pain. Obesity and persistent back pain are two more causes of sciatica. High-impact activities such as hamstring stretches and sleeping might increase sciatica pain (Jensen et al.,2019). Based on the patient’s history of chronic pain after an accident, diabetes background, and lab results, it is the most likely diagnosis.

ORDER NOW

Herniated disc

A herniated disc is an issue with one of the rubbery cushions (disks) that sit between the spine’s bones. It can occur as a result of spine injury that puts strain on these disks. This can cause back pain, loss of flexibility, and other issues. While a variety of factors might lead to a herniated disk, the most frequent cause is a vehicle accident or a fall (Cunha et al.,2018). This disease is differentiated by the position of the herniated disc. If it develops in the lower back, it causes discomfort to radiate to the hip and leg. It also produces numbness in the leg or foot, as well as reduced flexion, which were not observed in the case situation.

Osteoarthritis

Osteoarthritis is a kind of arthritis caused by the breakdown of cartilage in the joints. With time, the cartilage degrades and the bones scrape against one other, exerting additional pressure on the nerves, particularly those leading to the lower back and hips, resulting in pain, edema, and stiffness (Sharma,2021). Osteoarthritis can affect any joint, including the knees. This illness is distinguished by a low-grade temperature and loss of appetite, both of which were absent in the case scenario.

Primary diagnoses: sciatica

Lab test: X-Ray on lower back and hips is necessary

Medication: start the client on Lortab 5/325 PO Q6H PRN and recommend OTC, Aleve to be used for pain.

Non-pharmacological: Ice Therapy for 30 minutes Q6H as needed

Patient education: The patient must be taught when is necessary to the prescription because Lortab, an opioid-based medication can be addictive if misused or abused. The client must be instructed about how to utilize ice therapy and the precautions that must be taken throughout the operation. Because persistent low back pain is linked to lifestyle factors, the client must be educated on the need of altering certain lifestyle behaviors, such as quitting smoking, for better results.

Follow-up: The client should visit the clinic after 2 weeks for further check-up

Referral: To physical therapy for further guidance

References

Jensen, R. K., Kongsted, A., Kjaer, P., & Koes, B. (2019). Diagnosis and treatment of sciatica. Bmj, 367.

Cunha, C., Silva, A. J., Pereira, P., Vaz, R., Gonçalves, R. M., & Barbosa, M. A. (2018). The inflammatory response in the regression of lumbar disc herniation. Arthritis research & therapy, 20(1), 1-9.

Sharma, L. (2021). Osteoarthritis of the knee. New England Journal of Medicine, 384(1), 51-59.

SOAP Note: Birth Control Method

Patient Information

Patient initials: R.K Age:21 Gender: female Race: Hispanic

CC: “I need advice on various forms of contraception that will work for me.”

HPI: R.K, a 21-year-old Hispanic woman, presented at the clinic unaccompanied with the intention of seeking advice on the best contraceptive technique that would work best for her. She stated that she had suffered from migraines in the past two months, which had affected her vision, but the symptoms were well managed with Naratriptan. She stated that she had a 28-day period and denied any abnormal or excessive bleeding.

Medication; She is currently not on any medication. Reported taking naratriptan 1mg PO BID for migraine attack.

PMH:

GYN: 13-year-old menarche Menstruation is regular and lasts 3 to 4 days; no contraception has been used. Denies any previous history of STIs or vaginitis.

Immunization: up to date: last mammogram 7/9/2021

PSH: none

Family history: no significant family history reported.

Allergies: NKDA

SHx: R.K is her mother’s only child, and she grew up in Sonoma, California. She is a final-year college student; she is single but had a child with one of her boyfriend’s when she was 18-year-old. She works part-time as a cashier in a nearby store. She denies ever using illicit substances in the past or in the present. Denies ever smoking or exercising. She lives in a safe neighborhood with her mother and since they are not financially stable, she is not on a specific diet. Reports wearing seat whenever she drives.

ROS

General: Denies fevers, chills, weight changes, and night sweats

HEENT: denies loss of vision, no recent hearing loss, nosebleed, and post nasal drip.

Cardiovascular: Denies chest pain, heart murmur or galops.

Respiratory: Denies SOB, and chronic cough

GI: Reported decrease in appetite and nausea. Denies heartburn, vomiting, or diarrhea.

Msk: denies joint pain, and weakness

Neurologic: Denies dizziness, syncope, and muscle spasm. Reported instances of headache

Genitourinary: Denies vaginal itching or burning. LMP 24/6/22. G1p1

Psychiatric: Denies insomnia, homicidal ideation, and depression. R

Endocrine: Denies heat or cold intolerances.

Skin/lymph/heme: Denies changes in skin color or, rash.

VTS: BP 128/72 left arm, sitting using regular adult cuff. Wt.: 145lb Ht.: 5’4 T.: 37.1 RR: 20 P: 72 Sp02: 98%

General: A&Ox3, with no acute distress. Appear her stated age

HEENT; normocephalic and atraumatic. EOMI, PERRLA, no palpable masses.

Cardiovascular: RRR, S1, S2 head. no murmur, nor gallops

MSK: No edema. Full range of motion noted in all joints.

Skin: Intact without rashes. Normal texture.

Abdomen: Soft and non-tender. Bowel sounds are normoactive.

Pelvic: cervix non-tender, uterus anteflexed, and non-tender. Vagina pink without lesion. Ovaries non-tender without palpable masses.

Breast: soft and non-tender. No abnormal masses noted

Neuro: Memory and thought process intact. Stable gait

Psychiatric: Oriented to place and time. Her insight and judgement are good. She is well groomed.

Assessment:

Diagnostic test and result

Hemoglobin test: used to detect whether the patient is at danger of thromboembolism (Huguelet et al.,2022).

Cervical cytology is used to identify any abnormal cells in the cervix.

Screening for STDs: to determine if the patient has any STDs.

HCG test: to rule out pregnancy. Result negative

Diagnosis

Migraine with Aura

The patient complained of migraines. It is crucial to establish whether the migraine has an aura. This is because people who suffer migraine with aura are more likely to have a stroke if they use combined oral contraceptives (Carlton et al.,2018). If it is established that she has migraine with aura, it is recommended to prescribe progesterone-only contraception because estrogen in combination oral contraceptives is known to promote clots formation.

Plan

Lab test: Patient lipid profile need to be determined.

Medication: Depo-Provera IM for every three months or Minipril 1-tab OD for 28 days. Because she has had migraine with aura, a combined oral contraceptive is not recommended for her.

Patient education;

The patient must be educated on the various hormonal contraceptives available and why she should use one over the other. She must be educated about the hazards of taking estrogen-containing oral contraceptives to those suffering from migraine with aura. She must be informed on multiple routes of administering various hormonal contraceptives, such as implants, injectables, and oral contraceptives. Minipril, a progestin-only contraceptive medication, is recommended in such cases. If she chooses to take oral contraceptives, she must be reminded the significance of persistence. If the patient is worried about taking daily medications, injectables are an option. Hormonal contraceptives such as depot medroxyprogesterone acetate (DMPA) 150mg/ml IM, an injectable progestin, are a safe option for her.

While these choices are effective in her scenario, they do not protect against STDs, thus she must be urged to use a condom (Sathyamala et al.,2020)SOAP Note Essay Assignment Discussions. Since hormonal contraception has a number of negative side effects, some such as bloody coughing or chest pain, needs medical attention. The patient should be advised on the need of modifying her lifestyle, which includes exercising twice a week and eating a nutritional diet rich in fruits and vegetables. The patient should be advised about the significance of routine safety screening.

References

Carlton, C., Banks, M., & Sundararajan, S. (2018). Oral contraceptives and ischemic stroke risk. Stroke, 49(4), e157-e159.

Sathyamala, C. (2020). Depo-Provera and HIV Transmission: WHO to Trust?. Different Takes, 95, 1-6.

Huguelet, P., Alaniz, V., Scott, S., Buyers, E., & Laurin, J. (2022). Evaluation and management of acute abnormal uterine bleeding in adolescents: oral contraceptive pill taper versus single-dose therapy, a pilot study. Journal of Pediatric and Adolescent Gynecology, 35(2), 201.

SOAP note: Anxiety

Patient information Patient initials: G.R Age:26 Gender: female Race: Caucasian DOB; 2006

CC: “Fatigue, inability to sleep, and extreme irritability.”

HPI: G.R, a 26-year-old Caucasian woman, presented at the clinic complaining of being weary, unable to sleep, and irritated. He mentioned that the symptoms began 9 months ago when she discovered that his coworkers were ganging against her. They intend to fire her since she is immensely smarter than them. She also complains of recurrent stomach cramps, dizziness, and back pain. She reported the symptoms to have impeded her ability do her daily chores and her duties at her workplace. She is constantly anxious and irritated for no apparent reason, and she avoids her three-year-old daughter because she sees her as a threat to her. She has not yet sought treatment. She denies feeling depressed.

Medication; None

PMH: none

Allergies: NKDA

SHx: G.R, a 26-year-old woman, works as a full-time paralegal at a nearby law firm. She is married to a single man, with whom she has a three-year-old daughter. She denies smoking but confesses to drinking heavily to unwind. She is financially stable and is insured. She used to attend to gymnastics twice a week but has quit since she feels she is becoming thin. The patient lives in a secure neighborhood, regularly wears a seatbelt when driving, and eschewed using a phone and drive. She has been eating well-balanced diet but she has ended up losing her appetite and is eating less often than usual.

Family history: father (63 y/o): diabetes. Mother (57 y/o): hyperlipidemia. Maternal grandmother (deceased): hypertension. Maternal grandfather (89 y/o): diabetes. Paternal grandmother (deceased): bipolar disorder. Elder bother: Asthma

ROS

General: Denies fevers, chills, but reported significant weight loss.

HEENT: Negative for loss of vision, and hearing, nosebleed, and post nasal drip.

Cardiovascular: Negative for chest pain, heart murmur or galops.

Respiratory: Denies SOB, and chronic cough

GI: Reported decrease in appetite and nausea. Denies heartburn, vomiting, or diarrhea.

Msk: Reported instances of back pain.

Neurologic: Denies headache, dizziness, muscle spasm, and fainting.

Psychiatric: Denies homicidal ideation, and depression. Reported issue with sleep, irritability, social withdrawal and excessive worry.

Endocrine: Denies heat or cold intolerances.

Skin/lymph/heme: Denies changes in skin color or, rash.

VTS: BP 198/66 left arm, sitting using regular adult cuff. Wt.: 146lb Ht.: 5’4 T.: 37.4 RR: 20 P: 80 Sp02: 98%

General: A&Ox3, appear mildly distress.

HEENT; normocephalic and atraumatic. Visual acuity 20/20. EOMI, PERRLA.

Cardiovascular: irregular heart beat noted, no murmur, SI and S2 heard.

Respiratory: Chest wall is symmetric and nontender. Lung sound clear to auscultation. Resonance is normal upon percussion.

MSK: Full range of motion noted in all joints.

Skin: Intact without rashes. Normal texture.

Abdomen: Soft and symmetrical without distention. Bowel sounds are normoactive.

Extremities: Atraumatic without tenderness.

Neuro: Sensation intact bilaterally. Memory and thought process intact.

Psychiatric: Oriented to place and time, no abnormal affect noted. Appear paranoid. Her insight and judgement are fair.

Assessment:

Diagnostic test and result

GAD-7: scored 14

Differential diagnoses:

Generalized anxiety disorder

This is a mental disorder characterized by excessive, persistent, and unjustified anxiety over everyday events. It can also produce agitation, nervousness, difficulty concentrating, fatigue, irregular pulse, and difficulties controlling anxiety (Strawn et al.,2018)SOAP Note Essay Assignment Discussions. Patients suffering with this condition may feel threatened at times and may isolate themselves from friends or family. His has an effect on their work performance. This illness can only be identified once symptoms have been present for at least 6 months. This is the most likely diagnosis for the client based on the clinical presentation and results of the diagnostic tests.

Major depressive disorder

This is a mental illness that affects mood, behavior, and overall health. It is distinguished by prolonged sadness, general weariness, irritability, changes in food, sleep habits, considerable weight loss, and difficulties focusing (Sanada et al.,2020). People with this illness also have inexplicable physical aches and pains, such as back discomfort, which was evident in the case scenario. Nonetheless, patients with this illness are unlikely to report of excessive worry.

Social anxiety disorder

This is a psychiatric condition marked by an extreme and persistent dread of being evaluated by others. This can have an impact on one’s work or school performance, as well as other everyday activities. People who suffer from this illness are extremely uneasy, self-conscious in public, and shun social situations (Leigh et al.,2018). This diagnostic is ruled out since anticipated anxiety associated with social environment were not evident.

Primary diagnoses: generalized anxiety disorder.

Lab test: CBC is necessary to rule out other potential causes of the patient clinical presentation.

Pharmacological management: Administer Escitalopram 10mg po QD to the patient. I recommend this medicine since, in addition to being used as a first-line therapy for GAD, it is well tolerated and effective for managing GAD symptoms (McClelland et al.,2021). Furthermore, its negative consequences are limited.

Non-pharmacological: Initiate cognitive behavioral therapy with the patient. CBT is encouraged because, in addition to assisting with GAD symptoms, therapy can be tailored to each person’s unique set of destabilizing beliefs and inappropriate cognition, resulting in long-term benefits.

Patient education: Patient education entails teaching the patient about the condition, the need of following the doctor’s recommendation, the necessity of medicine and its adverse effects, and the need to stop drinking heavily. She needs to be counseled on coping methods and adequate sleep hygiene.

Follow-up: The patient to return to the clinic after four weeks of therapy for further assessment.

ORDER TODAY

References

Strawn, J. R., Geracioti, L., Rajdev, N., Clemenza, K., & Levine, A. (2018). Pharmacotherapy for generalized anxiety disorder in adult and pediatric patients: an evidence-based treatment review. Expert opinion on pharmacotherapy, 19(10), 1057-1070.

Sanada, K., Nakajima, S., Kurokawa, S., Barceló-Soler, A., Ikuse, D., Hirata, A., … & Kishimoto, T. (2020). Gut microbiota and major depressive disorder: A systematic review and meta-analysis. Journal of Affective Disorders, 266, 1-13.

Leigh, E., & Clark, D. M. (2018). Understanding social anxiety disorder in adolescents and improving treatment outcomes: Applying the cognitive model of Clark and Wells (1995). Clinical child and family psychology review, 21(3), 388-414.

McClelland, M., & McClelland, S. (2021). Case of a 21-year-old man with persistent lung collapse leading to a pericardectomy linked to vape use. Heart & Lung, 50(2), 262-267 SOAP Note Essay Assignment Discussions