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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 ROS: see above Objective data Vital Signs BP: 120/76 HR: 83 RR: 18 SPO2: 97% T: 98. Pain: 0/ Height: 5’10 Weight: 170 BMI: 24.4 normal Diagnostic results : GAD- 7 : score 10, which indicates moderate anxiety Panic Disorder Severity Scale: score 11 this is not a diagnostic tool but a score of 9 and above suggest the need for a formal diagnostic assessment. Thyroid function test, CBC, CMP, Troponin: Normal Toxicology screening: negative BAC level: normal ECG: Normal 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 is where the “facts” are located. Include relevant labs, test results, vitals, and Review of Systems (ROS) – if ROS is negative, “ROS noncontributory,” or “ROS negative with the exception of…” Include MSE, risk assessment here, and psychiatric screening measure results.
had similar episodes, which increases his risk of developing this condition. Social anxiety disorder : ICD 10 code F 40. According to DSM-5, the criteria for Social phobia includes:
- A fear of social performance situations in which the person is exposed to unfamiliar people or scrutiny by others
- Exposure to the feared situation almost invariably provokes anxiety, which may take the form of a panic attack. We can explore this possibility with D.C. and inquire about something that might’ve triggered his panic attacks, possibly school related. Plan Include a specific plan, including medications & dosing & titration considerations, lab work ordered, referrals to psychiatric and medical providers, therapy recommendations, holistic options and complimentary therapies, and rationale for your decisions. Include when you will want to see the patient next. This comprehensive plan should relate directly to your Assessment. Treatment plan
- Medication: Antidepressants are effective in reducing the intensity of panic episodes and their symptoms. When treating panic disorder, TCAs and SSRIs work well (Locke et.al., 2015). Medication selection is determined by D.C.’s preferences and the side effects. To avoid relapse, medication should be used for 12 months before weaning off
- According to Locke (2015), there is substantial evidence that cognitive behavior therapy is beneficial in treating panic disorder. D.C may benefit from cognitive behavior therapy alone or in conjunction with medications. Also, mindfulness reduction therapy and physical activity can reduce symptoms of GAD and PD (Locke et.al.,2015).
- Identifying and eliminating potential triggers (such as caffeine, dietary triggers, stress), as well as increasing physical activity and sleep quality and quantity, are common lifestyle advice that may lessen anxiety-related symptoms.
- Follow up with D.C. in 2 weeks to evaluate the side effects, and effectiveness of the treatment plan. References: American Psychiatric Association. (2022). Diagnostic and statistical Manual of Mental Disorders, text revision (5th ed.). American Psychiatric Association. Carlat, D. (2017). The psychiatric interview (4th ed.). Philadelphia Wolters Kluwer. Gottschalk, M. G., & Domschke, K. (2017). Genetics of generalized
anxiety disorder and related traits. Dialogues in clinical neuroscience , 19 (2), 159–168. https://doi.org/10.31887/DCNS.2017.19.2/kdomschke Locke, A. B., Kirst, N., & Shultz, C. G. (2015). Diagnosis and management of generalized anxiety disorder and panic disorder in adults. American family physician , 91 (9), 617–624.
