14 May 4 SOAP NOTES via telehealth sample and format in the attachment, will be shared in the file sharing area? to? (1) 72 year old with Generalized Anxiety Disorder (2) 51 ye

SOAP NOTE GAD, MDD

Writer: xxxx

Date: 5/01/24

ID: GG Age: 52, Sex: female, Race: African American, Marital status: Single, lives Alone occupation: Business.

C/C: “I have lots of regrets in my life, I feel sad and hopeless that I lost control of things that makes me happy.”

HPI: GG, a 52-year-old African American female with a Past Psychiatric History of Anxiety, Depression, PTSD, presents alone as a new patient via telehealth for evaluation for worsening daily anxiety and depression for the past 9 months. Denied any past medical history (PMH). Patient was diagnosed with anxiety at the age of 40 and diagnosed with depression in 2023. She states that her worsening anxiety and new onset of depression was triggered after losing her mother, father, and 2 siblings in a short time frame. Patient reports that life has been so unfair to her she could not imagine losing 4 of her loved ones within a short space of time. Pt reports night terrors associated with her history of abuse, but the night terrors have been occurring less frequently. Patient reports being in a state of constant worry and has a “persistent feeling of wanting to jump out of her skin.” She reports feeling worried about everything in her life. More recently, she worries about life and death. Patient states that her worsening anxiety causes her to feel “overwhelmingly sad.” She reports that most days she has a hard time getting out of bed and she struggles to leave her house. She wakes up crying most mornings and feels as if she is isolating herself. Patient quit her job 5 months ago due to her anxiety and depression. Patient complains she sleeps too much. Patient is currently taking Alprazolam 1 mg BID PRN, Trazodone 150 mg QHS, Quetiapine 100 mg QHS, Hydroxyzine 25 mg QID PRN. Denies suicidal ideation, and no homicidal ideation, but mood is dysphoric and depressed with flat affect.

Past Medical History: None

Psychiatrist History: Generalized Anxiety Disorder (age 40 onset), Moderate Depression (2023), Chronic PTSD (age 38 onset).

Past Surgical History: None

Current Medications: Alprazolam 1 mg BID PRN, Trazodone 150 mg QHS, Quetiapine 100 mg QHS, Hydroxyzine 25 mg QID PRN

Allergies: NKDA

Social History: Single never been married. Occupation Business. Smoke vapes a few times per week. Alcohol is used occasionally. No illicit drug uses. No history of arrests or incarcerations.

Family History: No family history of anxiety, depression, schizophrenia, bipolar disorder. Bereaved of Mother, Father, 2 siblings with 4 months

Objective: V/S not taken, Ht 5' 9" | Wt 170 lbs. stated by patient.

PHQ9 score: 19

Review of System

General: Appearance appropriate, AO x4, coherent speech, no S.I, no hallucinations, good eye contact.

HEENT: No seizures, no current head trauma

Lungs: Unremarkable

Heart: Unremarkable

Abdomen: Unremarkable

Extremities: Unremarkable

Neuro: Unremarkable

Mental Status Exam: Appearance: Appears well groomed, dressed appropriately. Tearful at times. Behavior: No acute distress. Patient is cooperative, responding normally and appropriately. Motor Activity: Regular gait and posturing. No tics, tremors, or EPS present. Speech: Patient is fluent and coherent. No pressured speech. Mood/Affect: Patient reports feeling down and in a state of constant worry. Congruent affect. Thought: Denies any suicidal or homicidal ideations. No delusions. Insight/Judgement: Patient is aware that she is struggling with excessive worry, depressed mood, decreased pleasure in activities, fatigue, all of which are interfering with her daily life. Patient desires to feel better and find a better management plan.

Memory/Attention: Recent and long-term memory intact.

Assessment: GG, A 52-year-old Hispanic female with past medical history of Major Depressive Disorder, Generalized Anxiety, and PTSD presents today via Telehealth as a new patient for evaluation of worsening anxiety and depression after being bereaved of 4 family members. The patient’s mental health and psychiatric medications have been managed by her primary care doctor until now. Patient is currently prescribed Alprazolam 1 mg BID PRN, Trazodone 150 mg QHS, Quetiapine 100 mg QHS, and Hydroxyzine 25 mg PRN (which she is not using). Patient symptoms of excessive worrying, fatigue, depressed mood, and decreased interest in normal activities are worsening despite being compliant with her current medical regimen. Vitals not checked, current height and weight was stated by patient, ROS was unremarkable, no history of trauma or seizures. Given the patient’s history, her current medical regimen is most likely not helping the patient’s anxiety and depression. Furthermore, there is no evidence to support a diagnosis of bipolar disorder in this patient; and a mood stabilizer antipsychotic, such as quetiapine should not be used as first line coverage for major depressive disorder and generalized anxiety. Sertraline, an SSRI, would be a more effective management for this patient as it provides effective coverage for anxiety, depression, as well as PTSD.

Differential Diagnosis

· Major Depressive Disorder- F32.9

· Persistent Depression -F33.9

· Adjustment disorder- F43.2

· Bipolar Disorder- F31.9

· Generalized Anxiety Disorder- F41.1

· PTSD- F43.1

Diagnosis according to DSM-5 Criteria: Major depressive disorder (ICD-10: F32.9), Generalized Anxiety Disorder (ICD-10: F41.1).