NR603 Week 6 part 1

SOAP Note

Patient Information:
  • Name: K.W.
  • Age: 36-year-old
  • Gender: Female
  • Ethnicity: Caucasian
  • Setting: Family practice clinic

Subjective (S):

  • Chief Complaint (CC): “I need a life GPS to function, I feel confused.”
  • History of Present Illness (HPI): K.W. reports that her symptoms began approximately six months ago. She describes struggling with procrastination and experiencing significant difficulty with organization, which has led her to feel anxious and depressed. Additionally, she reports feelings of guilt and loss of self-esteem. She is particularly concerned that by focusing her energies on managing her work responsibilities, she is neglecting other areas of her life, especially her children.

Past Medical History (PMHx):

K.W. reports a longstanding history of poor attention. During grade school, she was identified as requiring special accommodations and support from her teachers, although she was never formally diagnosed with a learning disability.
  • Surgeries:
    • Cesarean section x2
  • Medications:
    • None
  • Allergies:
    • NKDA (No known drug allergies)

Social History (Soc Hx):

K.W. has been married for 11 years and currently lives at home with her husband and two young children, ages 2 and 4. She recently returned to work after taking four years off to care for her children.
This SOAP note captures the key subjective data presented by the patient, emphasizing her ongoing struggles with attention, organization, and the resulting emotional distress. This information will be critical in further assessing and managing her symptoms, which may be related to an underlying condition such as attention-deficit/hyperactivity disorder (ADHD), anxiety, or depression. Further evaluation and diagnostic testing may be necessary to develop an appropriate treatment plan.