Focused SOAP Note – Patient with Generalized Anxiety Disorder
Subjective:
CC (chief complaint): The patient presents with a chief complaint of extreme anxiety, restlessness, apprehension, trouble concentrating, hyperventilation, heart palpitations, racing heart, sweating, and dizziness, and notes that all of these symptoms began this morning after opening up about his sex change and taking hormone pills. Our assignment writing help is at affordable prices to students of all academic levels and academic disciplines.
Age: 22
Gender: Male/Transgender
Diagnosis: GAD
A 22-year-old transgender male came into the office and reported feeling extremely anxious, restless, apprehensive, having trouble concentrating, hyperventilating, having heart palpitations, racing, sweating, and dizziness. The patient reported that he started feeling the symptoms after waking up this morning. He reported that he started noticing these symptoms since being open about his sex change and taking hormone pills. The patient reported that he has trouble sleeping at times. He states that his symptoms occur out of nowhere. He reports overall being a happy young man and rarely feels sad. He reports a good support system and a close-knit family with friends.
HPI: The 22-year-old transgender male patient presented to the office and stated that he started feeling extremely anxious, restless, apprehensive, had trouble concentrating, hyperventilating, had heart palpitations, racing, sweating, and dizziness. He notes these symptoms started this morning. He notes that he has occasionally experienced sleeplessness. He reports that these symptoms seemingly come on out of nowhere. He notes that these symptoms appeared when he opened up about his sex change and took hormone pills. He generally describes himself as a happy individual, rarely experiencing persistent sadness, as he has good social support from a close-knit family and friends.
Substance Current Use: The patient has no reported history of substance use.
Medical History:
- Current Medications: The 22-year-old patient is currently on hormone therapy. He takes hormone pills after undergoing sex change. The current hormone pills, dosage, and period the patient has been taking and is expected to take the pills have not been specified during this assessment.
- Allergies: The patient has no reported known allergies in the past or currently during his sex change hormone therapy.
- Reproductive Hx: The 22-year-old patient was born with feminine sex and gender, has undergone a transgender sex change, and currently identifies as a transgender male. He is currently under hormone therapy. The patient has no known history of his previous menstrual patterns, contraceptive use, or his previous and current preferred types of sexual intercourse or sexual activity. He also has no current sexual concerns.
ROS:
- GENERAL: The patient denies any fever, chills, fatigue, or unintentional weight loss. However, he reports feeling dizzy with increased sweating.
- HEENT: The patient does not report any headaches but notes he feels dizzy. He has visual disturbances, hearing loss, or a sore throat. He does not report nasal congestion or any nose-related issues in recent times. He does not report any smell issues. He does not report issues when swallowing.
- SKIN: No rash or scratches on the skin. Denies any itchiness.
- CARDIOVASCULAR: The patient complains he experiences irregular and fast heartbeats. The patient does not report any history of chest issues.
- RESPIRATORY: The patient does not report any breathing issues, including shortness of breath. The patient does not report having chest pain.
- GASTROINTESTINAL: The patient does not complain or report any gastrointestinal issues such as nausea, vomiting, abdominal pain, or changes in bowel movements.
- GENITOURINARY: The patient does not report any genitourinary issues, including burning on urination, urgency to go, hesitancy to go, odor, or odd urine color.
- NEUROLOGICAL: The patient complains of dizziness and feeling extremely anxious. He denies any focal neurological symptoms. No change in bowel or bladder control.
- MUSCULOSKELETAL: The patient does not report any issues, including pain or limitations in movement.
- HEMATOLOGIC: The patient reports no blood or bleeding issues and bruising.
- LYMPHATICS: The patient does not report any swollen or enlarged lymph nodes.
- ENDOCRINOLOGIC: The patient reports of sweating. He denies
