Academic level – Undergrad. 1-2
Type of paper – Coursework
Topic Title – Generalized Anxiety Disorder: SOAP Notes
Please see the template provided to guide your writing of SOAP notes.
Follow the rubric to develop your SOAP notes for this term.
The focus is on your ability to integrate your subjective and objective information gathering into formulation of diagnoses and development of patient-centered, evidence-based plans of care for patients of all ages with multiple complex mental health conditions. At the end of this term, your SOAP notes will have demonstrated your knowledge of evidence-based practice, clinical expertise, and patient/family preferences as expected for an independent nurse practitioner incorporating psychotherapy into practice.
The patient is a middle-aged male who presents with chronic anxiety persisting for the past six months. He describes feelings of tension and restlessness that usually continue throughout the day, regardless of his environment or activities. The patient believes his anxiety does not relate to specific events or circumstances because he experiences it as an underlying unease that varies in intensity. He acknowledges the difficulty in managing his worries, which occasionally impact his daily functioning. Additionally, the individual experiences muscle tension, headaches, and sleep disturbance. He also denies any history of substance abuse and is not currently taking any medications influencing his mental state.
The patient’s general appearance and hygiene are appropriate, physical examination reveals no abnormalities, and vital signs are within normal limits. However, the patient appears nervous and reports feeling overwhelmed during the assessment. He displays signs of increased muscle tension and restlessness, while his speech is rapid. The assessment revealed no symptoms of psychosis or other mental health disorders.
The patient meets the criteria for Generalized Anxiety Disorder (GAD) according to the Diagnostic and Statistical Manual of Mental Disorders (DSM-5, 2022). The factors that support the diagnosis are the patient’s persistent and excessive worry, multiple physical symptoms, and difficulties controlling his anxiety. The assessment has ruled out other contributing factors, such as medical conditions or substance use.
Hirsch, C. R., Beale, S., Grey, N., & Liness, S. (2019). Approaching cognitive behavior therapy for generalized anxiety disorder from a cognitive process perspective. Frontiers in Psychiatry, 10. https://doi.org/10.3389/fpsyt.2019.00796
Diagnostic and statistical manual of mental disorders: DSM-5. (2022). American Psychiatric Publishing.