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NURS 310 PROFESSIONAL NURSING PRACTICE FOCUSED SOAP NOTE 2
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NURS 310 PROFESSIONAL NURSING PRACTICE FOCUSED SOAP NOTE 2
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lOMoARcPSD|19857451NURS 310 PROFESSIONAL NURSING
PRACTICE FOCUSED SOAP NOTE 2
, lOMoAR cPSD| 19857451
Subjective
Date of visit: 4/4/2023 Patient: K. W.
Age: 43 Location: in office, face to
face. Reason for visit: Follow up for anxiety.
CC- "I suffer from severe anxiety, and I cannot get through the day"
"I lost my job now that they know I am trying to file for disability, and
now I do not know what to do" "I cannot drive anywhere, I have so
many things to do and I do not know where to start" "It's too
overwhelming and I am over it".
HPI: This is a 43-year-old Caucasian female who comes to the office
today suffering from severe anxiety. She has been suffering with anxiety
since she was 17 years old. She has been hospitalized once before in
2020 when covid started to hit hard. She has no trauma or event in the
past that is the trigger for her anxiety, she just over all does not like
people in general. She has been in multiple relationships without
advancing to the “serious stage” per the patient. She states that she
gets annoyed with the boyfriends, or they cannot stand her anymore.
She has one friend who she sees a few times a month but reports no
close relationships. She grew up in a single home with her mother, her
father left when she was 10. She is still in contact with her father and
has a love and hate relationship with him. She sees her mother weekly,
and she is annoyed with her mother most of the time as she states her
mother is very judgmental and does not like the person she is. She is
an only child. Her mother has anxiety and bipolar depression. Her father
has no psychiatric history. She reports having trouble concentrating now
and is having difficulty getting anything done due to her anxiety. She is
not able to get her disability papers together, because she is waiting for
her job to file “some paper” that is the cause of her denial for disability
the first time she sent it through. She has bounced from one job to the
next, not able to hold down a job for long. She denies using any illegal
drugs but does smoke cigarettes daily, around 10 per day for the last 15
years. Patient has a past psych history of anxiety disorder, depression,
Bipolar disorder, PTSD (Post Traumatic Stress Disorder), and
agoraphobia.
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