SOAP Note Information . Please include differential diagnosis as well.
Date of birth:11/20/1999
Ethnicity: White
Gender: Female
Lives in Lubbock
Works for enterprise
Dad is her emergency
contact: Brandon
No allergies to meds
Born and raised in
Dallas
Has a 4 month old baby
1st child
Medications: Lexapro 10
mg been on it since she delivered for post partum depression
Was taking zoloft but
her OBGYN wanted her to change after having baby because depression was higher
than anxiety and she feels like Lexapro is making her more depressed and she
stopped for a week but then had debilitating panic attacks. So Lexapro helps
with anxiety but she is more depressed
Diagnosed with MDD and
anxiety. But feels like anxiety is worse now
Duloxetine previously
but she doesn’t remember why they stopped it. 4 to 5 years. Took 30 mg.
Zoloft on for 1 year
Zoloft dose 50 mg
Her obgyn has been
prescribing and previously her pcp
Mood symptoms:
struggling with anxiety more
Panic attacks when she
doesn’t take meds
Not caused by anything
but caused by stress but not in a stressful situation. Light-headed, dizzy,
tunnel vision, disassociate, heart racing, shortness of breath, tingling hands,
disoriented.
When is the first time
she felt Mood symptoms? 5 years old
Started Medication at 16
years old
Last 6 weeks any
changes: met the baby father 1 year ago and got pregnant quickly. Daycare
expensive, new relationship. Yes to financial stress
Work is not stressful
it’s more work. She can’t go home and go to sleep she has to be a mom which she
loves but it’s a change
Home stress: boyfriend
has a bad porn addiction
On Medication she
worries about what he is doing
Why was she anxious at a
young age? Mom is anxious. No trauma as a child.
Abusive relationship as
a adult
Lives with her bf
Her bf pays bills and
works nights but he doesn’t work as many hours as her. He didn’t go to college
and she did. So he works in the oil field
Weight: 180 lbs
Ht: 5 ft 6 inches
No allergies
Not trying to conceive
Never been admitted due
to psych symptoms. Started therapy 4 months ago.
Grow therapy, doesn’t
remember name of therapist
Indigestion
My partner is 23 years
old. Been in relationship 13 months
Younger brother 24. 16
months apart
Paternal grandpa: mdd
and suicide
Maternal: none
Growing up mom dad and
brother
Christy (mom): 44 years
old. Mom associate degree. Mom works for Jcpenney Corporate office
Dad is 44 years old.
Real estate. High school
Highest degree: bachelor
Christian but doesn’t go
to church
No legal issues
Appetite: no breakfast,
snack at lunch and only eats dinner
PHQ9: 15/20
Sleep: good
No thoughts to harm
herself
Increase Lexapro to 15
mg.
Follow up 2 weeks
