SOAP Notes

Read the case study as listed and complete a SOAP note for an intake.

• What additional information do you need for subjective and objective data?

Next, design a treatment plan based on the information you have available; include pharmacological, non-pharmacological, patient education, referral, and follow-up.

Milton is a 68-year-old Asian American male who reports that his biggest problem is worrying non-stop. He worries all of the time and about “everything under the sun and beyond.” For example, he reports equal worry about his wife who is undergoing treatment for breast cancer, and whether he returned his book to the library yesterday to maintain a good patron status. He recognizes that his wife is more important than a book and is bothered that both cause him similar levels of worry even when he tries to rationalize the differences. Milton is unable to control his worrying with current mechanisms that he lists as distraction or self-talk. Supplementary, this excessive and uncontrollable worry is creating difficulty falling asleep and staying asleep, constant impatience with others, difficulty focusing at work, and significant back and muscle tension. Milton has had a lifelong problem with worry, recalling that his mother called him a “worry wart as a child.” His worrying does “wax and wane”, and worsened when his wife was recently diagnosed with breast cancer. He feels he is at a loss for what he can do to control it and relax.

Symptoms:

• Anxiety
• Concentration Difficulties
• Irritability
• Sleep Difficulties
• Worry

Vitals:

132/80 BP

72 HR

20 R

98.8 T

98% 02

Ht. 5’5”

Weight 149