SOAP Alexandra Katsaros Clinical SOAP Note

Clinical SOAP Note Subjective Include chief complaint, subjective information from the patient, names and relations of others presents in the interview, and basic demographic information of the patient. HPI, Pas ...

Clinical SOAP Note Subjective Include chief complaint, subjective information from the patient, names and relations of others presents in the interview, and basic demographic information of the patient. HPI, Past history, medical history, surgical history, Allergies, family history, Social History, Review of Systems (ROS), Psychiatric History. Patient Name: Alexandra Katsaros Race/Ethnicity: Gender: female DOB: xx/xx/xxxx Age: 22 Marital Status: N/A CC: "I was feeling overwhelmed." HPI: 22-year-old female presents to the hospital secondary to being unarousable. She reports that she cannot fully recall what happened but states that she used marijuana and had multiple alcohol beverages prior to going home and having an argument with her exboyfriend. During the argument, the ex-boyfriend revealed that he had gone out with patient's friend. She felt overwhelmed by this information and as she already had a headache, she proceeded to take four acetaminophens with Benadryl with intent of going to sleep. This did not work so she added two 1 mg tablets of alprazolam and was later found unarousable by exboyfriend and brought to the emergency room for evaluation. She reports difficulty falling asleep but not iHuman-AK 3 staying asleep. She also reports trouble focusing at school and work since she broke up with her boyfriend. She denies suicidal ideation. She reports feeling stressed. She is currently looking for a new place to live.  Psychiatric hx: Reports being diagnosed but not treated for depression in high school after a breakup, teacher thought she had ADHD but she was never diagnosed or treated and also states school has always been easy for her.  Medications: Synthroid 75 mcg daily, Alprazolam 1 mg, oral contraceptive  Medical hx.: Hypothyroidism  Surgical hx.: Denies  Allergies: Penicillin  Family hx.: Father-Alcohol abuse, Motherdepression  Social hx.: Reports growing up in a strict Catholic household that made her feel restricted. Has two sisters that live in town who she is close to and one brother. Works five hours a week as an art gallery moderator. She reports living with her boyfriend and she is currently looking for a new apartment after a recent break up with her boyfriend. She reports having two close girlfriends who have been support system since her breakup. She currently taking basic health sciences class at iHuman-AK 4 the community college. Reports two to three beers on nights when she does drink once or twice during the week typically on the weekends. She reports wine or hard liquor use when out with girlfriends but rarely both together. Marijuana use a couple of times a year. Denies use of tobacco.  Safety: Denies any thoughts of hurting or killing herself. Psychiatric Review of Systems (ROS):  Constitutional: Denies Weight loss/gain, fever/chills, headache  HEENT: Denies Vision/eye changes, headaches, hearing changes, ear pain, sinus problems, difficulty swallowing, chronic sore throats,  Cardiovascular: Denies chest pain, discomfort, or pressure, pain/pressure/dizziness with exertion or getting angry, palpitations, decreased exercise tolerance, blue/cold fingers, and toes.  Respiratory: Denies shortness of breath, wheezing, difficulty catching breath, chronic cough, sputum production.  Gastrointestinal: Reports change in appetite, Denies nausea, vomiting, constipation, abdominal pain, diarrhea, coffee ground emesis, dark tarry stools, bright red blood in bowel movements, early satiety, bloating iHuman-AK 5  Musculoskeletal: Denies muscle or joint pain, redness, swelling, muscle cramps, joint stiffness, joint swelling, or redness, back pain, neck or shoulder pain, hip pain.  Neurological: Denies dizziness, fainting, spinning room, seizures, weakness, numbness, tingling, tremor  Genitourinary: Denies pain, burning, blood, difficulty starting or stopping, dribbling, incontinence, urgency during day or night, or any changes in frequency.  Endocrine: Denies excessive thirst, change in appetite, heat/cold intolerance, frequent urination  Hematologic/Lymphatic: Denies bruising, bleeding gums, nose bleeds, increased bleeding  Psychiatric: anxiety, difficulty falling asleep. Objective This is where the “facts” are located. Include vitals relevant labs, test results, MSE, risk assessment here, and psychiatric screening measure results. HR 72 BP 116/72 supine/sitting 114/66 standing RR 18 SpO2 99% room air Temp 98.2 Height 5’ 5” inches Weight 122 lbs. BMI 20.3  GENERAL: Anxious and tearful  HEENT: Normocephalic/atraumatic, pupils reactive  NECK: Thyroid WNL for size and c