Anxiety Soap Note

SOAP Note

This SOAP note is prepared by medical professional Eddie E. Marshall from Spark Stride Electronics. Our patient is Madison Walker, a 21-year-old female demonstrating symptoms of anxiety. All assessments, observations, and treatment plans have been conducted and created using a specialized Anxiety SOAP Note.

Subjective

Objective

Assessment

Plan

  • Reports feeling restless and nervous most of the time.

  • Mentions having trouble concentrating due to constant worrying.

  • Expresses concern over her increasing inability to control feelings of anxiety.

  • Heart rate and blood pressure elevated

  • Found pacing and fidgeting during consultation

  • Evident weight loss, likely due to reduced appetite

  • Unequal pupil size observed

Based on Madison's subjective complaints and my objective findings, it can be ascertained that she is battling with anxiety that needs to be addressed medically. Other possibilities including hyperthyroidism or neurological disorders rule out based on her medical history and current examinations.

  • Recommend Madison to a psychologist for cognitive-behavioural therapy.

  • Prescribing a short-term meditation regime to reduce initial symptoms of anxiety.

  • Suggesting lifestyle modifications: proper sleep, healthy diet, and regular exercise.

  • Set a follow-up appointment after two weeks to evaluate response to interventions.

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