Focused SOAP Note and Patient Case Presentation

Focused SOAP Note and Patient Case Presentation

Subjective:

CC (chief complaint): “I am always afraid of everything; I face fear about everything on a daily

basis.”

HPI: Tatiana Green (TG) is a 23-year-old African American female who presented in the clinic

for the initial assessment accompanied by her mother. According to the mother, TG has

showcased symptoms of fear of everything and cases of anxiety since the age of 16 years old.

The symptoms got better as she grew up but they returned one year ago at age 23. However, the

mother denies any stressors at home that could cause the symptoms and reports no cases of panic

attacks. The mother reports TG’s current condition as depressed and tearful. According to TG,

she reported that one year ago, she started having an overactive imagination. Her mother added

that she noticed TG becoming more ritualistic in she performed daily activity in addition to being

obsessive about certain things around the same time. As a result of these symptoms, TG has

become more withdrawn from her friends both in collage and at home. She states that she is

afraid of being in class or school in general hence she is currently being taking online classes

from home. TG denies any suicide thoughts or intentions to harm others. She admits to having

hallucinations since she sometimes hears a voice in her head that telling her that something bad

will happen or a loved one will die. This has made TG obsessive about cleaning her pet bird’s

cage because if she doesn’t, her pet will die. TG has also created certain rituals to prevent bad

thing from happen such as, she counts steps and at a certain number, she stops for 1 minute then

continues to count so that horrible things are prevented. To make herself feel better, she

organizes everything and puts it at its place. This was evident when she started sorting out pens

and pencils according to color on my desk because the disorganized state of my pens was