Complete a SOAP note for the patient using the SOAP note template as a guide. The SOAP note should NOT be in a table format. This assignment should be done in a single-spaced Word document.
ALEXANDRA KATSAROS IHUMAN CASE STUDY
Identifying Data Name: Alexandra Katsaros Age: 22 years old Race: Caucasian Gender: Female Chief Complaint (CC) â€œI was feeling overwhelmed.â€ History of Present Illness (HPI) Alexandra Katsaros is a 22-year-old cisgender female who presents to the emergency department due to an unarousable episode. The client reports that she does not â€œremember exactly what happenedâ€ but states that she was out with friends the previous night, drinking â€œmaybe two beers and three hard drinksâ€ and smoking marijuana. The client reports going home afterward and having an argument with her ex-boyfriend, whom she lives with. The client states she remembers being â€œreally irritated and angryâ€ after her ex-boyfriend revealed that he went out with one of her â€œgood friends.â€ The client reports feeling overwhelmed by the argument as she already had a headache and ingested four acetaminophen with diphenhydramine with the intent to go to sleep. The client stated that â€œit didnâ€™t workâ€ and proceeded to take two 1 mg tablets of alprazolam. Per the clientâ€™s ex-boyfriend, the client could not wake up from the couch; he got distraught and brought her to the ER for evaluation. The client denies any SI, HI, AH, and VH. She denies any current or past suicidal ideation, suicide attempts, or self-harm behaviors. She reports feelings of worry started three weeks ago after her breakup and needing to find a new place to live, and â€œnot having to see my ex-boyfriend all the time.â€ She reports the breakup as a significant stressor contributing to increased anxiety symptoms, difficulty falling asleep but not staying asleep (9 hours of sleep per night), frequent headaches, muscle tension, and difficulty focusing at work and school. She reports that her anxiety feels better when she is with her sisters and states that getting away from her ex-boyfriend would make her feel â€œa little better.â€ Past Medical History (PMH) Allergies: Penicillin; client reports hives as an allergic reaction Current Medications: Synthroid 75mcg PO 1 tab daily, oral birth control pill, Tylenol OTC PRN, alprazolam 1mg tab PO PRN for insomnia (prescribed by PCP a year ago). Childhood Illnesses: Denies any significant childhood illnesses. Adult Illnesses: Hypothyroidism (diagnosed three years ago)