1.

Clinical Notes
Ethical SOAP Notes
4/24/24
Mr. Clyden Jaile Ramirez, 25 year old, male
Referral: None

S (Subjective):

Chief complaint: “ Increased anxiety and difficulty

sleeping.”
HPI (History of Present Illness): A 25-year-old man named Clyden
Jaile Ramirez comes in with a history
of escalating anxiousness and trouble
falling asleep during the previous few
months. He claims that his workload
and personal obligations are
overwhelming him, which has
increased his stress levels. Clyden
admits to having periodic instances of
worry in the past but disputes having
ever had any psychiatric issues. He
claims that the symptoms he is
currently experiencing are
significantly affecting his general
quality of life and his ability to perform
his job duties efficiently. No serious
medical disorders or substance
addiction are present in the past.
Allergies: NKA
Current Medication: None
Childhood Illness: Denies any significant childhood
illness or medical condition.
Health Maintenance: Keeping up a generally healthy
lifestyle, which includes going to the
doctor on a regular basis, exercising
and eating a balanced diet.
Family History: Maternal history of hypertension and
a paternal history of a diabetes.
Social History: Working as a project manager full
time for a technology company.
Exercise & Diet: Participates in regular
activity three to four times a week,
combining aerobic workouts like
running with weight training activities.
Eats a well-balanced diet low in
processed foods and sugary drinks,
high in fruits, vegetables, lean
proteins, and whole grains.
ROS (Review of Systems): Denies any significant abnormalities
on review of systems, except for the
reported symptoms of anxiety and
difficulty sleeping.