Description
Select a child/adolescent patient from your clinical experience that presents with a significant concern. Create a focused SOAP note for this patient using the template in the Resources. include 3 objectives for your audience, at least three possible discussion questions/prompts for your classmates to respond to, and at least five scholarly resources to support your diagnostic reasoning and treatment plan. (see sample attachment).Present the full complex case study. Include chief complaint; history of present illness; any pertinent past psychiatric, substance use, medical, social, family history; most recent mental status exam; current psychiatric diagnosis including differentials that were ruled out; and plan for treatment and management.Subjective: What details did the patient provide regarding their chief complaint and symptomology to derive your differential diagnosis? What is the duration and severity of their symptoms? How are their symptoms impacting their functioning in life? (Short Paragraph)Objective: What observations did you make during the psychiatric assessment? (Short Paragraph)Assessment: Discuss their mental status examination results. What were your differential diagnoses? Provide a minimum of three possible diagnoses and why you chose them. List them from highest priority to lowest priority. What was your primary diagnosis, and why? Describe how your primary diagnosis aligns with DSM-5-TR diagnostic criteria and is supported by the patient’s symptoms. Plan: What was your plan for psychotherapy (include one health promotion activity and patient education)? What was your plan for treatment and management, including alternative therapies? Include pharmacologic and nonpharmacologic treatments, alternative therapies, and follow-up parameters, as well as a rationale for this treatment and management plan. Discuss an identified social determinate of health impacting this patient’s mental health status and provide your recommendation for a referral to assist this patient in meeting this identified need (students will need to conduct research on this topic both in the literature and for community resources).Reflection notes: What would you do differently with this patient if you could conduct the session again? If you are able to follow up with your patient, explain whether these interventions were successful and why or why not. If you were not able to conduct a follow-up, discuss what your next intervention would be.five scholarly resources to support your diagnostic reasoning and treatment plan.
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Week 4: SOAP Note
PRAC 6675: PMHNP Care Across the Lifespan II
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Objectives
To be able to correctly identify and list all the symptoms experienced by the patient
To prioritize symptoms in order to form primary and differential diagnoses
To be able to conclude a primary diagnosis based on diagnostic tool results and
symptoms shown by the patient
Questions
What are treatment options for patients who have depression and show resistance to
medications?
Should parents be involved and educated about caring for the patient?
How can social and emotional support play a role in improving depression symptoms?
Week 4: SOAP Note
Comprehensive psychiatric evaluation is conducted to evaluate and better understand the
psychiatric, behavioral, and emotional health of a patient. It prompts a healthcare provider to
evaluate all spheres of life such as psychosocial life, interpersonal relations, and emotional
reactions (Shah et al., 2023). In this SOAP note, a comprehensive psychiatric evaluation of a
patient is conducted, primary and differential diagnoses are formed based on information
collected, and a patient-centered treatment plan is designed.
Subjective:
CC (chief complaint): “I feel depressed all the time, every day.”
HPI: Patient, K.T., is a 31-year-old female who has come to the clinic for her first
comprehensive psychiatric evaluation. Her primary complaint is that she feels depressed all the
time, every day. She has been crying a lot, for a major part of the day, since her boyfriend’s
death nine months ago. She has lost several beloved ones in her life and this life situation makes
her angry. She also feels unmotivated for doing anything in her life. She reported that she has no
desires to do out and socialize with anyone. She feels so sad that she wants to isolate herself,
from both family and friends. Her lack of control over her mood makes her feel desperate and
anxious. She has reported experiencing angry outbursts and wanting to be dead. However,
presently she has no desire to kill herself. She feels hopeless, helpless, and unmotivated about
everything. Reported sleeping difficulties and cannot sleep at night as she missed her boyfriend.
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Also mentioned reduced appetite, and less desire to eat meals. She even forgets if she has eaten
or not. Her mother makes sure she eats something at every mealtime. She denied hallucination,
delusion, and homicidal thoughts, at present.
Past Psychiatric History:
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General Statement: She has been feeling depressed all the time. This is her first
psychiatric evaluation and she has no previous history of diagnosis.
•
Caregivers (if applicable): She lives with her parents.
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Hospitalizations: None reported.
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Medication trials: None reported.
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Psychotherapy or Previous Psychiatric Diagnosis: No history of previous
psychiatric diagnosis or psychotherapy.
Substance Current Use: She has denied using cocaine, methamphetamine, and heroin. She has
denied drinking alcohol such as beer and wine. She has denied smoking cigarettes too.
Medical History:
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Current Medications: None reported.
•
Allergies: Denied pollen, dust, or drug allergy.
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Reproductive Hx: She is not sexually active and has no children.
Family Psychiatric/Substance Use History: She mentioned that her family drinks beer on
holidays and various occasions. Otherwise, they drink wine sometimes with dinner. They are not
heavy drinkers or alcoholics. She denied use of substance use in her family. Her brother
sometimes smokes due to an increased workload. Her mother was diagnosed with anxiety in her
40s and her maternal aunt with depression in her 50s, after her husband’s death.
Psychosocial History: Patient, K.T., is a 31-year-old female who works as an accountant. She
has taken medical leave from work due to her condition. She lives with her parents after the
death of her boyfriend. Her parents live on a farm, several miles away from the main city. She
used to live with her deceased boyfriend and had been living with him for eight years. She used
to work out with her boyfriend and go for long runs. However, she has stopped vigorous physical
activities since the death of her boyfriend. He passed away due to a gunshot during a street
robbery. She has reduced appetite and forgets to eat her meals. Her mother makes sure that she
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eats something during meals, and feeds her. Her friends have started to not invite her to social
gatherings as she is not interested in attending them.
ROS:
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GENERAL: She denied nausea, vomiting, chills, or fever.
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HEENT: Denied hearing loss, blurred vision, sneezing and sore throat.
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SKIN: Denied skin allergies or rashes.
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CARDIOVASCULAR: Denied chest discomfort, palpitations or chest pressure.
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RESPIRATORY: Denied sputum production or coughing.
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GASTROINTESTINAL: Denied abdominal pain, nausea or vomiting. She mentioned
that she has reduced appetite left and forgets to eat meals.
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GENITOURINARY: Denied burning sensation during urination, change in urine color
or change in urination frequency.
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NEUROLOGICAL: Denied dizziness, bladder, and bowel control, and headache.
Reported sleeping difficulties and cannot sleep at night as she missed her boyfriend.
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MUSCULOSKELETAL: Denied stiffness, muscle pain, or muscle tension.
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HEMATOLOGIC: Denied bruising, bleeding, or anemia.
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LYMPHATICS: Denied enlarged lymph nodes or pain in those nodes.
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ENDOCRINOLOGIC: Denied polydipsia or sweating problem.
Objective:
Vital signs:
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Blood Pressure: 121/72 mm Hg
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Height: 5’3
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Weight: 60 kg
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BMI: 23.4 kg/m2
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RR: 16
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Pulse: 85
Physical exam:
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HEENT: Hair was evenly distributed and no thinning out was observed. No lumps or
lesions were observed. Neck showed full range of motion.
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Respiratory: Breathing was at normal rate and rhythm. Lungs were clear to auscultation.
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Gastrointestinal: Abdomen was non-tender. Normoactive bowel sounds in all four
quadrants were heard.
Diagnostic results:
The Patient Health Questionnaire-9 (PHQ-9):
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It is a screening and diagnostic tool used for patients with depression. It is widely used
for screening depression due to its high efficacy. It also has high efficacy when assessing
the severity of MDD symptoms. Using PHQ-9 has several benefits such as the ability of
tracking symptoms of depression in psychiatric patients, as well as in follow-up visits
(Ma et al., 2021). Its total score range is zero to 27. Patient seen scored 22 which shows
that she has severe depression.
Labs:
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Complete Blood Count (CBC): It was recommended to identify any underlying clinical
problem (Ahmed et al., 2019). Results: No underlying clinical problem was detected.
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Thyroid Function Tests: This test was conducted to assess any dysfunction in the
thyroid gland or to detect disorders related to it (Soh & Aw, 2019). Results: No thyroidlinked disorder was detected.
Assessment:
Mental Status Examination:
Patient, K.T., is a 31-year-old female who was aware of her surroundings, date, and time
(Alert and oriented x3). She was dressed in clean and casual clothes. Her hair was not neatly
combed and tied haphazardly in a hair clip. She was not wearing makeup or jewelry. There were
no visible tattoos or scars on her neck, arms, or trunk. She was cooperative and friendly when
answering the questions. At the same time, she was also tearful during the interview. She did not
show signs of stuttering. Her mood was depressed and anxious. Her recent and remote memory
was intact. Her insight and coping skills were fair. Her speech rate and volume were normal. Her
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thought process was abstract. Her concentration level was poor. Her insight and coping skills
were fair too. No signs of delusion or hallucination were present. She showed poor motivation
and had poor energy levels. She has had suicidal thoughts in the past but during the interview,
she did not show suicidal ideation.
Diagnostic Impression:
1. Major Depressive Disorder (MDD) (Primary) (F32.2):
Depression is a mental health condition that is observed in both men and women.
However, it is twice as common in women as compared to men (Josefsson et al., 2019). Patient
is a female which makes it more a possibility for her to suffer from depression. As stated in
criterion A for MDD in DSM-5-TR, a patient has to show five of nine symptoms. These
symptoms are depressed mood, insomnia, psychomotor agitation, concentration problems, a
feeling of worthlessness or guilt, loss of energy or fatigue, recurrent thoughts of death, weight
loss or poor appetite, and loss of interest in pleasure activities (American Psychiatric Association
[APA], 2022). These symptoms must have been present and shown by a patient, showing a
change from their previous functioning state. Furthermore, at least one of the symptoms should
be either a depressed mood or loss of interest in pleasure activities. Patient has reported that she
wants to stay isolated, has no interest in social activities or communicating with people, loss of
energy, is unmotivated, depressed mood, has periods of outbursts where she wants to cry, feels
depressed all the time, and has a poor appetite. She fulfilled criterion A because she has shown
more than five symptoms. Similarly, criterion B mentions that symptoms experienced by an
MDD patient affect their social, interpersonal, occupational, and other significant areas of life
(APA, 2022). Patient has reported that her friends have started not inviting her to social
gatherings because of a lack of interest in socializing. She remains isolated from friends and
family. This shows her social and family life is affected, fulfilling criterion B. Criterion C states
that symptoms reported by the patient are not because of another medical condition or substance
use (APA, 2022). Patient has no history of any other medical condition and denied using any
recreational drug. Therefore, she fulfilled criterion C as well. She has scored 22 on the PHQ-9
screening test which shows that she has severe depression. This confirmed MDD as a diagnosis
for the patient. This is why MDD was selected as the primary diagnosis for the patient.
2. Adjustment Disorder (F43.0):
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According to criterion A mentioned in DSM-5-TR, a patient must develop behavioral or
emotional symptoms in response to an identifiable stressor that occurs within three months of the
onset of the stressor (APA, 2022). Patient has reported feeling depressed all the time and has a
strong desire to cry all the time. These symptoms began to develop more prominently nine
months ago, after the death of her boyfriend. She fulfilled criterion A. Similarly, criterion B
states that a person should show marked emotional or behavioral symptoms by either showing
significant distress that has severe intensity or by notable impairment in social, occupational, or
other areas of life (APA, 2022). She mentioned notable social impairment and prominent distress
after her boyfriend’s death. Thus, fulfilling criterion B. Criterion C for adjustment disorder state
that a stress-linked disturbance should not meet criteria for other mental health disorders or an
exacerbation of other mental health disorder (APA, 2022). Patient fully met the criteria for
MDD, thus, it was ruled out.
3. Other Specified Anxiety Disorder (F41.8):
According to DSM-5-TR, a patient must show signs which are characteristic of an
anxiety disorder that results in notable social distress and impairment in social relations (APA,
2022). Patient reported feeling anxious for her condition. However, as per DSM-5-TR criteria, a
patient must not meet the full criteria of any of other disorder such as adjustment disorder with
anxiety or adjustment disorder with depressed mood or mixed anxiety (APA, 2022). Patient
meets some criteria of adjustment disorder, and she completely fulfills criteria for MDD thus,
anxiety disorder was ruled out.
Reflections:
Learning and Doing Differently: I would ask a few more questions to the patient to understand
her case more thoroughly. I would ask her if she was forcefully separated from her parents or
other attachment figures during her childhood. Separation from parents or other attachment
figures can lead to emotional and behavioral disturbance in children. It can also make them
fearful or depressed in the later stage of life when encountered a similar situation. Thus, it is
necessary to inquire if she was separated from her parents or any other guardian for a long
period.
Next Intervention: It would include psychotherapy and selecting an accurate medication for the
patient. It would also include changes in diet and lifestyle to reduce MDD symptoms.
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Ethical/Legal Considerations: Patient was in a vulnerable and highly emotional state. It was
visible from her tearful state during the interview. She needs empathy from someone to help her
fight against her distorted thinking due to depression. It is an ethical duty of a psychiatrist to
listen to the problems of a patient without rushing them and provide empathy to psychiatric
patients (Moudatsou et al., 2020). Thus, patience and understanding must be shown by a
psychiatrist toward the patient and her situation.
Case Formulation and Treatment Plan:
Patient, T.K., is a 31-year-old female who has come to the clinic for her first psychiatric
evaluation. Her primary complaint is that she feels depressed all the time. She feels sad and
unmotivated and experiences periods of outbursts where she wants to kill herself. She mentioned
a desire to remain isolated from everyone, including both her family and friends. She feels
hopeless and helpless. She has been experiencing these symptoms since the death of her
boyfriend which happened nine months ago. She denied using recreational drugs or smoking
cigarettes. She has been diagnosed with major depressive disorder.
Pharmacological: Selective serotonin reuptake inhibitors (SSRIs) is the first in-line
pharmacological option for treating MDD patients. Six of the major SSRIs widely available and
marketed in the United Nations are paroxetine, fluoxetine, sertraline, fluvoxamine, citalopram,
and escitalopram (Edinoff et al., 2019). Paroxetine is sold in the market by the name of Paxil.
She was recommended Paxil 10 mg for 30 days in the morning. She is recommended to adhere to
medications as taking them only according to the therapist’s instructions will improve MDD
symptoms.
Psychotherapy and Non-pharmacological:
Patient’s care plan included cognitive behavioral therapy (CBT). It is the most researched
and scientifically validated psychotherapy for MDD treatment (Vasile, 2020). In CBT, a
psychiatrist helps a patient in identifying their irrational cognitive patterns beginning from
distorted thinking (Vasile, 2020). In the next step, the emotions linked with irrational thinking
are identified. Patient and a psychotherapist works together on reshaping thoughts and help them
change their distorted thinking, leading to positive emotional changes (Vasile, 2020).
Patient Education:
Research studies have shown chronic or heavy alcohol intake can cause a person to
experience depressive episodes by impacting neural regulation involved in causing depressive
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episodes (Keyes et al., 2019). Furthermore, consuming alcohol when undergoing treatment for
psychiatric disorders can interfere with treatment. Thus, not producing the expected positive
health results. Patient was educated on the importance of not consuming alcohol when
undergoing treatment for MDD to ensure that expected positive health outcomes are produced.
Health Promotion Activity:
According to research studies, the Mediterranean diet has anti-inflammatory effects
which are beneficial in reducing symptoms of depression (Firth et al., 2020). Thus, the patient
was recommended to include omega-3 fatty acids and low-calorie food in her diet. She was also
recommended to avoid junk food. Similarly, according to several scientific researches, moderate
intensity of exercise is sufficient to lower symptoms of depression, however, increasing intensity
is beneficial for overall functioning (Xie et al., 2021). She was recommended to include
moderate-level exercise such as vigorous walking in her routine to improve symptoms of
depression. It has to be intentional and sometimes forceful in the initial stage of treatment to
build a routine of exercising.
Social Determinant of Health:
Sometimes patients are not recommended healthcare services such as screening for
cancer. In other instances, patients live far away from healthcare settings that provide these
services. Healthy People 2030 aims to improve the number of community organizations that
provide prevention services (Office of Disease Prevention and Health Promotion [ODPHP],
2023). Patient had not received depression prevention services after the death of her boyfriend.
As she mentioned that she lives on a farm with her parents, she has poor access to preventive
services and to other healthcare services. Thus, improving the number of community
organizations that provide prevention services will be beneficial for several psychiatric patients
in the early detection and screening of their psychiatric disorders.
Follow-up: She was recommended a follow-up visit after 30 days.
Referral: No referral was made.
Conclusion
Patient, K.T., is a 31-year-old female whose primary complaint is feeling depressed all
the time. She has lost her appetite, wants to cry all the time, has social isolation, and has no
motivation to do anything. PHQ-9 score showed that she had severe depression. She was
recommended Paxil 10 mg for 30 days, CBT sessions, and a lifestyle change.
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References
Ahmed, M. M., Ghauri, S. K., Javaeed, A., Rafique, N., Hussain, W., & Khan, N. (2020). Trends
of utilization of complete blood count parameters for patient management among doctors
in Azad Kashmir. Pakistan Journal of Medical Sciences, 36(5), 999–1004.
https://doi.org/10.12669/pjms.36.5.1885.
American Psychiatric Association. (2022). DSM-5-TR classification.
https://books.google.com.tr/books/about/DSM_5_TR_tm_Classification.html?id=Zmejzg
EACA.
Firth, J., Gangwisch, J. E., Borsini, A., Wootton, R. E., & Mayer, E. A. (2019). Food and mood:
How do diet and nutrition affect mental wellbeing? British Medical Journal, 369(1), 110. https://doi.org/10.1136/bmj.m2382.
Josefsson, A., Vikström, J., Bladh, M., & Sydsjö, G. (2019). Major depressive disorder in
women and risk for future generations: population-based three-generation study. British
Journal of Psychiatry, 5(1), 1-12. https://doi.org/10.1192/bjo.2018.83.
Keyes, K. M., Allel, K., Staudinger, U. M., Ornstein, K. A., & Calvoa, E. (2019). Alcohol
consumption predicts incidence of depressive episodes across 10 years among older
adults in 19 countries. International Review of Neurobiology, 2019(1), 1–38.
https://doi.org/10.1016/bs.irn.2019.09.001.
Ma, S., Yang, J., Yang, B., Kang, L., Wang, P., Zhang, N., & Liu, Z. (2019). The patient health
questionnaire-9 vs. the Hamilton rating scale for depression in assessing major depressive
disorder. Frontiers in Psychiatry, 12(1), 1-17. https://doi.org/10.3389/fpsyt.2021.747139.
Moudatsou, M., Stavropoulou, A., Philalithi, A., & Koukouli, S. (2020). The role of empathy in
health and social care professionals. Healthcare (Basel), 8(1), 1-13.
https://doi.org/10.3390/healthcare8010026.
Office of Disease Prevention and Health Promotion. (2023). Health care access and quality.
https://health.gov/healthypeople/objectives-and-data/browse-objectives/health-careaccess-and-quality
Shah, H., Somaiya, M., Chauhan, N., & Gautam, A. (2023). Clinical practice guidelines for
assessment and management of children and adolescents presenting with psychiatric
emergencies. Indian Journal of Psychiatry, 65(2), 159–174.
https://doi.org/10.4103/indianjpsychiatry.indianjpsychiatry_494_22.
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Soh, S. B., & Aw, T. C. (2019). Laboratory testing in thyroid conditions – Pitfalls and clinical
utility. Annals of Laboratory Medicine, 39(1), 3–14.
https://doi.org/10.3343/alm.2019.39.1.3.
Vasile, C. (2020). CBT and medication in depression (Review). Experimental and Therapeutic
Medicine, 20(4), 3513–3516. https://doi.org/10.3892/etm.2020.9014.
Xie, Y. Z. W., Sun, L., Zhou, L., Wang, G., Xiao, L., & Wang, H. (2021). The effects and
mechanisms of exercise on the treatment of depression. Frontiers in Psychiatry, 12(1), 112. https://doi.org/10.3389/fpsyt.2021.705559.
Objectives
1. To be able to correctly identify and list all the symptoms experienced by the patient
2. To prioritize symptoms in order to form primary and differential diagnoses
3. To be able to conclude a primary diagnosis based on diagnostic tool results and symptoms
shown by the patient
Questions
1. What are treatment options for patients who have depression and show resistance to
medications?
2. Should parents be involved and educated about caring for the patient?
3. How can social and emotional support play a role in improving depression symptoms?
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