| SOAP Note | Rationale |
| Demographic Info: | 17-year-old white female student in her last year of high school. |
| SUBJECTIVE: | |
| CC: | “I feel sad and hopeless. I am continuing with therapy.” |
| HPI: | The patient, a 17-year-old female student,is availed to a clinic for diagnosis and treatment of major depressive disorder. The patient reports feelings of disarray, emptiness, and hopelessness. She has lost interest in normal activities, including her hobbies and sports. She experiences reduced appetite and weight loss. She has slowed thinking, sleep disturbances, and says she experiences feelings of worthlessness. She does not present complaints of low moods or anhedonia. She feels her medication is working well. |
| PMHx: | The patient has been treated with antidepressant therapy. She has no known allergies to drugs or environmental aspects but is allergic to anaphylaxis in chocolates and hives in oranges. She denies the alcohol consumption, tobacco, or other illicit drug abuse in the past. She asserts she has been diagnosed before for psychiatric depression. She has no suicidal attempts but has thought of suicide. |
| Surgeries: | No known surgeries |
| OB/GYN: | No known OB/GYN procedures |
| Fam Hx: | The patient is an only child. The patient’s mother died in a car accident recently. The patient’s father has type 2 diabetes and is hypertensive and is currently undergoing treatment. Both grandparents are deceased. |
| Soc Hx: | The patient reports she is introverted and spends most of her time alone. She is a student in her last year of high school and is more focused on her final exams than engaging in active social gatherings. She has gotten into fights in the past few years. She walks alone and does not exercise a lot. She denies the use of alcohol and other drugs. |
| Allergies: | Hives in oranges and anaphylaxis in chocolates. |
| Current Meds: | She goes for checkups for diabetes as it is historical in her family. Current medication includes Cholest of 450 mg daily, Zetia 10 mg daily, Synthroid 25 mcg daily, and Ground flax seed two tablespoons daily. |
| Immunizations: | She is up to date with vaccinations. She receives insulin regulators to ensure she does not get diabetic. |
| ROS: | |
| General/Constitutional: | General body systems are optimal. No jaundice, rash, or tingling. Normal pulse. |
| HEENT: | No head traumas or injuries. No visual complaints, is not prescribed glasses, has no history of glaucoma or cataracts. No hearing problems. Chewing is normal and has no oropharyngeal issues she swallows normally. The patient does not use dentures. |
| Cardiovascular: | The patient does not currently experience chest pain or palpitations. The patient does not have problems with PVD or HTN. |
| Respiratory: | She has no cough and denies any history of asthma |
| GI: | The patient has not experienced constipation, nausea, or vomiting. Her last bowel movements were the day before. |
| GU: | She exhibits no dysuria, polyuria, or other difficulties in passing urine. |
| Musculoskeletal: | The patient denies any problems with mobility. |
| Skin: | No known skin problems. |
| Psych: | The patient asserts a history of anxiety and feelings of hopelessness. She denies panic attacks. |
| Neuro: | The patient notes she experiences headaches in and out of school. She relieves the pain with Advil. |
| OBJECTIVE: | |
| VS: | BP=100/80, Pulse=72, Respiration=18, |
| Temperature=98.5F, Height 5’2”, Weight, 111 lbs., BMI=20.34 | |
| General Appearance: | Adolescent white female who looks her age appears to be in acute distress, appears to have a flat affect. |
| Appears to be well-nourished, alert, and answers questions appropriately. | |
| Head: | The Head is normocephalic without any signs of injury or lesions. |
| Hair is evenly distributed on the head. | |
| Eyes: | Sclera are white and conjunctiva normal in color |
| PERRLA with no erythema or visible discharge. | |
| Ears: | Bilateral normal external ears. The canals are normal without wax buildup. Positive light reflex. |
| Nose/Sinuses: | No erythema or edema observed. No nasal discharge, the septum is intact. |
| No nosebleeds or stuffiness, thyroid not enlarged. | |
| Mouth: | Oral mucosa is moist and pink. Teeth white with no dental decay. A tongue without any mass. |
| No visible exudates, no presence of petechiae. | |
| Neck: | No lymphadenopathy noted. The thyroid is non-palpable. Supple symmetrical tracheal midline. |
| No carotid brut, no JVD. | |
| Heart: | Heart with S1 And S2 regular rhythm. No murmurs, galops, or rubs. Capillary refills in 2 seconds. There are radial pulses. No egophony, normal radial, and pedal pulses. |
| Peripheral pulses are present. | |
| Lungs: | The lungs are resonant. The breath sounds are vesicular. There are no adventitious sounds; the tactile fremitus is normal. |
| There is a normal respiratory function | |
| Abdomen : | The abdomen is soft, tender, non-distended, and liver and spleen are non-palpable. |
| Stomach is tender and tymphanic, No splenomegaly, | |
| Extremities: | ROM is unaffected and all extremities have normal joint stability. |
| Skin: | There are no skin changes or retractions. |
| Neuro: | There is no scoliosis noted, no neurological alerts, and no sensory deficits. |
| Balance is stable and normal gait—flat affect. No tremors. | |
| Laboratory & Diagnostic Testing: | CBC normal w/H&H 14/42 |
| TSH normal at 2.2 | |
| HbA1c normal at 5.3 | |
| Potassium 4.1 | |
| HDL- 75 | |
| LDL- 182 | |
| Creatinine- 0.82 | |
| ASSESSMENT: | |
| The patient is young and healthy and does not exhibit any physical health issues. Her vision, auditory, neurological, gastrointestinal, and respiratory systems all operate within normal capacities. | |
| Major Depressive Disorder | When one experiences persistent hopelessness, they are diagnosed with depression. The patient presents symptoms of major depressive disorder. The patient exhibits a bleak outlook on life. She experiences sleep changes, appetite, and weight changes. The characteristics of MDD include depressed mood, diminished interest, impaired cognitive function, and vegetative symptoms (Otte et al., 2016). The patient exhibits feelings of hopelessness and has experienced the ideation of suicide. Her feelings of hopelessness are fueled by her lifestyle, which involves staying away from people, lack of exercise, and suicidal ideations. The family history of the patient suggests she recently suffered a significant loss. The death of her mother, coupled with the chronic diabetes of her father, are some of the underlying factors causing her hopelessness. Her thinking is logical, and her thought processes appear appropriate. Her loss of weight and disruptive sleep patterns seem a result of depressive thoughts. |
| Dysthymia | The patient has a persistent mild depression, , also known as dysthymia. This assessment is derived from her prolonged feelings of hopelessness. The patient has both long-term depressive moods and transient periods of normal mood that are atypical of dysthymia . What distinguishes the timing and consistency of symptoms from MDD are the frequency and severity. The symptoms of dysthymia include low moods on a continuum to dysphoria (Calles, 2016). |
| Disruptive mood dysregulation disorder (DMDD) | The patient has engaged in fights in the past few years, suggesting that she could have DMDD. The consistent fights show a chronic tendency to get irritable and engage in battles. A significant characteristic of DMDD is frequent tempers and outbursts (Althoff et al., 2016). The patient mostly keeps to herself andgets irritable around crowds. |
| PLAN: | |
| Continue current management | The ongoing therapeutic process is meant to improve the patient’s well-being. Individualized assessment of patients and frequent monitoring and use of antidepressant medication is advised (Kennedy et al., 2016).The patient is advised to engage in physical exercise to manage MDD. The patient will be directed to a psychiatrist to be given antidepressant medication for her dysthymic tendencies. Some of the self-care points for the patient against MDD episodes include getting more rest, adding more structure and activities to their daily schedules. Remission is the goal of the therapy session. The therapist will continue to monitor the client and ensure depressive moods are managed. |
| Referral to psychiatrist | The disruptive mood and dysthymic tendencies of the patient can be managed through medications prescribed by a psychiatrist. Given the patient suffers from clinical depression, a psychotherapist will be better placed to help the client manage the condition. The psychiatrist will determine whether the mental condition was caused by mental health or other physical ailments. The findings can help create a safe space for the patient to recover. The psychiatrist can do medical testing to rule out whether negative feelings were brought by chemical imbalances or existing environmental conditions. |
| Follow-up in 30 days | The therapist will do a follow-up on the progress of the patient. The psychiatrist will observe whether the medication given to the patient affects their body. Depression is well controlled with medication, and therefore the follow up will be to ensure the client takes their medication as prescribed. The follow-up is also meant to determine the methods used in the treatment are effective. |
| Discussing participation in a support group | The patient can be encouraged to join a support group to help manage their depression. The therapist will explain that the members of the support group are going through a similar situation, and talking about it helps the patient feel that they are not alone. The therapist will assure the patient that joining support groups helps alleviate feelings of loneliness, reducing distress, talking openly and honestly about one’s feelings, and staying motivated to manage chronic depression. |
| COMMENTS: | |
| Managing depression involves accepting social support. The patient can be advised to go more and exercise outdoors. A follow-up is necessary to ensure the patient receives support, and their condition is improving. | |
| Depression has no cure but can only be managed, and therefore management through medication and support is vital. |
References
Althoff, R. R., Crehan, E. T., He, J. P., Burstein, M., Hudziak, J. J., &Merikangas, K. R. (2016). Disruptive mood dysregulation disorder at ages 13–18: results from the national comorbidity survey—adolescent supplement. Journal of child and adolescent psychopharmacology , 26 (2), 107-113.
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Calles Jr, J. L. (2016). Major depressive and dysthymic disorders: A review. Journal of Alternative Medicine Research , 8 (4), 393.
Kennedy, S. H., Lam, R. W., McIntyre, R. S., Tourjman, S. V., Bhat, V., Blier, P., ... &McInerney, S. J. (2016). Canadian Network for Mood and Anxiety Treatments (CANMAT) 2016 clinical guidelines for the management of adults with major depressive disorder: section 3. Pharmacological treatments. The Canadian Journal of Psychiatry , 61 (9), 540-560.
Otte, C., Gold, S. M., Penninx, B. W., Pariante, C. M., Etkin, A., Fava, M., ... &Schatzberg, A. F. (2016). Major depressive disorder. Nature reviews Disease primers , 2 (1), 1-20.
