Major Depressive Disorder Soap Note Assignment

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Major Depressive Disorder Soap Note Assignment

Subjective:

CC (chief complaint): “I’m sad, and I just can’t seem to go to sleep.”

 

HPI: SP is a 28-year old Caucasian male who comes in complaining of feeling sad and not getting enough sleep. According to him, the only thing he wants to do every day is lounge about outside in the sun, doing nothing.  In addition, he notes that he feels exhausted and lacks the strength to carry out his regular activities. He reveals that he has not been attending his master’s classes for the last two months due to the fact that he does not feel like doing so anymore. He claims that he has been getting emotional outbursts that he is unable to control. Denies suicidal ideation or hallucinations. Major Depressive Disorder Soap Note Assignment

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Past Psychiatric History:

 

 

  • General Statement: Denies history of mental illnesses

 

 

  • Caregivers (if applicable): Non-contributory

 

 

  • Hospitalizations: Denies past hospitalizations.

 

 

  • Medication trials: None

 

  • Psychotherapy or Previous Psychiatric Diagnosis: Denies

 

Substance Current Use and History: Denies alcohol or tobacco use. Reports that he has used marijuana in the past but stopped 3 years ago. Denies illicit drug use.

 

 

Family Psychiatric/Substance Use History: Denies family psychiatric or substance use history.

 

Psychosocial History: Patient reports that he is single, with no children. Reports that he is an orphan, with one younger sister. He lives alone in a rented apartment. He states that he runs a grocery shop and is pursuing his Masters in Accounting but stopped attending classes 2 months ago. Denies history of abuse.

Medical History: Asthma

Current Medications: None

 

  • Allergies: NKA

 

  • Reproductive Hx: Single, heterosexual, denies sexual activity, no children

 

ROS:

 

 

  • GENERAL: Reports fatigue and weakness. Denies changes in weight.

 

  • HEENT: Denies headache, eye problems, ear problems, a stuffy nose or

 

  • SKIN: Denies rash or itching

 

 

  • CARDIOVASCULAR: Denies chest pain or edema

 

 

  • RESPIRATORY: Denies cough or shortness of breath Major Depressive Disorder Soap Note Assignment

 

 

  • GASTROINTESTINAL: Denies diarrhea, vomiting, or

 

  • NEUROLOGICAL: Denies dizziness, vertigo, or loss of coordination

 

 

  • MUSCULOSKELETAL: Denies back pain or muscle pain

 

 

  • ENDOCRINOLOGIC: Denies increased thirst or night sweats

 

 

Objective:

 

Diagnostic results:

 

Hamilton Rating Scale for Depression (HAM-D): 19

Assessment

Mental Status Exam:

Patient is a 28-year-old Caucasian male who looks his stated age. He appears well-dressed, well-groomed and in good nutritional status. He is cooperative, with a limited attention span. He maintains minimum eye contact but speaks clearly and coherently, without contradictions. He displays a sad mood with a flat affect. Both short-term and long-term memories are intact. He has a good judgment and a good insight into his health condition. He displays no suicidal ideation, delusions, or hallucinations.

 

Differential Diagnoses:

 

  • Major Depressive Disorder (MDD) F32. 9: Major depressive disorder is characterized by symptoms such as an overall depressed mood and a lack of drive to engage in day-to-day activities. A patient’s quality of life might suffer when they have MDD. It is characterized by a wide range of symptoms, the most common of which are a sad mood, disturbed sleep, extreme weariness, and an inability to focus on anything (Belujon & Grace, 2017). Patient SP suffers from a sad mood, disturbed sleep, extreme fatigue, and an inability to focus, suggesting that she has major depressive disorder.
  • Bipolar Disorder: This is a mental illness that produces unpredictable mood swings, fluctuations in energy and activity levels, difficulties concentrating, and the inability to carry out daily tasks. People who suffer from bipolar disorder might experience periods of unusually elevated mood, as well as shifts in their normal patterns of sleep and energy levels, as well as behavioral problems, which they may not necessarily identify as being detrimental or unpleasant (McIntyre, & Calabrese, 2019).
  • Borderline personality disorder (BPD): This is a mental disease that is characterized by mood swings, erratic behavior, and strained or unstable relationships. Instability of emotions, feelings of hopelessness, nervousness, impulsivity, and damaged social ties are all symptoms of borderline personality disorder (Cristea et al., 2017). Major Depressive Disorder Soap Note Assignment

Plan

  • For depression: Bupropion XL 150mg in the Bupropion is an effective antidepressant because it inhibits the reuptake of norepinephrine, serotonin, and dopamine, and so helps correct the neurotransmitter disequilibrium that underlies depression (Yasin et al., 2019).
  • For depression and Insomnia: Amitriptyline10mg before Amitriptyline  is used to treat insomnia in persons who are simultaneously experiencing signs of depression.
  • CBT sessions

Reflections

I believe that I was successful in implementing all of the appropriate steps to treat the condition of this patient. Because of this, there is not a single aspect of the session in which I would alter my approach if I had the chance to carry it out once again. On seeing the patient again, I discovered that he had improved from his first set of symptoms.

 

References

Belujon, P., & Grace, A. A. (2017). Dopamine system dysregulation in major depressive disorders. International Journal of Neuropsychopharmacology, 20(12), 1036-1046. https://doi.org/10.1093/ijnp/pyx056

Cristea, I. A., Gentili, C., Cotet, C. D., Palomba, D., Barbui, C., & Cuijpers, P. (2017). Efficacy of psychotherapies for borderline personality disorder: a systematic review and metaanalysis. Jama Psychiatry, 74(4), 319-328. https://doi.org/10.1001/jamapsychiatry.2016.4287

McIntyre, R. S., & Calabrese, J. R. (2019). Bipolar depression: The clinical characteristics and unmet needs of a complex disorder. Current Medical Research and Opinion, 35(11), 1993-2005. https://doi.org/10.1080/03007995.2019.1636017

Yasin, W., Ahmed, S. I., & Gouthro, R. V. (2019). Does Bupropion impact more than mood? A case report and review of the literature. Cureus. https://doi.org/10.7759/cureus.4277

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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.
Report normal diagnostic results as the name of the test and “normal” (rather than specific value). Abnormal results should be reported as a specific value.
Specifically address the following for the patient, using your SOAP note as a guide:
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?
Objective: What observations did you make during the psychiatric assessment?
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 diagnostic criteria and supported by the patient’s symptoms. Major Depressive Disorder Soap Note Assignment
Plan: Describe your treatment plan using clinical practice guidelines supported by evidence-based practice. Include a discussion on your chosen FDA-approved psychopharmacologic agents and include alternative treatments available and supported by valid research. All treatment choices must have a discussion of your rationale for the choice supported by valid research. What were your follow-up plan and parameters? What referrals would you make or recommend as a result of this treatment session?
In your written plan include all the above as well as include one social determinant of health according to the HealthyPeople 2030 (you will need to research) as applied to this case in the realm of psychiatry and mental health. As a future advanced provider, what are one health promotion activity and one patient education consideration for this patient for improving health disparities and inequities in the realm of psychiatry and mental health? Demonstrate your critical thinking.
Reflection notes: What would you do differently with this patient if you could conduct the session over? 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. Major Depressive Disorder Soap Note Assignment