Focused SOAP Note
For this Assignment, you will document information about a patient that you examined during the last three weeks, using the Focused SOAP Note Template provided. You will then use this note to develop and record a case presentation for this patient.
- 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.
- Plan: In your assignment, 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 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.
- Include at least five scholarly resources to support your assessment, diagnosis, and treatment planning.
Patient: John Doe
Date of assessment: March 1, 2023
Subjective:
Mr. John Doe is a 32-year-old male who presents with a chief complaint of feeling anxious and depressed for the past three months. He reports experiencing a constant feeling of worry, which is impacting his daily life, including his ability to work and concentrate. He reports poor sleep and fatigue, with difficulty falling and staying asleep. He reports feeling hopeless and helpless at times and experiencing a loss of interest in activities that he once enjoyed. Mr. Doe denies any suicidal or homicidal ideation. He reports a history of depression and anxiety, for which he was previously treated, but he has not been on any medications for the past two years.
Objective:
During the psychiatric assessment, Mr. Doe appeared anxious and depressed. He was cooperative and engaged in the interview. His speech was normal in rate, tone, and volume. He exhibited poor eye contact and a sad affect. He denied any hallucinations, delusions, or paranoia. His insight and judgment appeared to be intact.
Assessment:
Mental Status Examination:
Appearance: anxious and depressed
Behavior: cooperative and engaged
Speech: normal rate, tone, and volume
Mood: depressed
Affect: sad
Thought process: coherent
Thought content: no suicidal or homicidal ideation, no hallucinations, delusions, or paranoia
Insight: intact
Judgment: intact
Differential diagnoses:
- Major depressive disorder (MDD)
- Generalized anxiety disorder (GAD)
- Adjustment disorder with depressed mood
The primary diagnosis is Major Depressive Disorder (MDD) based on the DSM-5 diagnostic criteria, which requires at least five of the following symptoms to be present for at least two weeks, including depressed mood, diminished interest or pleasure, significant weight loss or gain, insomnia or hypersomnia, psychomotor agitation or retardation, fatigue, feelings of worthlessness or guilt, and impaired concentration. Mr. Doe exhibits at least six of these symptoms, including depressed mood, diminished interest or pleasure, insomnia, fatigue, feelings of worthlessness, and impaired concentration. His symptoms have been present for at least three months and are causing significant impairment in his daily functioning.
Plan:
Treatment plan:
The treatment plan for Mr. Doe includes a combination of pharmacotherapy and psychotherapy.
Pharmacotherapy:
I would prescribe an SSRI antidepressant, such as escitalopram, based on the efficacy and safety profile of this class of medications. I would start at a low dose and titrate as tolerated. I would monitor for side effects and drug interactions. I would educate Mr. Doe about the potential benefits and risks of the medication, including the risk of suicidal ideation.
Psychotherapy:
I would refer Mr. Doe to a licensed therapist for cognitive-behavioral therapy (CBT), which has been shown to be effective in the treatment of MDD and GAD. CBT would focus on identifying and modifying negative thought patterns and developing coping strategies to manage anxiety and depression symptoms.
Follow-up plan:
I would schedule a follow-up appointment with Mr. Doe in two weeks to assess his response to the medication and psychotherapy. I would monitor for side effects and adjust the treatment plan as necessary.
Referrals:
I would recommend a referral to a nutritionist to evaluate Mr. Doe’s dietary habits and provide recommendations for a healthy diet. I would also recommend a referral to a social worker to assess any social determinants of health that may be impacting Mr. Doe’s mental health, such as financial stressors or lack of social support.
Social determinant of health:
One social determinant of health that may be impacting Mr. Doe’s mental health is access to healthcare. Mr. Doe reports not having health insurance