Posted: July 4th, 2023

SOAP Note: Psychiatric Case Study

Psychiatric Case Study SOAP note

Suicidal Ideation and Depression in Adolescent
The patient is a 15‐year‐old Puerto Rican adolescent female living with both her parents and a younger sibling. Her parents presented with significant marital problems, had been separated several times and were discussing divorce. Her mother reported having a history of psychiatric treatment for depression and anxiety and indicated that the patient’s father suffered from bipolar disorder and had been receiving psychiatric treatment. He was hospitalized on multiple occasions during previous years for serious psychiatric symptoms.
The patient is failing several classes in school, and her family was in the process of looking for a new school due to her failing grades and difficulties getting along with her classmates. She presented the following symptoms: frequent sadness and crying, increased appetite and overeating, guilt, low self‐concept, anxiety, irritability, insomnia, hopelessness, and difficulty concentrating. In addition, she presented difficulties in her interpersonal relationships, persistent negative thoughts about her appearance and scholastic abilities, as well as guilt regarding her parents’ marital problems. She states that sometimes she feels the world would never know if she disappeared.
The patient’s medical history reveals that she suffers from asthma, used eyeglasses, and is overweight. Her mother reported that she had been previously diagnosed with MDD 3 years ago and was treated intermittently for 2 years with supportive psychotherapy and anti‐depressants (fluoxetine and sertraline; no dosage information available). This first episode was triggered by rejection by a boy for whom she had romantic feelings. Her most recent episode appeared to be related to her parents’ marital problems and to academic and social difficulties at school.
Chafey, M. I. J., Bernal, G., & Rossello, J. (2009). Clinical Case Study: CBT for Depression in A Puerto Rican Adolescent. Challenges and Variability in Treatment Response. Depression and Anxiety, 26, 98-103. https://doi.org/10.1002/da.20457

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Pharmacological tx
Non-pharmacological to
Patient Education
Referral to other providers
Follow-up
Use the Case Study template to show your assessment collection data as well as the thought processes for diagnosis and treatment. Support your diagnosis and treatment plan with a minimum of two reference in Ace homework tutors – APA form within last 5 years.

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SOAP Note Components:
• Chief Complaint
• HPI
• Past Psychiatric History
• Age of manifestations of symptoms
• Previous Diagnoses and when they were diagnosed
• Psychotropic History
• All psychotropic medications
• Why stopped
• How long they were on
• Adherence
• Suicide Attempt/Homicidal Ideation History
• Legal History
• Trauma History
• Substance Use History
• Address
• Tobacco
• Alcohol
• Abuse of Prescription Drugs or Illicit Substances
• Length of time used substances
• Last Use
• Sobriety
• Detox/Rehab history
• Withdrawal Symptom History
• Social History
• Where born and raised
• Parental history
• Married or divorced during childhood
• Relationship with parents during childhood and now
• Siblings
• How many and where they are in the order
• Any developmental issues
• Highest level of education
• Current employment status
• If on disability – list why they are on disability
• Relationship status
• Married
• Divorced
• Single
• Widowed
• Children
• Number
• Ages
• Relationship
• Living arrangements
• Who they live with
• Do they feel safe
• Past medical history/surgical history
• Family medical/psychiatric history
• Review of Systems/Physical Assessment
• Mental Status Exam
• Appearance
• Speech
• Mood
• Affect
• Thought Process
• Thought Content
• Cognition
• Insight
• Judgement
• Psychiatric Screening Tools if any are utilized during the appointment and their results (Example PHQ-9 is 21 and very difficult
• Diagnostic Tests Reviewed
• Make sure to include any pertinent results
• Laboratory results reviewed with patient, discussed abnormal Vitamin D level and treatment options
• If no issues with labs:
• Laboratory results reviewed with patient, no abnormal results noted
• Differential Diagnoses
• With rationale
• 3 are required
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• Definitive Diagnoses
• With rationale
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• It’s rare that patient’s only have 1 diagnosis
• The number of diagnoses can affect your reimbursement as a provider

• Treatment Plan/Plan of Care
• One of the most important parts of the note
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• Medication management
• Medication, Dose, Route, Time
• State Reason for the Medication (I will mark down if this is not included in the plan)
• State reason for any changes
• Discontinued Abilify related to side effects of weight gain
• Increase Lexapro to 10mg daily for depression and anxiety, if patient continues to have depressive symptoms may increase to 15mg at next appointment
• Decreased Seroquel to 100mg daily at bedtime for sleep as the patient c/o increased daytime fatigue
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• Risks, benefits and side effects were discussed in-depth with the patient.
• Patient’s medications were eprescribed and sent to the patient’s designated pharmacy
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• Complementary and Alternative Approaches
• Get custom essay samples and course-specific study resources via course hero homework for you service – Include referral for therapy
• Get custom essay samples and course-specific study resources via course hero homework for you service – Include type of therapy and why you are recommending
• Example
• Patient was referred for EMDR due to history of trauma
• Patient was referend for DBT due to history of borderline personality disorder
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• It is recommended that the patient follow-up with PCP for any medical issues.
• Will refer patient out for neuropsychological examination for cognitive decline
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_____________________________
SOAP Note: Psychiatric Case Study

Subjective:

Chief Complaint: The patient presents with frequent sadness, crying, increased appetite, guilt, low self-concept, anxiety, irritability, insomnia, hopelessness, difficulty concentrating, and suicidal ideation.

History of Present Illness: The patient is a 15-year-old Puerto Rican adolescent female living with both her parents and a younger sibling. Her parents are experiencing significant marital problems, with multiple separations and discussions of divorce. The patient’s mother has a history of psychiatric treatment for depression and anxiety, while her father has bipolar disorder and has received psychiatric treatment, including hospitalizations in the past. The patient is currently failing several classes in school and experiencing difficulties getting along with her classmates. She also expresses persistent negative thoughts about her appearance and scholastic abilities, as well as guilt regarding her parents’ marital problems. The patient reports feeling that the world would not notice if she disappeared.

Past Psychiatric History: The patient was previously diagnosed with Major Depressive Disorder (MDD) three years ago, following a romantic rejection. She received intermittent treatment for two years with supportive psychotherapy and antidepressant medications (fluoxetine and sertraline). The most recent episode appears to be triggered by her parents’ marital problems and academic and social difficulties at school.

Psychotropic History: The patient was prescribed fluoxetine and sertraline for her previous episode of MDD. No specific dosage information is available. The medications were discontinued after two years of intermittent treatment.

Suicide Attempt/Homicidal Ideation History: The patient expresses suicidal ideation, stating that sometimes she feels the world would never know if she disappeared. There is no history of suicide attempts or homicidal ideation.

Social History: The patient was born and raised in Puerto Rico. Her parents have a history of marital problems, including multiple separations. She has a younger sibling. The patient’s mother has a history of psychiatric treatment for depression and anxiety. The patient’s father has bipolar disorder and has received psychiatric treatment, including hospitalizations. The patient’s relationship with her parents during childhood and now is affected by the marital problems. The patient has difficulties in her interpersonal relationships and experiences persistent negative thoughts about her appearance and scholastic abilities.

Review of Systems/Physical Assessment: The patient has a medical history of asthma, uses eyeglasses, and is overweight. No other physical abnormalities are noted.

Mental Status Exam:

Appearance: The patient’s appearance is appropriate for her age and cultural background.
Speech: The patient’s speech is coherent and normal in rate and rhythm.
Mood: The patient reports frequent sadness, crying, and hopelessness.
Affect: The patient’s affect is consistent with her reported mood, displaying sadness and irritability.
Thought Process: The patient’s thought process is coherent and logical.
Thought Content: The patient expresses persistent negative thoughts about her appearance, scholastic abilities, and guilt related to her parents’ marital problems. She also reports suicidal ideation.
Cognition: The patient’s cognitive functioning appears intact.
Insight: The patient demonstrates some insight into her difficulties and acknowledges the need for help.
Judgment: The patient’s judgment is currently impaired due to her depressive symptoms and suicidal ideation.
Diagnostic Tests Reviewed: No specific diagnostic tests were mentioned in the case study.

Assessment:

Differential Diagnoses:

Major Depressive Disorder (MDD), single episode, moderate (ICD-10: F32.1): The patient meets the diagnostic criteria for MDD, including persistent sadness, anhedonia, increased appetite, guilt, low self-esteem, anxiety, irritability, insomnia, hopelessness, difficulty concentrating, and suicidal ideation.
Adjustment Disorder with Depressed Mood (ICD-10: F43.21): The patient’s depressive symptoms are related to her parents’ marital problems and academic/social difficulties at school. However, the severity and persistence of her symptoms are consistent with MDD.
Body Dysmorphic Disorder (ICD-10: F45.22): The patient’s persistent negative thoughts about her appearance may indicate a comorbid diagnosis of Body Dysmorphic Disorder. Further assessment is needed to confirm this diagnosis.
Definitive Diagnoses:

Major Depressive Disorder (MDD), single episode, moderate (ICD-10: F32.1)
Body Dysmorphic Disorder (ICD-10: F45.22) – Provisional Diagnosis pending further assessment.
Treatment Plan:

Medication Management:

Prescribe fluoxetine (SSRI) at an initial dose of 10mg/day for the treatment of MDD and body dysmorphic symptoms. Monitor closely for therapeutic response and side effects. Adjust the dosage as needed based on clinical response and tolerability.
Consider adjunctive psychoeducation and supportive therapy for medication adherence and coping strategies.
Non-Pharmacological Interventions:

Referral for individual Cognitive-Behavioral Therapy (CBT) to address depressive symptoms, negative thoughts about appearance, and maladaptive coping strategies.
Family therapy to address the impact of the parents’ marital problems on the patient’s emotional well-being and provide support for the family system.
Psychoeducation for the patient and her family regarding depression, body dysmorphic symptoms, and the importance of treatment adherence.
Patient Education:

Educate the patient about the nature of depression, body dysmorphic disorder, and the factors contributing to her symptoms.
Provide information about the benefits and potential side effects of fluoxetine.
Teach coping skills, such as relaxation techniques and cognitive restructuring, to manage negative thoughts and improve mood.
Ace my homework – Write my paper – Online assignment help tutors – Discuss the importance of regular therapy sessions and medication adherence.
Provide suicide prevention education, including resources for crisis intervention and hotlines.
Referral to Other Providers:

Refer the patient to a qualified therapist experienced in CBT for individual therapy.
Consider referral to a family therapist to address the family dynamics and parental marital problems.
Follow-Up:
Schedule a follow-up appointment in two weeks to assess the patient’s response to fluoxetine, evaluate treatment adherence, and monitor any emerging side effects. Continuously assess for suicidal ideation and ensure appropriate safety measures are in place.

References:
Chafey, M. I. J., Bernal, G., & Rossello, J. (2009). Clinical Case Study: CBT for Depression in A Puerto Rican Adolescent. Challenges and Variability in Treatment Response. Depression and Anxiety, 26, 98-103. https://doi.org/10.1002/da.20457

American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Arlington, VA: American Psychiatric Publishing.

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