SOAP Note 14-years-old African American girl diagnosed with Major depressive disorder and generalized anxiety disorder
This SOAP note should be written on 14-years-old African American girl diagnosed with Major depressive disorder and generalized anxiety disorder. It should be written by an experienced professional psychiatric nurse practitioner SOAP note writer. Please do not assign this writing to a beginner and inexperienced writer.
PMHNP’s must document information to substantiate assessments, diagnoses, and plans of care. This facilitates safe patient care and appropriate transition management. In this assignment, you will create a SOAP note and discuss what you learned through a specific patient encounter.
Do not include any identifying patient information on your assignment.
The purpose of this assignment is to facilitate the learner’s ability to create a comprehensive SOAP note.
At the conclusion of this assignment, the learner will be able to:
· Present a comprehensive SOAP note regarding a specific patient encounter
· Identify a particular piece of learning that took place via this specific patient encounter
Select a patient encounter in which you learned something new. Create a fully-formed SOAP note regarding this patient encounter.
Soap Note Virtual Case Submission Rubric
Criteria 20 Points 19 Points 18 Points 0 Points
Subjective Communicates a clear & precise assessment data supported with subjective findings.
This should include but not limited to biological, psychological, sociocultural, spiritual, ethnic, and family factors. Communicates an assessment but may be missing 1-2 important piece of data Communicates a brief & vague assessment while missing key important details of the assessment data No paper submitted or substantial content missing /20
Objective Communicates a clear & precise assessment data supported with objective findings.
This should include but not limited to Mental Status Exam, biological, psychological, sociocultural, spiritual, ethnic, and family factors. Communicates an assessment but may be missing 1-2 important piece of data Communicates a brief & vague assessment while missing key important details of the assessment data No paper submitted or substantial content missing /20
Assessment Thoroughly describes all relevant differential diagnoses and the actual DSM-V diagnosis with ICD 10 codes. Describes differential diagnoses but omits one that should be considered Describes differential diagnoses but omits more than one that should be considered No paper submitted or content missing /20
Plan Develops and provides a clearly written treatment plan, including relevant health promotion and patient education information. Clearly defines and delineates the levels of evidence that support the treatment plan. Develops a clear set of written orders but omits an important order for the diagnosis or outdated approach not supported by evidence. Covers educational topics and health promotion, but no plan is developed. Develops and provides a brief set of orders for the treatment plan with more than one omission and lacks evidential support. Health promotion and patient education are substantially lacking or not covered. No paper submitted or content missing /20
Criteria 10 Points 8 Points 6 Points 0 Points /10
Grammar, spelling, and punctuation There are no errors in grammar, spelling, and punctuation There are a few minor errors in grammar, spelling, and punctuation that do not detract from the meaning There are multiple errors in grammar, spelling, and punctuation that detract from the meaning
There are major errors in grammar, spelling, and punctuation that do not reflect scholarly writing
APA and references The paper meets APA format guidelines and/or all references are peer reviewed, relevant, scholarly and contemporary, up to 5 years. There are minor APA format errors and/or references meet two requirements of relevant, scholarly or contemporary, up to 5 years. There are multiple errors in format and/or references meet one requirement of relevant, scholarly or contemporary There are significant errors in format and/or references meet one requirement of relevant, scholarly or contemporary /10
Total Points Possible = 100
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SOAP Note Assignment
Pt. Initials: XX Age: 14 years
CC: “I have sadness that won’t go away and I keep feeling like I am on the edge. I am tired and I cannot take this helplessness and hopelessness anymore.”
HPI: XX is a 14-year-old Caucasian female who presented to the clinic accompanied by the mother with complaints about sadness, fatigue, anxiety, and feeling being on the edge. The mother reported that for the last few months the daughter had become withdrawn, was always sad, never enjoyed watching TV as she used to, was irritable, had lost appetite, her academic performance had declined significantly. She reported that she has been having excessive worry for no apparent reason. XX also reported that she sometimes experienced a fast heartbeat, muscle aches, tension, excessive sweating, and sometimes breath shortness. The mother further reported that XX has had anxiety for a long time but it has been increasing for the past one week. Anxiety is associated with body tension, insomnia, and shakiness. The symptoms have affected her functionality because sometimes she does not attend school and also her academic performance has significantly declined yet she used to be an A student. The client has had numerous life stressors. Her parents divorced a year ago and according to the mother, this significantly affected her as she was very close with the father. She also lost her favorite cousin several months ago and she is still grieving. XX was tearful as she recounted how they used to do things together with the cousin and how the dad was her pillar. Additionally, she also lost a friend to suicide two years ago and she has never recovered from that as she always gets teary when talking about the traumatic loss of her friend. The mother reports that XX was sexually abused when she was 8 years old by a family friend. After the sexual abuse, she started self-harming by cutting and piercing herself. The last time she performed self-harming behavior was 2 years ago. She has never taken medications for mental problems. She has however used vitamin supplements and CBD oil to improve her mental health but this has not helped. The mother reports that XX has lost so much weight within the last 6 months. The patient does not have a history of suicide attempts and has never been hospitalized for a mental health problem.
Past Psychiatric History:
XX is a 14-year-old Caucasian female who was reported to have been sexually abused in the past and lost a friend to suicide. These two events significantly affected her mental health. She has not been taking any medications. XX also has a history of self-harm (cutting and piercing herself). The mother is the main caregiver because the parents are divorced.
Hospitalizations: XX has never been hospitalized for a mental health issue. No history of homicide or suicide attempts.
Medication Trials: None
Psychotherapy or previous psychiatric diagnoses: N/A
Substance Current Use and History: None
Family Psychiatric/Substance Use History: The mother has a history of opioid addiction. The father has a history of substance abuse (marijuana and cocaine). Maternal grandfather has a history of major depressive disorder while her paternal grandmother has a history of type 2 bipolar disorder. Two of her paternal aunties have a history of substance abuse and alcoholism.
Psychosocial History: XX was born and grew up in California, USA. She currently lives with her mother and sister. Her parents are divorced. She has not seen the father for the last one year. She attends school and she is in high school. She had a comparatively challenging childhood. The father was always violent towards the mother and the mother would sometimes run away and leave her with the sister alone for days. she did not manifest any developmental problems as a child. She has always been an above-average student, but currently, her academic performance has significantly declined. She has one close friend. She is also very close to her cousins but lately, she has isolated herself from everyone. The mother is a teacher. They live in a rental house.
Medical History: XX had a meningitis attack at the age of 6-years old. He was hospitalized for 28 days. She does not have any history of head trauma or seizures.
Current medications: Zinc 10 mg daily, Vitamin C 500 mg daily
Allergies: Allergic to dust mice and cats
Reproductive Hx: She is not in a relationship but reports liking her male classmate. She is not yet sexually active.
Medical Diagnoses: N/A
Family Medical History: Father has a history of high blood pressure and arthritis. The hypertension is well controlled using lifestyle medications while arthritis has since been subsidized. The mother was diagnosed with asthma and she uses an albuterol inhaler whenever she has an asthma attack. Paternal uncle was diagnosed with high blood pressure. The paternal grandfather succumbed to myocardial infarction. Paternal grandmother has type 2 diabetes. The maternal grandmother succumbed to colorectal cancer. The sister is overweight and asthmatic; the asthma is well controlled.
Weight: 45 kgs; Height 5’1 inch; Blood pressure 116/71; Temp 36.5 0 C; Heart rate 76; Respiratory rate 17.
General: A well-developed Caucasian female with normal weight and height for her age. She is alert and well oriented. no acute distress. She however appears sad and teary. No tics or tremors.
Head: Head is symmetric, atraumatic, and normocephalic
Neck: No carotid bruits, no lymphadenopathy. No JVD. No evidence of swollen thyroid.
Respiratory: Chest expansion is symmetrical. Lungs clear to percussion bilaterally. Lungs clear to auscultation.
Cardiovascular: Regular heart rate. Regular heart rhythm. S1 and S2 normal.
GIT: Normoactive bowel sounds. Soft and non-tender abdomen. No CVA. No tenderness. No palpable mass.
Musculoskeletal: No joint stiffness. Full range of motion in all joints.
- DSM-5 diagnostic criteria: DSM-5 diagnostic criteria will be utilized to come up with the diagnosis of the mental disorder the client may be having. The client manifests symptoms of mental disorder such as social withdrawal, sad mood, anhedonia, excessive anxiety, loss of appetite, loss of weight, among other symptoms. Additionally, the symptoms have affected XX’s functionality as his academic performance has significantly declined.
- Neuropsychological testing: This test can diagnose various mental disorders the client may be having.
- GAD-7 Screening tool: This scale will be used in screening the symptoms of anxiety the client manifests. It can also reveal how severe the anxiety symptoms are. GAD-7 tool is validated to screen anxiety disorders such as GAD (Johnson et al., 2019).
- Suicide screening: It will also be important to integrate suicide screening to screen for any suicidal thoughts, suicidal plans, or suicidal behaviors for XX. The current symptoms of depression and anxiety, a history of self-harm behaviors and recent acute stressors pose the risk of the client manifesting suicidal behaviors.
- No history of suicide attempts.
- History of self-harm
- Immediate risk: Moderate
- Lifetime risk: Minimal
Mental Status Examination:
XX is a 14-year-old female who appears well developed for her age. Her speech is clear, logical, and coherent. She is well oriented to time, place, event, and person. She is well-groomed and properly dressed for the occasion and weather. She does not manifest any noteworthy gestures or tics. She gets teary when talking about her life. The self-reported mood is depressed and sad mood. Flat affect. Attention and concentration are intact. No delusional or paranoid thought process. No visual or audio hallucinations. Insight and judgment are intact. No suicidal or homicidal ideation or plan. Cognitive functioning is intact and age-appropriate. Memory is intact. Ability to do arithmetic calculations and abstract intact. She was cooperative and attentive during the session.
Major depressive disorder: Major depressive disorder is characterized by symptoms such as sad and depressed mood, lack of pleasure or interest in activities that used to be pleasurable, lack of appetite, weight loss, social isolation, sleep problems, irritability, feeling of hopelessness, concentration difficulties, suicidal thoughts, and plans, among other symptoms (McIntyre et al., 2019). The symptoms are significant enough to cause distress or impact normal functioning. XX manifests a majority of these symptoms such as irritability, isolation, loss of appetite, anhedonia, depressed mood and feeling hopelessness, and weight loss. The symptoms have also affected her functioning as indicated by declined academic performance.
Generalized Anxiety Disorder (GAD): The main symptoms of GAD include anxiety and excessive worry that are hard to control and they lead to significant distress and impair normal functioning. Other symptoms of GAD include nervousness, restlessness, muscle tension, increased heartbeat, and breath shortness (Stein et al., 2021). These symptoms should exist for at least six months. XX reported that she has been experiencing symptoms such as excessive anxiety, feeling being on the edge, breath shortness, muscle tensions, and excessive sweating, indicating a possible diagnosis of GAD.
Cyclothymic Disorder: This disorder is characterized by numerous weeks of low-level depressions and mild mania symptoms that last for numerous days. depressive symptoms include irritability, sleep disturbances, weight changes, loss of appetite, feeling of hopelessness, concentration problems, fatigue, and suicidal thoughts (Van Meter et al., 2018). Mania symptoms include extreme self-confidence, excessive talking, speaking fast, racing thoughts, hyperactivity, lack of sleep, impulsive behavior, increased anxiety, and lack of focus (Van Meter et al., 2018). This diagnosis is less likely because XX does not manifest mania symptoms and her symptoms meet the diagnostic criteria for major depressive disorder.
Diagnosis: Generalized Anxiety Disorder and Major Depressive Disorder
Negative life events have been major triggers for the depressive symptoms and anxiety symptoms for XX. The client is however determined to recover and the positive thinking pattern towards her recovery will facilitate her treatment adherence. In the future, as an NP, I would order more diagnostic tests to inform the diagnoses. Additionally, in the future, I would utilize multiple assessment tools and techniques in order to diagnose a variety of disorders. This is because client XX may be having other mental disorders contributing to her current symptoms.
XX appears to have major depressive disorder and generalized anxiety disorder as informed by both objective and subjective data. The treatment goal for this client is to reduce symptoms and eventually attain full symptom resolution for both disorders. The client also needs to be monitored closely because clients who feel hopeless and manifest self-harm behaviors tend to have suicidal thoughts and may have suicidal plans.
Cognitive-behavioral therapy (CBT): CBT will be utilized to alter the client’s maladaptive thinking pattern into a more positive thinking pattern in order to improve her mood, affect, and behavior (Shafran et al., 2018). CBT normally focuses on changing thinking patterns by teaching the client to learn and recognize their maladaptive thinking pattern contributing to the mental problems and then reexamining them problems realistically and positively; gain a better understanding of behavior; adopt a more positive and adaptive thinking pattern; utilizing problem-solving and coping skills to cope with difficult life situations; and developing a high self-confidence in one’s abilities (Halder & Mahato, 2019). Additionally, during CBT treatment, individuals are also taught to face their fears rather than avoid them and learn to calm the mind and relax the body through various relaxation techniques (Carpenter et al., 2018). Therefore, through CBT, the client will have a positive thinking pattern causing the symptoms to improve as she will adopt a more positive thinking pattern. Moreover, since she will be taught coping skills, she will be able to cope with difficult life situations such as the loss of loved ones. Evidence shows that CBT is effective in improving depressive symptoms and anxiety symptoms (Carpenter et al., 2018).
Fluoxetine 20 mg: Fluoxetine is a selective serotonin reuptake inhibitor that is FDA approved to treat major depressive disorder in the pediatric population. The medication works by preventing the reuptake of serotonin; this increases the level of serotonin in the brain and hence improves the depressive symptoms by improving mood (Boaden, Tomlinson, Cortese & Cipriani, 2020). Additionally, fluoxetine is also used to treat GAD symptoms in adolescences. Therefore, fluoxetine will improve the depressive symptoms and as well as the GAD symptoms for the client. Fluoxetine is well tolerated and associated with minimal side effects the reason why it was selected for this client (Boaden et al., 2020). The client will be reviewed after 2 weeks to evaluate the treatment progress and for any side effects.
Boaden, K., Tomlinson, A., Cortese, S., & Cipriani, A. (2020). Antidepressants in Children and Adolescents: Meta-Review of Efficacy, Tolerability, and Suicidality in Acute Treatment. Frontiers in psychiatry, 11, 717. https://doi.org/10.3389/fpsyt.2020.00717
Carpenter, J. K., Andrews, L. A., Witcraft, S. M., Powers, M. B., Smits, J., & Hofmann, S. G. (2018). Cognitive-behavioral therapy for anxiety and related disorders: A meta-analysis of randomized placebo-controlled trials. Depression and anxiety, 35(6), 502–514. https://doi.org/10.1002/da.22728.
Halder, S., & Mahato, A. K. (2019). Cognitive Behavior Therapy for Children and Adolescents: Challenges and Gaps in Practice. Indian journal of psychological medicine, 41(3), 279–283. https://doi.org/10.4103/IJPSYM.IJPSYM_470_18
Johnson, S. U., Ulvenes, P. G., Øktedalen, T., & Hoffart, A. (2019). Psychometric Properties of the General Anxiety Disorder 7-Item (GAD-7) Scale in a Heterogeneous Psychiatric Sample. Frontiers in psychology, 10, 1713. https://doi.org/10.3389/fpsyg.2019.01713
McIntyre, R. S., Zimmerman, M., Goldberg, J. F., & First, M. B. (2019). Differential diagnosis of major depressive disorder versus bipolar disorder: current status and best clinical practices. The Journal of clinical psychiatry, 80(3), 0-0.
Stein, D. J., Kazdin, A. E., Ruscio, A. M., Chiu, W. T., Sampson, N. A., Ziobrowski, H. N., … & Kessler, R. C. (2021). Perceived helpfulness of treatment for a generalized anxiety disorder: a World Mental Health Surveys report. BMC psychiatry, 21(1), 1-14.
Shafran, R., Wroe, A., Nagra, S., Pissaridou, E., & Coughtrey, A. (2018). Cognitive behavior treatment of co-occurring depression and generalized anxiety in routine clinical practice. PloS one, 13(7), e0201226. https://doi.org/10.1371/journal.pone.0201226
Van Meter, A., Goldstein, B. I., Goldstein, T. R., Yen, S., Hower, H., Strober, M., Merranko, J. A., Gill, M. K., Diler, R. S., Axelson, D., Ryan, N. D., Keller, M. B., & Birmaher, B. (2018). Parsing cyclothymic disorder and other specified bipolar spectrum disorders in youth. Journal of affective disorders, 238, 375–382. https://doi.org/10.1016/j.jad.2018.06.023