Focused SOAP Note and Patient Case Presentation
- Select a patient of any age that you examined during the last 3 weeks.
- Create a Focused SOAP Note on this patient using the template provided in the Learning Resources. There is also a completed Focused SOAP Note Exemplar provided to serve as a guide to assignment expectations.
- All SOAP notes must be signed, and each page must be initialed by your Preceptor. Note: Electronic signatures are not accepted.
- When you submit your note, you should include the complete focused SOAP note as a Word document and PDF/images of each page that is initialed and signed by your Preceptor.
- You must submit your SOAP note using SafeAssign. Note: If both files are not received by the due date, faculty will deduct points per the Walden Grading Policy.
- Include at least five scholarly resources to support your assessment, diagnosis, and treatment planning.
Record yourself presenting the complex case study for your clinical patient. In your presentation:
- Dress professionally with a lab coat and present yourself in a professional manner.
- Display your photo ID at the start of the video when you introduce yourself.
- Ensure that you do not include any information that violates the principles of HIPAA (i.e., don’t use the patient’s name or any other identifying information).
- 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.
- Be succinct in your presentation, and do not exceed 8 minutes. 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.
- Plan: What was your plan for psychotherapy? What was your plan for treatment and management, including alternative therapies? Include pharmacologic and nonpharmacologic treatments, alternative therapies, and follow-up parameters, as well as a rationale for this treatment and management plan. Also be sure to include at least one health promotion activity and one patient education strategy.
- 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.
Expert Answer and Explanation
Patient Initials: MJ is a 17-years-old Caucasian of female origin.
CC (chief complaint): “I have trouble sleeping, I have been feeling stressed lately, and I do not want to go to school.”
HPI: MJ is a 17-years-old Caucasian of female origin who came to the healthcare facility complaining of stress, trouble sleeping, and activities withdrwal for the past two months. The patient noted that she does not want to go to school anymore. The patient also noted that she has been sad for months. She started feeling depressed after the death of her mother. She noted that she loved her mother so much and feels empty now because she is not there. She has not taken any medication. She also reported that she is not feeling any pain.
Substance Current Use: She denies use of hard drugs.
Medical History: The patient does not have any major or chronic conditions.
- Current Medications: No history of medications.
- Allergies: Denies any drug, food, and environmental allergies.
- Reproductive Hx: She saw her periods last week.
- GENERAL: Positive for fatigue, worthlessness, weight loss, decreased appetite.
- HEENT: Non contributory.
- SKIN: Negative for rashes or itchiness.
- CARDIOVASCULAR: Denies heart-related problems.
- RESPIRATORY: Denies breathing-related problems.
- GASTROINTESTINAL: Denies diarrhea, nausea, vomiting, or any other gastrointestinal problems.
- GENITOURINARY: Denies genitourinary problems.
Diagnostic results: Blood tests will taken to rule out other diseases that might cause depressive symptoms. The blood tests check for anemia and thyroid problems. These diseases are some of the physical conditions that might cause depressive symptoms.
Complete Blood Count: The test shows haemoglobin 12 grams per deciliter. The test shows that the patient’s haemoblobin is normal.
Mental Status Examination: The patient’s mental status exam was conducted using Beck Depression Inventory (BDI). During the test, the patient scored 19 out of 21.
- Major depressive disorder: According to Köhler‐Forsberg et al. (2019), when a person scores a BDI test of 18 and above has MDD. The subjective information provided by the patient shows that she has MDD.
- Bipolar disorder: The patient has suffered sleep problems, low motivation, low energy, and depressive thoughts which are some forms of bipolar disorder (Perich et al., 2017).
- Borderline personality disorder: The patient has depressive symptoms and the feeling of worthlessness (Hyland et al., 2019).
The diabgostics tools used to diagnose the patient have helped in deciding the diseases impacting the patient. However, if I could conduct the session again, I would use Hamilton Depression Rating Scale. This scale is one of tools popularly used screen for depression. During follow-up, I would aks the patient to come back to the clinic after two weeks for check-ups.
Case Formulation and Treatment Plan:
Based on the subjective and objective data collected above, MJ is suffering from MDD. I would recommend a combination of medication and talk therapy. I would prescribe sertraline 50 mg orally twice a day (Lewis et al., 2019). I would increase the dose by 25 mg at one week intervals if the patient is not reactying well to medications. The medication therapy would continue for at least six months. I would also refer the patient to a psychologist for talk therapy to help her undergo grief (Maddox et al., 2018).
Hyland, P., Karatzias, T., Shevlin, M., & Cloitre, M. (2019). Examining the discriminant validity of complex posttraumatic stress disorder and borderline personality disorder symptoms: Results from a United Kingdom population sample. Journal of Traumatic Stress, 32(6), 855-863. https://doi.org/10.1002/jts.22444
Köhler‐Forsberg, O., N. Lydholm, C., Hjorthøj, C., Nordentoft, M., Mors, O., & Benros, M. E. (2019). Efficacy of anti‐inflammatory treatment on major depressive disorder or depressive symptoms: meta‐analysis of clinical trials. Acta Psychiatrica Scandinavica, 139(5), 404-419. https://doi.org/10.1111/acps.13016
Lewis, G., Duffy, L., Ades, A., Amos, R., Araya, R., Brabyn, S., … & Lewis, G. (2019). The clinical effectiveness of sertraline in primary care and the role of depression severity and duration (PANDA): a pragmatic, double-blind, placebo-controlled randomised trial. The Lancet Psychiatry, 6(11), 903-914. https://doi.org/10.1016/S2215-0366(19)30366-9
Maddox, B. B., Kang-Yi, C. D., Brodkin, E. S., & Mandell, D. S. (2018). Treatment utilization by adults with autism and co-occurring anxiety or depression. Research in Autism Spectrum Disorders, 51, 32-37. https://doi.org/10.1016/j.rasd.2018.03.009
Perich, T. A., Roberts, G., Frankland, A., Sinbandhit, C., Meade, T., Austin, M. P., & Mitchell, P. B. (2017). Clinical characteristics of women with reproductive cycle–associated bipolar disorder symptoms. Australian & New Zealand Journal of Psychiatry, 51(2), 161-167. https://doi.org/10.1177%2F0004867416670015
Other Answered Questions:
[ANSWERED] Create your own script for building a health history and use the Health History Template for guidance (consider the type of language you would use to help your patient be more comfortable).