NRNP6675 Focused SOAP Note Assignment
Subjective
Chief complaint: “I’m feeling really down and hopeless.”
History of present illness: Mr. Tremaine reports that he has been feeling depressed for the past 6 months. He describes feeling sad, hopeless, and unmotivated. He has also lost interest in activities that he used to enjoy. He has difficulty sleeping and concentrating. He has had thoughts of death, but he has not made any plans to harm himself.
Past psychiatric history: Mr. Tremaine has a history of major depressive disorder. He has been treated with medication and psychotherapy in the past.
Medication trials and current medications: Mr. Tremaine is currently taking sertraline 100 mg/day. He has tried other antidepressants in the past, but they have not been effective.
Psychotherapy or previous psychiatric diagnosis: Mr. Tremaine has been in psychotherapy in the past. He found it to be helpful.
Pertinent substance use, family psychiatric/substance use, social, and medical history: Mr. Tremaine does not use drugs or alcohol. He has a family history of depression. He has no significant medical history.
Allergies: Mr. Tremaine is allergic to penicillin.
ROS: Mr. Tremaine denies any physical complaints.
Objective
General appearance: Mr. Tremaine is a well-groomed, well-nourished male in no acute distress.
Vital signs: BP 120/80, HR 72, RR 12, SpO2 98% on room air.
Mental status exam: Mr. Tremaine is oriented to person, place, and time. His mood is depressed. His affect is congruent with his mood. His thought process is linear and coherent. His speech is fluent and non-pressured. His attention is good. His memory is intact. His judgment is impaired.
Assessment
Major depressive disorder, recurrent, moderate
Differential diagnoses:
Dysthymia
Persistent depressive disorder
Adjustment disorder with depressed mood
Major depressive disorder, recurrent, severe
Bipolar disorder
Plan
Psychotherapy: I will refer Mr. Tremaine to a therapist who specializes in the treatment of depression.
Medication: I will increase Mr. Tremaine’s dose of sertraline to 150 mg/day.
Health promotion: I will encourage Mr. Tremaine to engage in regular exercise and healthy sleep habits.
Patient education: I will educate Mr. Tremaine about the symptoms of depression and the importance of seeking help if his symptoms worsen.
Reflection notes
I would like to follow up with Mr. Tremaine in 2 weeks to assess his response to treatment.
I would also like to discuss with Mr. Tremaine the possibility of adding cognitive-behavioral therapy to his treatment plan.
I am concerned about Mr. Tremaine’s thoughts of death. I will monitor his mood closely and make sure that he has a safety plan in place.
I am hopeful that Mr. Tremaine will respond well to treatment and that he will be able to manage his depression.
References
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: Author.
National Institute of Mental Health. (2022, January 25). Depression. Retrieved from https://www.nimh.nih.gov/health/topics/depression/index.shtml
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Subjective
Chief complaint: “I’m feeling really down and hopeless.”
History of present illness: Mr. Tremaine reports that he has been feeling depressed for the past 6 months. He describes feeling sad, hopeless, and unmotivated. He has also lost interest in activities that he used to enjoy. He has difficulty sleeping and concentrating. He has had thoughts of death, but he has not made any plans to harm himself.
Past psychiatric history: Mr. Tremaine has a history of major depressive disorder. He has been treated with medication and psychotherapy in the past.
Medication trials and current medications: Mr. Tremaine is currently taking sertraline 100 mg/day. He has tried other antidepressants in the past, but they have not been effective.
Psychotherapy or previous psychiatric diagnosis: Mr. Tremaine has been in psychotherapy in the past. He found it to be helpful.
Pertinent substance use, family psychiatric/substance use, social, and medical history: Mr. Tremaine does not use drugs or alcohol. He has a family history of depression. He has no significant medical history.
Allergies: Mr. Tremaine is allergic to penicillin.
ROS: Mr. Tremaine denies any physical complaints.
Objective
General appearance: Mr. Tremaine is a well-groomed, well-nourished male in no acute distress.
Vital signs: BP 120/80, HR 72, RR 12, SpO2 98% on room air.
Mental status exam: Mr. Tremaine is oriented to person, place, and time. His mood is depressed. His affect is congruent with his mood. His thought process is linear and coherent. His speech is fluent and non-pressured. His attention is good. His memory is intact. His judgment is impaired.
Assessment
Major depressive disorder, recurrent, moderate
Differential diagnoses:
Dysthymia
Persistent depressive disorder
Adjustment disorder with depressed mood
Major depressive disorder, recurrent, severe
Bipolar disorder
Plan
Psychotherapy: I will refer Mr. Tremaine to a therapist who specializes in the treatment of depression.
Medication: I will increase Mr. Tremaine’s dose of sertraline to 150 mg/day.
Health promotion: I will encourage Mr. Tremaine to engage in regular exercise and healthy sleep habits.
Patient education: I will educate Mr. Tremaine about the symptoms of depression and the importance of seeking help if his symptoms worsen.
Reflection notes
I would like to follow up with Mr. Tremaine in 2 weeks to assess his response to treatment.
I would also like to discuss with Mr. Tremaine the possibility of adding cognitive-behavioral therapy to his treatment plan.
I am concerned about Mr. Tremaine’s thoughts of death. I will monitor his mood closely and make sure that he has a safety plan in place.
I am hopeful that Mr. Tremaine will respond well to treatment and that he will be able to manage his depression.
References
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: Author.
National Institute of Mental Health. (2022, January 25). Depression. Retrieved from https://www.nimh.nih.gov/health/topics/depression/index.shtml
