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

 

What is your diagnosis and treatment plan for this case? Include the following:

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 APA form within last 5 years.

 

 

 

Please include this when apply

 

 

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

· Must Include ICD codes

· Definitive Diagnoses

· With rationale

· Must Include ICD Codes

· 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

. Include the following

. 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

· Include a statement such as

. 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

· Include any diagnostics that were ordered at this appointment

· Complementary and Alternative Approaches

· Include referral for therapy

· 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

· Include any type of referrals for anyone else and why

· It is recommended that the patient follow-up with PCP for any medical issues.

· Will refer patient out for neuropsychological examination for cognitive decline

· Include Follow-Up appointment

· Include CPT Codes for visit