MDD SOAP NOTE AND soap notes for major depressive disorder. The focus is on your ability to integrate your subjective and objective information gathering into the formulation of diagnoses and the development of patient-centered, evidence-based plans of care for patients of all ages with multiple, complex mental health conditions. Also includes generalized anxiety disorder soap notes, psychiatry soap note and examples of soap notes.
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MDD SOAP NOTE AND SOAP notes for major depressive disorder
| Criteria | Clinical Notes |
| Informed Consent | The patient gave informed consent to the psychiatric interview process and the subsequent psychiatric/ psychotherapy treatment. This means both verbal and written consent was secured since the patient demonstrated both ability and capacity to respond and appears to fathom the risks, benefits, and promises to review additional consent at any stage of the treatment plan discussions. |
| Subjective | CC: “I just feel depressed and it’s all my fault”. HPI: CF is a 51 y/o African American female single lady with a history of depression who presents to the clinic c/o increased anxiety. She admits anxiety has been a chronic problem that has steadily increased in the past few weeks accompanied by lack of sleep, body tension, and shaking. She reports just feeling depressed with symptoms such as losing interest in meeting friends, increasing fatigue, and irritability, the severity being enough to interfere with activities considered instrumental for daily living. She reports she is currently on medication therapy but feels that the symptoms gradually getting worse despite her taking Lexapro 10 PO once daily. Prior to that, the medication seems to be taking the edge off. She’s positive to many recent life stressors like having a benign tumor on her left breast with subsequent hospitalization and her mother is on her death bed. Six months ago, she lost her older sister and admits she is still in the grieving process. She reports her steady partner was supportive until eight months ago when he decided to move on with the previous relationship with a 30 y/o female workmate. She reports having consulted a psychiatrist for anxiety/depression in the past. CF denies mood swings, mania, or hypomania behaviors. She denies smoking and claims to be a teetotaller Past Medical Hx: Medical history: The patient admits she has hypertension. Acute illnesses include a loss of a finger after she accidentally cut it off while she was chopping a piece of sugarcane at age 33. Reports a lumpectomy but denies other surgical histories Surgical history: Lumpectomy at age 51 yrs. Past Psychiatric Hx: Previous psychiatric diagnoses: diagnosis of, depression, and anxiety. Describes worsening course of illness. Current Medications: Lexapro 10mg PO once daily (Contraceptives): None Supplements: Calcium 500mg and Vitamin B6 500mg Previous medication trials: Unknown. Allergies: NKDA Therapy History: Anxiety: CF confirms significant social anxiety and reported this began in high school. Reported that she experiences challenge leaving the house and is engulfed with intense fear accompanied by shaking and fast breathing. She has taken Benadryl an OTC medication and found it to be fast-acting and convenient though she can’t recall the dosage. Pro-essays.com has the top and most qualified writers to help with any of your assignments. All you need to do is place an order with us (MDD SOAP NOTE) Depression: Patient reports feeling depressed since last year April when a string of misfortunes and tragedies struck her close family members and relatives. The mood swings have increased in intensity in the last two weeks. She reports inability to sleep in a bed she had shared with her late sister and gets three to four hours of sleep. Confirms having sought treatment for depression and admits having experienced other episodes prior to this occurrence. Mental health treatment history discussed: History of outpatient treatment: three-month CBT course for depression Previous psychiatric hospitalizations: Unknown at this time Prior substance abuse treatment: Negative Trauma history: Client reports no forms of childhood abuse or even as an adult. Substance Use: Negative- Patient claims to be a tee–totaller Past Psych Med Trials: unknown at this time Family Medical Hx: Mother at 71 years diagnosed with advanced stage breast cancer, father died at age 63 years due to complications arising from T2DM. Family Psychiatric Hx: Noncontributory except for a maternal uncle who committed suicide by taking drug overdose. Birth and Development History: Reports no issues with developmental milestones as all were attained with no challenges. ROS: Constitutional: Healthy looking AA female, alert, afebrile and in mild acute distress Eyes: Negative for eye pain, no discharge, and no sight changes. ENT: Negative for hearing changes.no running nose, bleeding, no difficulties in swallowing food. Cardiac: Denies chest pain, edema or orthopnea. Respiratory: Denies shortness of breath, cough or wheezing. GI: Negative abdominal pain abdomen is soft, non-tender. Normoactive bowel sounds. GU: Negative for excessive thirst and frequent urination. Musculoskeletal: Negative for joint pain or swelling. Skin: Negative for rash, lesion, and abrasions. Neurologic: Denies seizures, blackout, numbness, or focal weakness. Endocrine: Negative for both polyuria and polydipsia. Hematologic: Negative for blood clots or easy bleeding or splenectomy Allergy: Negative for hives or allergic reaction. Reproductive: LMP 10 days ago Cycle length and frequency 3/28 light bleeding IMB –Absent PCB-Absent Age of Menarche/Menopause- 12 and 48 years respectively Miscarriages G 3 P 2A 1 L 1 Pro-essays.com has the top and most qualified writers to help with any of your assignments. All you need to do is |
| HPI | |
| Objective | Vital Signs: BP 151/97, HR 90, Temp 97.5, RR 19, O2 97% Lab tests results CBC: currently unavailable. TSH- 1.9mU/L BUN levels- 12 mg/dL Serum creatinine levels 0.64mg/dL Physical Exam: None Contributory. MSE: Appearance: Well groomed, dressed for the occasion and appears the stated age Behavior: Composed, focused with intermittent eye contact Attitude: Cooperative, easy to establish a discussion Level of consciousness: Awake, Alert Orientation: A*4 Speech and Language: Soft clear, coherent Mood: context appropriate Affect: Mood congruent, moderately restricted Thought process/form: organized, goal directed, logical Thought content: Depressed, suicidal ideations Suicidality and homicidally: Has history of suicide attempts denies homicidal thoughts Insight and judgement: Insight considered to be good, judgement moderate Attention span: adequate to the needs of an outpatient program, age appropriate Memory: Both recent and remote deemed intact Intellectual functionality: Intellectually capable Relevant Screening Tools GAD-7: Was used to screen for generalized anxiety and her score was 13 –moderate anxiety Patient Health Questionnaire (PHQ-9) -12 moderate depression Columbia Suicide Severity Rating Scale (C- SSRS): Moderate risk Appearance: Good hygiene, neat appearance, looks stated age 2. Behavior: Calm, focused, eye contact intermittent 3. Attitude: Cooperative, friendly, open to discussion 4. Level of Consciousness: Awake and Alert 5. Orientation: Oriented to person, place, and time 6. Speech and Language: Soft, clear, and coherent 7. Mood: Appropriate to context 8. Affect: Mildly restricted, congruent with mood 9. Thought Process/Form: Organized and goal directed, logical 10. Thought Content: Depression, suicidal thoughts 11. Suicidality and Homicidally: Prior suicidal/homicidal thoughts, denies any suicide attempts 12. Insight and Judgment: Insight deemed good; judgement is fair 13. Attention Span: Appropriate for age and adequate to needs of outpatient program 14. Memory: Recent and remote memory intact 15. Intellectual Functioning: Intellectually capable Appearance: Good hygiene, neat appearance, looks stated age 2. Behavior: Calm, focused, eye contact intermittent 3. Attitude: Cooperative, friendly, open to discussion 4. Level of Consciousness: Awake and Alert 5. Orientation: Oriented to person, place, and time 6. Speech and Language: Soft, clear, and coherent 7. Mood: Appropriate to context 8. Affect: Mildly restricted, congruent with mood 9. Thought Process/Form: Organized and goal directed, logical 10. Thought Content: Depression, suicidal thoughts 11. Suicidality and Homicidally: Prior suicidal/homicidal thoughts, denies any suicide attempts 12. Insight and Judgment: Insight deemed good; judgement is fair 13. Attention Span: Appropriate for age and adequate to needs of outpatient program 14. Memory: Recent and remote memory intact 15. Intellectual Functioning: Intellectually capable Appearance: Good hygiene, neat appearance, looks stated age 2. Behavior: Calm, focused, eye contact intermittent 3. Attitude: Cooperative, friendly, open to discussion 4. Level of Consciousness: Awake and Alert 5. Orientation: Oriented to person, place, and time 6. Speech and Language: Soft, clear, and coherent 7. Mood: Appropriate to context 8. Affect: Mildly restricted, congruent with mood 9. Thought Process/Form: Organized and goal directed, logical 10. Thought Content: Depression, suicidal thoughts 11. Suicidality and Homicidally: Prior suicidal/homicidal thoughts, denies any suicide attempts 12. Insight and Judgment: Insight deemed good; judgment is fair 13. Attention Span: Appropriate for age and adequate to needs of outpatient program 14. Memory: Recent and remote memory intact 15. Intellectual Functioning: Intellectually capable Appearance: Good hygiene, neat appearance, looks stated age 2. Behavior: Calm, focused eye contact intermittent 3. Attitude: Cooperative, friendly, open to discussion 4. Level of Consciousness: Awake and Alert 5. Orientation: Oriented to person, place, and time 6. Speech and Language: Soft, clear, and coherent 7. Mood: Appropriate to context 8. Affect: Mildly restricted, congruent with mood 9. Thought Process/Form: Organized and goal-directed, logical 10. Thought Content: Depression, suicidal thoughts 11. Suicidality and Homicidally: Prior suicidal/homicidal thoughts, denies any suicide attempts 12. Insight and Judgment: Insight is deemed good; judgment is fair 13. Attention Span: Appropriate for age and adequate to the needs of outpatient program 14. Memory: Recent and remote memory intact 15. Intellectual Functioning: Intellectually capable Appearance: Good hygiene, neat appearance, looks stated age 2. Behavior: Calm, focused eye contact intermittent 3. Attitude: Cooperative, friendly, open to discussion 4. Level of Consciousness: Awake and Alert 5. Orientation: Oriented to person, place, and time 6. Speech and Language: Soft, clear, and coherent 7. Mood: Appropriate to context 8. Affect: Mildly restricted, congruent with mood 9. Thought Process/Form: Organized and goal-directed, logical 10. Thought Content: Depression, suicidal thoughts 11. Suicidality and Homicidally: Prior suicidal/homicidal thoughts, denies any suicide attempts 12. Insight and Judgment: Insight is deemed good; judgment is fair 13. Attention Span: Appropriate for age and adequate to the needs of outpatient program 14. Memory: Recent and remote memory intact 15. Intellectual Functioning: Intellectually Pro-essays.com has the top and most qualified writers to help with any of your assignments. All you need to do is |
| Assessment | DSM5 Diagnosis: with ICD-10 codes Diagnosis F33.1 Major Depressive Disorder F41.1 Generalized Anxiety Disorder F31.9 Bipolar disorder F40.0 Agoraphobia Differential Diagnoses: F33.1 Major Depressive Disorder Recurrent, Moderate (MDD)-confirmed Bains & Abdijadid (2021) note that individuals who present with sleep disturbances report a significant loss of interest in activities that used to give them pleasure and are currently guilt-ridden for real or imaged causes and feeling worthless are likely candidates for MDD diagnosis. Using the Mnemonic SIG-E-CAPS the MDD diagnosis was confirmed because, in addition to sleeplessness, interest loss in earlier pleasurable activities, and guilt- complex, the patient reports a lack of energy manifesting as fatigue. While her cognition is not significantly affected by excessive appetite, psychomotor agitation through anxiety, and being haunted by suicidal thoughts. Most importantly these symptoms have lasted for more than six months increasing in intensity in the last seven weeks. Some potential medications to treat MDD are Selective serotonin reuptake inhibitors: Lexapro, Sertraline, and Fluoxetine. Serotonin-norepinephrine reuptake inhibitors with Cymbalta and Effexor can be another substitute if SSRIs are to be excluded. SSRI classification of medication would be an adequate choice for the patient because of the cost, targeting depression and anxiety, and studied efficacy and acceptability for most patients with minimal side effects. The patient will benefit from Lexapro because she has been successful with the medication on the lower dose, maybe increasing the dose will be the first intervention before switching to another SSRI. Lexapro regulates a wide range of human behavioral processes, which include mood, perception, memory, anger, aggression, fear, stress response, appetite, addiction, and sexuality (Landy et. al., 2022). Considering increasing the dose of Lexapro will be the next step as the patient tolerates the medication with no side effects. Pro-essays.com has the top and most qualified writers to help with any of your assignments. All you need to do is place an order with us (MDD SOAP NOTE) F41.1 Generalized Anxiety Disorder (Confirmed) Mental healthcare providers are reminded that GAD and MDD can co-occur and even have overlapping symptoms like irritability, insomnia, and restlessness. A patient with GAD constantly worries and has difficulties controlling the worry (Stein et al, 2021). It was confirmed as a co-occurring condition t because the patient in context has mood swings, and displays a flat affect with marked appetite changes as evidenced in excessive eating in addition to palpitations and fast breathing amongst other signs and symptoms of GAD. Some potential medications to treat GAD are Selective serotonin reuptake inhibitors: Lexapro, Sertraline, and Fluoxetine; Serotonin-norepinephrine reuptake inhibitors with Cymbalta and Effexor can be another substitute if SSRI is to be excluded as mentioned on MDD. The patient will benefit from Lexapro because she has been successful with the medication on the lower dose, maybe increasing the dose will be the first intervention before switching to another SSRI. Considering increasing the dose of Lexapro will be the next step as the patient tolerates the medication with no side effects F31.10 Bipolar Disorder unspecified –(Refuted) CF symptoms as reported are considered unlikely because she admits to not having marked impairment and has never been admitted to the hospital for psychiatric reasons. She denies exhibiting mood swings, mania, or hypomania behavior. Patients with bipolar disorder will most likely experience a full manic episode necessitating admission to a psychiatric institution, unlike those with bipolar II who experience a less severe hypomanic episode with depression. F40.0 Agoraphobia – (Refuted) This diagnosis does not pertain to CF. The patient reports anxious behavior but did not report around others, especially in crowds at school or feeling trapped. Treatment goals: (F33.1) Major Depressive Disorder Recurrent, Moderate – Reduction of depressive behaviors, able to enjoy things that she normally enjoys without affecting her daily lives (Reduce PHQ 9 score). Increasing the dose of Lexapro will help restore a healthy balance of serotonin in the brain and improve her quality of life. (F41.1) Generalized Anxiety Disorder – Improved coping with anxiety and anxiety symptoms (Reduce GAD 7 score). Increasing the dose of Lexapro will help restore the healthy balance of serotonin in the brain and improve her quality of life. In case of a missed dose, CF should take it as soon as possible but if the next dose is almost due, CF should skip the missed dose and go back to her regular dosing schedule. CF should not take a double dose. Pro-essays.com has the top and most qualified writers to help with any of your assignments. All you need to do is Plan to incorporate teaching/ patient education on how to overcome some of the life challenges through adjunct psycho-education for the patient and key family caregivers. CF should be discouraged from the use of OTC medications.CF should also be encouraged to engage in physical activity. The patient will benefit from cognitive behavioral therapy (CBT) which is the most evidence-based psychological intervention for the treatment of depression and anxiety disorders. Informed Consent Ability: The patient has the ability/capacity appears to respond to psychiatric pharmacological and psychotherapy interventions and appears to understand the need for medications/psychotherapy and is ready and willing to adhere to the recommended treatment and care plan. |
| Informed Consent Ability | |
| Plan | Pharmacological Interventions The escitalopram dosage should be increased to 20mg /day to determine the medication’s maximum effectiveness. (Jiang et al, 2016). According to this researcher, the efficacy of Lexapro medication in treating MDD comorbid with a generalized anxiety disorder has been determined in short-term studies. The drug works by increasing intrasynaptic levels of neurotransmitters serotonin. It does this action by blocking the reuptake of the neurotransmitter into the presynaptic neuron. Will obtain CBC with diff, fasting lipids, and HbgA1C. Pro-essays.com has the top and most qualified writers to help with any of your assignments. All you need to do is Nonpharmacological interventions Education First education to CJ was to be aware of the importance of adhering to her medication and CBT times. The patient should be made aware of Escitalopram 20mg side effects of headache, nausea, dry mouth, and constipation. Other side effects associated are weight gain, flatulence, menstrual disorder, and decreased libido. CJ was educated to avoid any use of alcohol, nicotine, or drugs, including medications not prescribed for her. Pro-essays.com has the top and most qualified writers to help with any of your assignments. All you need to do is The patient was informed to communicate with other people and talk with people she trusts about how she’s feeling. Attend all your psychiatrist and therapist appointments Educate the patient on relaxation techniques to lower stress. Educate CJ to do things that she enjoys such as (gardening, walking in nature, and going to a movie). Always Reward self for every success. Referral The patient is to be referred to a Psychotherapist for CBT. The patient will be referred to the Primary care Physician for follow-up regarding the mild BP elevation. Follow up Return for follow-up in 4-6 weeks, or earlier if the symptoms get worse despite the increased dosage of Lexapro to 20mg. |
References
Bains, N., & Abdijadid, S. (2021). Major depressive disorder. StatPearls [Internet].
Cosci, F., & Fava, G. A. (2021). When anxiety and depression coexist: the role of differential diagnosis using clinimetric criteria. Psychotherapy and Psychosomatics, 90(5), 308-317.
Jiang, K., Li, L., Wang, X., Fang, M., Shi, J., Cao, Q. & Hu, C. (2017). Efficacy and tolerability of escitalopram in treatment of major depressive disorder with anxiety symptoms: a 24-week, open-label, prospective study in Chinese population. Neuropsychiatric Disease and Treatment, 13, 515.
Landy K, Rosani A, Estevez R. Escitalopram. [Updated 2022 Jan 19]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK557734/
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 generalized anxiety disorder: a World Mental Health Surveys report. BMC Psychiatry, 21(1), 1-14.
Van Krugten, F. C., Kaddouri, M., Goorden, M., Van Balkom, A. J., Bockting, C. L., Peeters, F. P., & Decision Tool Unipolar Depression (DTUD) Consortium. (2017). Indicators of patients with major depressive disorder in need of highly specialized care: A systematic review. PLoS One, 12(2), e0171659.
Landy K, Rosani A, Estevez R. Escitalopram. [Updated 2022 Jan 19]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK557734/
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