Develop a Focused SOAP Note, including your differential diagnosis and critical-thinking process to formulate a primary diagnosis. Incorporate the following into your responses in the template:
Subjective: What details did the patient provide regarding their chief complaint and symptomatology 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 the patient’s mental status examination results. What were your differential diagnoses? Provide a minimum of three possible diagnoses with supporting evidence, listed in order from highest to lowest priority. Compare the DSM-5-TR diagnostic criteria for each differential diagnosis and explain what DSM-5 criteria rules out the differential diagnosis to find an accurate diagnosis. Explain the critical-thinking process that led you to the primary diagnosis you selected. Include pertinent positives and pertinent negatives for the specific patient case.
Plan: What is your plan for psychotherapy? What is 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 incorporate one health promotion activity and one patient education strategy.
Reflection notes: Reflect on this case. Discuss what you learned and what you might do differently. Also include in your reflection a discussion related to legal/ethical considerations (demonstrate critical thinking beyond confidentiality and consent for treatment!), social determinates of health, health promotion, and disease prevention that takes into consideration patient factors (such as age, ethnic group, etc.), PMH, and other risk factors (e.g., socioeconomic, cultural background, etc.).
Full Answer Section
concentrate, finding it "almost impossible" to focus on schoolwork, leading to a drop in grades from A's and B's to C's and D's. He also expresses feelings of worthlessness, stating he feels like a "failure" and "a burden" to his parents. He denies current suicidal ideation, but admits to passive thoughts of "not wanting to wake up" about 2-3 times a week, without a plan or intent. He reports increased irritability, snapping at his parents and younger sister more frequently. Appetite has decreased, leading to unintentional weight loss of approximately 5 pounds over the past 3 months. He reports persistent worry about school performance, future, and social interactions, often accompanied by physical symptoms like stomachaches, headaches, and muscle tension, which have worsened over the past 6 months. He denies substance use. Family history is significant for maternal anxiety and paternal depression. No past psychiatric history. He lives at home with both parents and a younger sister. He feels his symptoms are significantly impacting his academic performance, social life, and family relationships.
Objective: J.K. is a casually dressed adolescent male who presents with somewhat slumped posture, makes limited eye contact, and speaks in a soft, monotonous tone. His psychomotor activity appears slightly slowed. He is cooperative during the interview but exhibits clear signs of distress. He fidgets occasionally with his hands but overall appears fatigued. No evidence of bizarre behavior or disorganized thought. No signs of acute distress. His affect is restricted and congruent with his reported depressed mood. No visible signs of self-harm.
Assessment:
Mental Status Examination (MSE) Results:
- Appearance: Adolescent male, casually dressed, appears fatigued.
- Behavior: Slumped posture, limited spontaneous gestures, slightly slowed psychomotor activity.
- Speech: Soft volume, monotonous tone, normal rate and rhythm, coherent.
- Mood: "Down," "sad," "heavy."
- Affect: Restricted, congruent with mood.
- Thought Process: Linear and goal-directed.
- Thought Content: Preoccupation with feelings of worthlessness, failure, and worry about school/future. Denies delusions, hallucinations, paranoid ideation. Passive suicidal ideation present, without plan or intent.
- Perceptual Disturbances: Denies hallucinations or illusions.
- Cognition: Alert and oriented to person, place, and time. Difficulty with concentration and attention reported subjectively. Appears to have intact remote and recent memory.
- Insight: Fair (recognizes he is "not himself" and needs help).
- Judgment: Fair (able to identify consequences of academic decline, but struggling with proactive steps).
Differential Diagnoses (in order of highest to lowest priority):
-
Major Depressive Disorder (MDD), Single Episode, Moderate (F32.1)
- Supporting Evidence (Pertinent Positives): J.K. meets criteria for at least five symptoms present during the same 2-week period, representing a change from previous functioning, with at least one symptom being depressed mood or anhedonia.
- Depressed mood: "Feeling down, sad, heavy" almost daily for 4-5 months.
- Anhedonia: Marked diminished interest/pleasure in all or almost all activities (video games, soccer).
- Insomnia/Hypersomnia: Hypersomnia (sleeping 9-10 hours, unrefreshed) and insomnia (difficulty falling asleep, middle-of-night awakenings).
- Fatigue/Loss of Energy: Persistent fatigue despite adequate sleep.
- Diminished ability to think/concentrate: Reports "almost impossible" to focus on schoolwork.
- Feelings of worthlessness/guilt: States he feels like a "failure" and "a burden."
- Weight loss: Unintentional 5-pound weight loss in 3 months.
- Irritability: Increased snapping at family.
- Clinical Significance: Symptoms cause significant distress and impairment in social (reduced social interaction, snapping at family) and occupational/academic (drop in grades) functioning.
- Duration: Symptoms present for 4-5 months, exceeding the 2-week minimum.
- Pertinent Negatives for other disorders: No history of manic/hypomanic episodes (rules out Bipolar Disorders). Symptoms not attributable to physiological effects of a substance or another medical condition. Not better explained by Schizoaffective Disorder, Schizophrenia, Schizophreniform Disorder, Delusional Disorder, or other Psychotic Disorders.
-
Generalized Anxiety Disorder (GAD) (F41.1)
- Supporting Evidence: J.K. reports excessive anxiety and worry (apprehensive expectation) occurring more days than not for at least 6 months, about a number of events or activities (school performance, future, social interactions).
- Associated symptoms: Restlessness/feeling on edge (fidgeting), easily fatigued (persistent fatigue), difficulty concentrating (reported inability to focus), irritability (increased snapping), muscle tension (reported). He has at least 3 of 6 symptoms.
- Clinical Significance: The anxiety causes significant distress and impairment in academic and social functioning.
Sample Answer
Hypothetical Patient Case:
Patient Name: J.K. Age: 15 Gender: Male Race/Ethnicity: Caucasian Chief Complaint (CC): "I've been feeling down, tired, and just can't focus on anything, especially school, for the past few months."
Focused SOAP Note
Subjective: J.K. is a 15-year-old male presenting with chief complaints of persistent low mood, fatigue, and significant difficulty concentrating. He reports feeling "down" and "sad" almost daily for the past 4-5 months. He describes his mood as consistently heavy, stating, "It's like there's a cloud over everything." He denies any periods of elevated mood, increased energy, or racing thoughts. He reports a significant decrease in interest and pleasure in previously enjoyed activities, including playing video games with friends and participating in soccer, which he used to love. He notes persistent fatigue despite sleeping 9-10 hours per night, often feeling unrefreshed upon waking. His sleep is disrupted by difficulty falling asleep due to "worrying about everything," and he sometimes wakes up in the middle of the night. He reports a diminished ability to think or