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 non pharmacologic 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.).
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Full Answer Section
- Duration and severity: The patient reports that his symptoms have been getting worse over the past few months. He says that he is now at the point where he feels like he can't cope with his daily life.
- Impact on functioning: The patient's symptoms are having a significant impact on his functioning in life. He is having trouble at work and in his relationships. He is also withdrawing from social activities and hobbies.
Objective
- Appearance: The patient is well-groomed and dressed appropriately. He has good eye contact and is cooperative throughout the interview.
- Speech: The patient's speech is clear and coherent. His rate of speech is normal.
- Mood: The patient's mood is depressed. He appears sad and hopeless.
- Affect: The patient's affect is congruent with his mood. He expresses his emotions appropriately.
- Thought process: The patient's thought process is linear and logical. He has no difficulty concentrating or staying on topic.
- Thought content: The patient does not have any delusions or hallucinations. He has no suicidal or homicidal ideation.
Mental Status Examination
- Alertness: Oriented to person, place, and time.
- Attention: Able to focus and maintain attention.
- Memory: Intact short- and long-term memory.
- Mood: Depressed.
- Affect: Congruent with mood.
- Thought process: Linear and logical.
- Thought content: No delusions or hallucinations. No suicidal or homicidal ideation.
Differential Diagnoses
- Major depressive disorder (MDD)
- Persistent depressive disorder (dysthymia)
- Adjustment disorder with depressed mood
DSM-5-TR Diagnostic Criteria
Major Depressive Disorder
Five (or more) of the following symptoms have been present during the same 2-week period and represent a change from previous functioning; at least one of the symptoms is either (1) depressed mood or (2) loss of interest or pleasure in most activities:
- Depressed mood most of the day, nearly every day, as indicated by either subjective report (e.g., feeling sad, down, hopeless, empty) or observed by others (e.g., appears tearful, downcast, lacking in energy; cannot cry).
- Markedly diminished interest or pleasure in all or almost all activities most of the day, nearly every day (either by subjective account or as observed by others).
- Significant unintentional weight loss or gain (when not dieting) or decrease or increase in appetite nearly every day.
- Insomnia or hypersomnia nearly every day.
- Psychomotor agitation or retardation nearly every day (observable by others, not merely subjective feelings of restlessness or being slowed down).
- Fatigue or loss of energy nearly every day.
- Feelings of worthlessness or excessive or inappropriate guilt (which may be delusional) nearly every day (not merely self-criticism or self-blame).
- Diminished ability to think or concentrate, or indecisiveness, nearly every day (either by subjective account or as observed by others).
- Recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a specific plan, or a suicide attempt.
Persistent Depressive Disorder
Depressed mood for most of the day, for more days than not, lasting for at least 2 years (1 year in children or adolescents). During this period of depressed mood, two (or more) of the following symptoms have been present for at least 2 years (1 year in children or adolescents):
- Diminished interest or pleasure in all or almost all activities.
- Changes in appetite (either increased or decreased appetite, or weight loss or gain).
- Insomnia or hypersomnia nearly every day.
- Fatigue or loss of energy nearly every day.
- Low self-esteem.
- Difficulty concentrating or indecisiveness.
- Feelings of hopelessness.