SOAP Note for Major Depressive Disorder Subjective: CC (chief complaint): “I have had depression for many years.” HPI: MM is a 24-years-old female of white origin who came to group therapy complaining of depression since the age of 13. She noted that she started experiencing relational and emotional difficulties with her family, especially her sisters. She also noted that she sometimes has a depressed mood and feels low. She reported a loss of interest in her job which she loved before. Associated symptoms include fatigue, weakness, and unintended weight loss. Her depression severity is 7/10.

 SOAP Note for Major Depressive Disorder

Subjective:

CC (chief complaint): “I have had depression for many years.”

HPI: MM is a 24-years-old female of white origin who came to group therapy complaining of depression since the age of 13. She noted that she started experiencing relational and emotional difficulties with her family, especially her sisters. She also noted that she sometimes has a depressed mood and feels low. She reported a loss of interest in her job which she loved before. Associated symptoms include fatigue, weakness, and unintended weight loss. Her depression severity is 7/10.

Past Psychiatric History:

 	
General Statement: Her first treatment for depression was at the age of 13.
 	
Caregivers: No caregivers.
 	
Hospitalizations: No hospitalization. She also denies suicidal and homicidal thoughts.
 	
Medication trials: No medical trials.
 	
Psychotherapy or Previous Psychiatric Diagnosis: She was diagnosed with MDD at the age of 13.

Substance Current Use and History: Denies tobacco, cocaine, heroin, alcohol, or any drug use.

Family Psychiatric/Substance Use History: No family history of substance uses or mental health problems.

Psychosocial History: She was born and raised in New York City by her parents until the age of 12. Her parents divorced when she was 13 and moved to Aurora, Colorado with her mother. She has three siblings, two sisters and a brother. She is the second born in the family. She is not married and single. She has no children.

She lives with her alone in school. She is pursuing her degree in economics. She likes football but has not gone to training for the last two months. She does not work. She reports no history of violence, trauma, or legal issues.

Medical History: No underlying mental problem.

 	
Current Medications: No medications.
 	
Allergies:No allergies.
 	
Reproductive Hx:She is sexually active. No reproductive abnormalities.

ROS

 	
GENERAL: Reports fatigue, weakness, and unintended weight loss.
 	
HEENT: Non-contributory.
 	
SKIN: She denies dryness, itching, or rashes.
 	
CARDIOVASCULAR: No chest discomfort, pain, or swelling
 	
RESPIRATORY: No shortness of breath.
 	
GASTROINTESTINAL: No nausea, abdominal pain, or diarrhea.
 	
GENITOURINARY: No UTI or burning or urination.
 	
NEUROLOGICAL: No neurological disorders.
 	
MUSCULOSKELETAL: No joint or muscle abnormalities.
 	
HEMATOLOGIC: No bruising.
 	
LYMPHATICS: No history of splenectomy.
 	
ENDOCRINOLOGIC: No endocrinologic abnormalities.

Objective:Physical exam:

Vital Signs: T 36.5, HR 78, BP 111/90, Ht. 5’5 Wt. 56kgs, RR 18.

 	
HEENT: Head: Non-contributory.
 	
Skin: Warm, no rash, and dry.
 	
CV: No murmurs, chest clear, no chest swelling. Regular heart rate and rhythm.
 	
Respiratory: No distress while breathing. No wheezes.

Diagnostic results:

The Hopkins Symptoms Checklist with 25 Items (HSCL-25): HSCL-25 is one of the tools used to screen for depression. Skogen et al. (2017) note that the tool can help a mental health professional screen for anxiety or depression. The HSCL-25 results show that the patient has depression.

Assessment:Mental Status Examination: She is dressed inappropriately. She has good eye contact, is on the verge of tears, appears calm, relates well. Speech volume and rate are standard. She was shaking when talking about her emotional feelings. She denies any homicidal or suicidal thoughts. She is A&O x4. She reports poor concentration. Her memory is intact. Her thoughts are intact. She denies hallucinations, delusions, or paranoid thoughts. She reports low mood and affect.

Differential Diagnoses: 

 	
Recurrent MDD DSM-5 (296.99 (F34.8)
 	
MDD DSM-5 296.33 (F33.2)
 	
Bipolar II Disorder DSM-5 (296.89 (F31. 81)

The primary diagnosis is severe recurrent MDD. Recurrent MDD is associated with repeated depression episodes without reports of independent episodes of mania, increased energy, or mood elevation (Yan et al., 2019). Individuals with recurrent MDD have had at least a single depressive symptom for a minimum of two weeks.

The patient is said to have recurrent MDD because she has experienced repeated episodes of MDD. The second disorder is MDD. The patient reports a depressed mood, lack of interest in things she loved before, fatigue, weakness, and unintended weight loss which are all symptoms of MDD (Bot et al., 2019). However, the MDD is not initial because the patient has experienced the symptoms since age 13.

The last diagnosis is bipolar II disorder. The disorder causes depressive episodes and that is why it is part of the diagnosis (McKnight et al., 2017). However, it is a secondary disorder because it causes hypomania and the patient does not have hypomania (APA, 2013).

Reflections:

I agree with the preceptor’s diagnosis. She also noted that the patient has recurrent MDD which is correct. I have learned from this case that recurrent MDD is hard to diagnose. If I was given the chance again, I would have included MRI as part of the diagnostic studies to improve my diagnosis. In terms of ethical considerations, I would consider our professional boundaries. I would ensure that we maintain a professional relationship. Another ethical issue is veracity (Hsin & Torous, 2016). I will ensure that I use facts to made decision.

Case Formulation and Treatment Plan:

The patient has recurrent MDD. She should start Zoloft 25mg orally daily in addition to the CBT group therapy she is currently undergoing. Duffy et al. (2019) reported that Zoloft is an effective treatment for depression. Hence, combining Zoloft and CBT group therapy can improve her depressive symptoms.

References

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Author.

Bot, M., Brouwer, I. A., Roca, M., Kohls, E., Penninx, B., Watkins, E., van Grootheest, G., Cabout, M., Hegerl, U., Gili, M., Owens, M., Visser, M., & MooDFOOD Prevention Trial Investigators (2019). Effect of multinutrient supplementation and food-related behavioral activation therapy on prevention of major depressive disorder among overweight or obese adults with subsyndromal depressive symptoms: The MooDFOOD randomized clinical trial. JAMA, 321(9), 858–868. https://doi.org/10.1001/jama.2019.0556

Duffy, L., Lewis, G., Ades, A., Araya, R., Bone, J., Brabyn, S., … & Woodhouse, R. (2019). Antidepressant treatment with sertraline for adults with depressive symptoms in primary care: the PANDA research programme including RCT. Programme Grants for Applied Research, 7(10), 108. https://doi.org/10.3310/pgfar07100