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 symptomology 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 priority to lowest priority. Compare the DSM-5-TR diagnostic criteria for each differential diagnosis and explain what DSM-5-TR 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: What would you do differently with this patient if you could conduct the session again? Discuss what your next intervention would be if you could follow up with this patient. Also include in your reflection a discussion related to legal/ethical considerations (demonstrate critical thinking beyond confidentiality and consent for treatment!), health promotion, and disease prevention, taking into consideration patient factors (such as age, ethnic group, etc.), PMH, and other risk factors (e.g., socioeconomic, cultural background, etc.).
- Provide at least three evidence-based, peer-reviewed journal articles or evidenced-based guidelines that relate to this case to support your diagnostics and differential diagnoses. Be sure they are current (no more than 5 years old).
Subjective: The patient, a 28-year-old male, presented with a chief complaint of persistent sadness, decreased interest in activities, and difficulty sleeping. He reported feeling “down” for the past six months and described his mood as low, with frequent feelings of hopelessness and worthlessness. He stated that his symptoms have significantly impacted his daily functioning, including his ability to concentrate at work and engage in social activities. The patient denied any history of manic or hypomanic episodes, psychotic symptoms, or current suicidal or homicidal ideation.
Objective: During the psychiatric assessment, the patient appeared sad and had a flat affect. He exhibited psychomotor retardation, with slowed speech and movements. His speech was coherent and relevant, without evidence of flight of ideas or pressured speech. The patient’s thought process appeared logical, but he displayed excessive guilt and self-blame. He reported poor appetite and weight loss over the past six months. The patient had difficulty falling asleep, experienced early morning awakening, and reported feeling tired throughout the day. No signs of psychosis or cognitive impairment were noted.
Assessment: Based on the mental status examination results, the following differential diagnoses are considered:
- Major Depressive Disorder (MDD): The patient meets the DSM-5-TR diagnostic criteria for MDD, including the presence of five or more symptoms during the same two-week period, with depressed mood and/or loss of interest or pleasure being essential. The patient’s persistent sadness, anhedonia, psychomotor retardation, guilt, poor appetite, weight loss, and sleep disturbances align with this diagnosis.
- Persistent Depressive Disorder (PDD): The patient’s symptoms have lasted for at least six months, fulfilling the criteria for PDD. However, given the severity of symptoms and functional impairment, MDD is a higher priority differential diagnosis.
- Adjustment Disorder with Depressed Mood: Although the patient’s symptoms may be triggered by stressors, the duration, severity, and functional impairment make this diagnosis less likely. Furthermore, the patient’s symptoms are not better explained by another mental disorder or bereavement.
The critical-thinking process leading to the primary diagnosis of Major Depressive Disorder (MDD) involved ruling out other potential diagnoses such as PDD and Adjustment Disorder. The severity and persistence of symptoms, as well as their impact on daily functioning, were key factors in differentiating MDD from other mood disorders.
Plan: For psychotherapy, a combination of Cognitive Behavioral Therapy (CBT) and supportive therapy is recommended. CBT will help the patient identify and challenge negative thoughts and beliefs contributing to his depressive symptoms. Supportive therapy will provide emotional support and validation of his experiences.
In terms of treatment and management, a trial of selective serotonin reuptake inhibitor (SSRI) medication is warranted. SSRIs, such as escitalopram or sertraline, have demonstrated efficacy in treating MDD. Nonpharmacologic interventions, such as regular exercise, sleep hygiene, and stress reduction techniques, should also be incorporated.
Follow-up parameters include regular monitoring of symptom severity using validated scales (e.g., Patient Health Questionnaire-9), assessing treatment response, and evaluating potential side effects of medication. The patient should be scheduled for follow-up visits every two to four weeks initially and then every four to six weeks once stable.
One health promotion activity for the patient could be encouraging regular physical exercise, as it has been shown to improve mood and overall well-being. Patient education should focus on the nature of depression, its treatment options, and the importance of adherence to therapy. Providing resources for support groups or online communities may also be beneficial.
Reflection notes: If I could conduct the session again, I would explore the patient’s social support network and inquire about any recent life stressors. This information would provide a more comprehensive understanding of the patient’s circumstances and help tailor the treatment plan accordingly. Additionally, conducting a thorough assessment of the patient’s suicide risk and safety precautions would be crucial.
For the next intervention, a follow-up session with the patient would involve evaluating the treatment response, assessing medication side effects, and addressing any concerns or challenges encountered during therapy. It would be essential to monitor the patient’s progress and make appropriate adjustments to the treatment plan if necessary.
In terms of legal/ethical considerations, it is important to ensure the patient’s confidentiality and informed consent throughout the treatment process. Additionally, cultural factors should be taken into account when developing the treatment plan, considering the patient’s ethnic background and beliefs surrounding mental health.
Evidence-based References:
- Cuijpers, P., van Straten, A., Warmerdam, L., & Andersson, G. (2008). Psychological treatment of depression: A meta-analysis of treatment outcome studies. Journal of Consulting and Clinical Psychology, 76(6), 909-922.
- Qaseem, A., Barry, M. J., Kansagara, D., & Clinical Guidelines Committee of the American College of Physicians. (2016). Nonpharmacologic versus pharmacologic treatment of adult patients with major depressive disorder: A clinical practice guideline from the American College of Physicians. Annals of Internal Medicine, 164(5), 350-359.
- Uher, R., & McGuffin, P. (2010). The moderation by the serotonin transporter gene of environmental adversity in the etiology of depression: 2009 update. Molecular Psychiatry, 15(1), 18-22.