Posted: December 17th, 2022

Diagnosis: Depression

Soap note
Pt Name: A.G Age: 79 Years old. Diagnosis: Depression Chief Complain:Having memory issues. Pt is a 79 year old male, who presented to the clinic with the issue of memory loss. Pt complained that he is having problem with the spouse because of his inability to remember what happened in the past. The wife as well questions every thing that he doses believing that he dose not accept her views. This is creating a big problem between them. When asked if is seeing a therapist , he said yes but added that the wife also needs to see a therapist but she thinks she dose not need one. Pt believes he is not depressed and is doing well with his medications. He is encouraged to continue taking his medications and also to continue seeing his therapist in order not to get overwhelmed with the issues going on at home. Pt is on Wellburtrin 200 mg, Trazadone 50 mg, Primidone 100 mg. Pt is asked to come back to the clinic in 3 months for follow up.

ASSIGNMENT
• Based on your SOAP note of this patient, develop a case study presentation.
• Your presentation should include objectives for your audience, at least 3 possible discussion questions/prompts for your classmates to respond to, and at least 5 scholarly resources to support your diagnostic reasoning and treatment plan.
• State 3–4 objectives for the presentation that are targeted, clear, use appropriate verbs from Bloom’s taxonomy, and address what the audience will know or be able to do after viewing.
• Present the full complex case study. Include chief complaint; history of present illness; any pertinent past psychiatric, substance use, medical, social, family history; most recent mental status exam; current psychiatric diagnosis including differentials that were ruled out; and plan for treatment and management.
• Report normal diagnostic results as the name of the test and “normal” (rather than specific value). Abnormal results should be reported as a specific value.
• Pose three questions or discussion prompts, based on your presentation, that your colleagues can respond to after viewing your video.
• Be succinct in your presentation, and do not exceed 8 minutes. Specifically address the following for the patient, using your SOAP note as a guide.
o 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?
o Objective: What observations did you make during the psychiatric assessment?
o Assessment: Discuss their mental status examination results. What were your differential diagnoses? Provide a minimum of three possible diagnoses and why you chose them. List them from highest priority to lowest priority. What was your primary diagnosis, and why? Describe how your primary diagnosis aligns with DSM-5-TR diagnostic criteria and is supported by the patient’s symptoms.
o Plan: What was your plan for psychotherapy (include one health promotion activity and patient education)? What was 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. Discuss an identified social determinate of health impacting this patient’s mental health status and provide your recommendation for a referral to Help this patient in meeting this identified need (students will need to conduct research on this topic both in the literature and for community resources).
o Reflection notes: What would you do differently with this patient if you could conduct the session again? If you are able to follow up with your patient, explain whether these interventions
Subjective:
CC (chief complaint):
HPI:
Substance Current Use:
Medical History:

• Current Medications:
• Allergies:
• Reproductive Hx:
ROS:
• GENERAL:
• HEENT:
• SKIN:
• CARDIOVASCULAR:
• RESPIRATORY:
• GASTROINTESTINAL:
• GENITOURINARY:
• NEUROLOGICAL:
• MUSCULOSKELETAL:
• HEMATOLOGIC:
• LYMPHATICS:
• ENDOCRINOLOGIC:
Objective:
Diagnostic results:
Assessment:
Mental Status Examination:
Diagnostic Impression:
Reflections:
Case Formulation and Treatment Plan:

References

were successful and why or why not. If you were not able to conduct a follow-up, discuss what your next intervention would be.

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