Posted: May 28th, 2023

A 15-year-old boy who is brought to the clinic by his concerned mother

Psychiatric SOAP Note Template

Encounter date: ______17/05/2023__________________

Patient Initials: ___G.W.___ Gender: M/F/Transgender _Male___ Age: __15___ Race: ___Caucasian__ Ethnicity __White__

Reason for Seeking Health Care: “For the past three weeks, my son has been quite depressed. He has not been eating well and prefers to spend his after-school hours alone in his room. He used to like swimming, but now he does not appear to want to. I worry that he might have a medical issue.”

HPI: _____ __The patient is a 15-year-old boy who is brought to the clinic by his concerned mother. The patient’s mother admitted that the symptoms, which began three weeks ago, coincided with the beginning of a new school term. The mother admitted that the patient has been extremely sad and has expressed constant feelings of hopelessness and worthlessness. The mother also admitted that the patient has also had a decrease in appetite, which has resulted in the loss of a couple of pounds. The mother also admitted that the patient has been complaining of difficulty falling asleep as well as disrupted sleep patterns, which often have him waking repeatedly during the night. The mother reported that, as a result of a lack of sufficient sleep, the patient often looks fatigued and lacks energy during the day. The mother also reported that she has noticed a drop in his social interactions, often preferring to spend long periods alone in his room. The mother also admitted that the patient has also lost interest in any extracurricular activities, including swimming, which he used to enjoy doing. The mother admitted that she noticed that the symptoms worsened during stressful situations, such as exams or social events. The mother admitted that the symptoms are persistent, however, even when he is relaxing. The mother admitted that on a scale of 1 to 10, the severity of his symptoms is 7/10. The mother denied that the patient was taking any over-the-counter or prescription medication. ______________________________________________________________________________
SI/HI: ________The patient admitted that he had been experiencing recurrent suicidal ideations. He denied having attempted suicide. _______________________________________________________________________

Sleep: _________ The patient admitted to having difficulty falling asleep as well as disrupted sleep patterns. __Appetite: ____ The patient admitted to a decreased appetite as he does not feel like eating ____________________
Allergies (Drug/Food/Latex/Environmental/Herbal): The mother admitted that the patient has a severe allergy to peanuts, which results in immediate itching, and swelling of the face, lips, and throat. The mother admits that the reaction necessitates medical attention and that the patient carries an epinephrine auto-injector at all times. _

Current perception of Health: Excellent Good Fair Poor
Psychiatric History:
Inpatient hospitalizations:
Date Hospital Diagnoses Length of Stay
None
None None None
None None None None

Outpatient psychiatric treatment:
Date Hospital Diagnoses Length of Stay
None None None None
None None None None

Detox/Inpatient substance treatment:
Date Hospital Diagnoses Length of Stay
None None None None
None None None None

History of suicide attempts and/or self-injurious behaviors: _____ The patient denied having had a history of suicidal attempts, however, he admitted to having a history of self-injurious behavior whereby he repeatedly bit himself on his arms, which resulted in marks on the skin.
Past Medical History
● Major/Chronic Illnesses __ The mother denied the patient has a history of major or chronic illnesses _______________________________________________
● Trauma/Injury ___ The mother admitted that the patient has in the past been a victim of physical assault from bullies in his school which resulted in several bruises. ________________________________________________________
● Hospitalizations __The mother denied the patient having a history of hospitalizations. ________________________________________________________
● Past Surgical History ___ The mother denied the patient has any history of a surgical procedure performed on him. ______________________________________________
Current psychotropic medications:

___________None______________________________ ________________________________
_________________________________________ ________________________________
_________________________________________ ________________________________

Current prescription medications:

____________None_____________________________ ________________________________
_________________________________________ ________________________________
_________________________________________ ________________________________

OTC/Nutritionals/Herbal/Complementary therapy:

_____________None____________________________ ________________________________
_________________________________________ ________________________________
Substance use: (alcohol, marijuana, cocaine, caffeine, cigarettes)

Substance Amount Frequency Length of Use
None None None None
None None None None
None None None None
None None None None

Family Psychiatric History:
● The patient’s father who is currently 45 years old has a history of generalized anxiety disorder and social anxiety disorder which he manages with antipsychotic medications and occasional psychotherapy.
● The patient’s older brother, who is currently 19 years old, was diagnosed with attention-deficit/hyperactivity disorder when he was 7 years old and has been taking stimulant medications under the supervision of a psychiatrist. He is also engaging in ongoing behavioral therapy to manage his symptoms.
● The patient’s 70-year-old maternal grandmother has a history of major depressive disorder and has been getting antidepressant medication and regular therapy sessions for some time.
● The patient’s paternal uncle, who is currently 54 years old, has a history of bipolar 1 disorder. He has been experiencing episodes of both manic and depressive symptoms over the years and has been receiving treatment with mood stabilizers and regular psychiatric follow-ups to manage his condition.
Social History
Lives: Single-family House/Condo/ with stairs: ___5-bedroom apartment________ Marital Status: __Single_____
Education: ________10th grade student____________________
Employment Status: __Unemployed____ Current/Previous occupation type: _____None____________
Exposure to: _Denies_ _Smoke__ Denies__ ETOH __Denies __Recreational Drug Use: __________________
Sexual Orientation: __Homosexual_____ Sexual Activity: __Not active__ Contraception Use: ___None_________
Family Composition: Family/Mother/Father/Alone: ___The patient lives with his mother, father, and his older brother. __________________________
Other: (Place of birth, childhood hx, legal, living situations, hobbies, abuse hx, trauma, violence, social network, marital hx): _____
The patient was born in a small town in Minnesota. He grew up in a stable household as both his parents are supportive and nurturing. Currently, he resides with his parents and older brother in a suburban neighborhood. The patient used to enjoy spending his free time engaging in swimming and painting. He is also an avid reader and loves exploring different genres of literature.
Health Maintenance
Screening Tests:
● The patient underwent vision screening on November 5, 2023, the results revealed a visual acuity of 20/20 in both eyes.
● The patient underwent height and weight measurements on January 10, 2023. The results revealed that he had a height of 5 feet 8 inches and a weight of 145 pounds which was within the normal range.
● The patient underwent cholesterol screening on the 10th of January 2023. The Results revealed that his total cholesterol level was 165 mg/dL which was within desirable range.
● The patient undergoes dental checkups every 6 months with the last checkup on the 5th of November 2022. The results were negative for signs of cavities or dental issues identified.
Exposures: The patient’s mother denies the patient being exposed to any chemicals, including secondhand smoke or ethanol.
Immunization HX:
The patient is currently on all his immunizations, including tetanus, diphtheria, and pertussis (Tdap) booster and the HPV (human papillomavirus) vaccine.
Review of Systems:
General: The patient’s mother admitted to the patient having significant weight loss, fatigue, decreased energy levels, a lack of motivation, and difficulty falling asleep.
HEENT: The patient’s mother denies head trauma, dry scalp, or loss of hair. She denies the patient having any visual disturbances, eye injuries, or infections. She denied the patient having any hearing problems or earaches and admitted to occasional middle ear infections when he was younger. The mother admitted the patient has occasional nose bleeds, a runny nose, and a congested nose. The mother denied the patient having mouth sores, bleeding gums, missing teeth, or cavities.
Neck: The patient denies any neck pain, stiffness, or swollen glands.
Lungs: The patient denies any shortness of breath, cough, or wheezing.
Cardiovascular: The patient denies any chest pain, palpitations, or irregular heartbeats.
Breast: The patient denied any breast or nipple injury, enlargement of the breast, or breast pain
GI: The patient denies any abdominal pain, nausea, vomiting, or changes in bowel habits. However, the patient’s mother admitted to the patient having a loss of appetite and unintentional weight changes.
Male or female genital: The patient denies any genital pain, penile discharge, or lesions.
GU: The patient denies any urinary frequency, urgency, or burning sensation during urination.
Neuro: The patient denies any history of seizures, tremors, or loss of consciousness. However, the patient admitted to difficulty concentrating and a general feeling of being slowed down.
Musculoskeletal:

Subjective

A 15-year-old boy is brought to the clinic by his mother for Assessment of depression. The mother reports that the patient has been sad and withdrawn for the past three weeks. He has lost interest in his usual activities, including swimming and playing video games. He has also been sleeping more than usual and has lost his appetite. The mother is concerned that the patient may be suicidal.

Objective

The patient is a well-developed, well-nourished male in no acute distress. His vital signs are within normal limits. His physical examination is unremarkable.

Assessment

The patient meets the diagnostic criteria for major depressive disorder. He is experiencing depressed mood, anhedonia, changes in sleep and appetite, and fatigue. He is also at risk for suicide.

Plan

The patient will be started on an antidepressant medication and will be referred for psychotherapy. He will also be monitored closely for suicidal ideation.

Progress Notes

The patient was seen in follow-up one week after starting treatment. He reported that he was feeling better and that his symptoms had improved. He was also feeling less suicidal. He was continued on his medication and will be seen again in one month.

The patient was seen in follow-up two months after starting treatment. He reported that he was doing well and that his symptoms had continued to improve. He was feeling much better and was no longer feeling suicidal. He was discharged from care and will be seen again as needed.

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