Focused SOAP on Psychiatric Evaluation

SUBJECTIVE

CC: A.J, a 42-year-old female presents to clinic for "feeling down and tired all the time for the past few months."

HPI: A.J. presents to clinic for evaluation of persistent low mood, fatigue, and sleep disturbances over the past 3 months.

Acute Concern 1: Depression and fatigue

• Onset: Gradual onset approximately 3 months ago, worsened over past 6 weeks
• Location: Generalized feelings of sadness, mostly prominent in mornings
• Duration: Persistent daily symptoms for 3 months
• Character: Describes mood as "heavy, empty, hopeless" with episodes of crying
• Aggregators: Stressful work situations, isolation, rainy weather, mornings
• Relievers: Brief improvement with distraction (watching TV), warm baths
• Treatments: Has tried increasing sleep, reducing caffeine, no formal treatment

Chronic Disease 1: Hypertension - diagnosed 2 years ago, currently on lisinopril 10mg daily, last BP readings at home averaging 135/85, taking medication consistently

Chronic Disease 2: Type 2 Diabetes - diagnosed 4 years ago, managed with metformin 1000mg BID, last A1C was 7.8% three months ago, reports good medication compliance

Functional Assessment: This patient states that she has serious functional impairment in various areas. Her diet has been altered as she does not have an appetite these days leading to a weight loss of eight pounds in two months, and she currently eats one to two meals daily. She denies any constipation, but describes her bowel movements as hard with the interval of two to three days. She is emotionally expressing high levels of stress with the possibility of job layoffs and is managing it mostly by social isolation, saying she gets overwhelmed with her day-to-day tasks. She is an administrative assistant and complains that she is worried about her job security as a result of downsizing in the company. Sleep patterns are grossly disturbed as they have difficulty initiating sleep or early morning awakening at 4 AM thus having four to five hours of sleep daily. She complains of lack of motivation to perform self-care activities, yet she is independent in all the activities of daily living.

Medical History: The medical history of the patient is significant with hypertension diagnosed in 2021 with current lisinopril 10mg a day use and home blood pressure measurements of 135/85 mmHg. She has also type 2 diabetes mellitus diagnosed in 2019 that is treated by metformin 1000mg twice a day, and her last HbA1c was within three months (7.8%). She denies any history of noncompliance with medications with both conditions. She has no psychiatric hospitalization history or past history of mental health treatment.

Surgical History: The surgical history of the patient is that she had cholecystectomy in 2015 and cesarean section in 2008, both with no complications.

Family History: Family history is important in maternal depression and maternal grandmother who committed suicidal acts at the age of 45, which is also a crucial risk factor to mood disorders (Carlson et al., 2025). Her mother was hypertensive as well and died at 68 due to stroke. Her father is 72 years, with a type 2 diabetes mellitus and alive. No family history of bipolar disorder, psychosis or substance abuse disorder.

Social History: The patient is divorced, and she has a cordial relationship with her former spouse that occurred three years ago. She has a 17 year old daughter who lives with her father during weekdays and comes over the weekends. She lives alone in a flat and works as an administrative assistant a job she has been serving 15 years. Her social support network is minimal, as she has two close friends that she sees monthly and her daughter with whom she has a close relationship.

Substance Use: The patient denies substance use, except that she gets drunk on alcohol over the weekend, which has escalated to 4-5 glasses per week in the last month. She has never smoked tobacco products or used illicit drugs regularly, but she reports that she has tried marijuana on with a few experiments when she was in college. Caffeine consumption has not declined since she is still taking two cups of coffee a day.

Sexual and Reproductive History: The patient denies dysfunction in her menstrual cycles and her most recent menstrual cycle was two weeks ago. She is not sexually active at present and has not had any partners within the last one year and thus, has low pregnancy potential. She has no sexual history of sexually transmitted infections.

Immunizations: Flu immunization is up to date. She has sufficient MMR immunity and denies any childhood chicken pox. She has taken hepatitis A and B series and has not taken HPV vaccination because she was not within the recommended age group when it was introduced.

Allergies: The patient reports allergies to sulfa drugs causing rash and penicillin causing hives.

Drug Therapy:

1. Lisinopril 10mg daily (hypertension)
2. Metformin 1000mg BID (diabetes)
3. Multivitamin daily (general health)
4. Ibuprofen 400mg PRN headaches (2-3 times per week)

Review of Systems:

• HEENT: Mild headaches, no changes in sight, no hearing changes
• Neck: No pain, stiffness, or swelling
• CV: No chest pain, palpitations, or shortness of breath
• Neuro: No dizziness, weakness, or numbness; reports difficulty concentrating
• GI: Decreased appetite, constipation, no nausea/vomiting
• GU: No dysuria, frequency, or urgency
• Repro: Regular menses, no abnormal bleeding
• MSK: No joint pain or stiffness
• Skin: No rashes or lesions
• Psych: PHQ-9 score: 16 (moderate-severe depression), denies suicidal ideation but reports thoughts that "life isn't worth much," no visual or auditory hallucinations. Feels safe at home, no one making her feel unsafe.

OBJECTIVE:

Vital Signs:

• HR: 78 bpm
• BP: 138/86 mmHg
• RR: 16
• O2 sat: 98% on room air
• Temp: 98.4°F
• Ht: 5'6"
• Wt: 152 lbs (down from 160 lbs)
• BMI: 24.5

Physical Exam:

• General: 42-year-old female appearing her stated age, sitting comfortably but with flat affect and minimal eye contact. Appears tired with dark circles under eyes.
• HEENT: Normocephalic, atraumatic. PERRLA, EOM intact. TMs clear bilaterally. Oral mucosa moist, no lesions.
• Neck: Supple, no lymphadenopathy, no thyromegaly, no JVD
• CV: Regular rate and rhythm, no murmurs, rubs, or gallops. S1 and S2 present.
• Neuro: Alert and oriented x3, speech clear, thought process linear but with psychomotor retardation noted
• GI: Abdomen soft, non-tender, non-distended, bowel sounds present in all quadrants
• GU: Deferred
• Repro: Deferred
• MSK: No obvious deformities, normal gait
• Skin: Warm, dry, intact, no rashes or lesions noted

ASSESSMENT:

Primary Diagnosis: Major Depressive Disorder, Moderate Severity (F32.1)

The patient meets the DSM-5 criteria of the Major Depressive Disorder with at least five symptoms over a period of more than two weeks, including depressed mood, anhedonia, significant weight reduction, sleep disturbance, fatigue, and struggle in concentration (Bains & Abdijadid, 2025). Her PHQ-9 score of 16 is moderate to severe depression, which is related to her functional impairment. Relevant positive data is in the form of persistent depressed levels three months, severe anhedonia, severe loss of weight of eight pounds unintentionally, rising in the morning, extreme fatigue, inability to concentrate, hopelessness and psychomotor retardation evidenced. Also, her family history is relevant because of maternal depression and suicidal death of a maternal grandmother, which puts her at high risk of having mood disorders (Carlson et al., 2025). Relevant negative results are the lack of current suicidal ideation with plan or intention, no psychotic condition and no history of manic or hypomanic episodes, and no serious substance abuse, but some slight escalation of alcohol use is observed as a possible maladaptive coping.

Differential Diagnosis:

Adjustment Disorder and Depressed Mood (F43.21) was taken into account because the triggering factor of the disorder was a recognizable work instability and prior divorce. The adverse impact and the time span of symptoms, as well as a serious level of functional impairment, which continues to be experienced after six months of the original stressor, however, justify the Major Depressive Disorder over the Adjustment Disorder (Bains & Abdijadid, 2025).

Hypothyroidism was also included in the differential since it may also manifest itself in fatigue, weight changes, depression, and constipation that resemble primary mood disorders and require laboratory investigation using thyroid function studies (Yang et al., 2022).

Chronic Medical Conditions: The patient has poorly managed hypertension and measurements of her blood pressure are 138/86 mmHg. Her most recent HbA1c of 7.8% which was above the general area of less than 7% is also suboptimal in controlling her diabetes mellitus. Her depression can affect both the conditions and can influence medication adherence and self-care behaviors.

PLAN:

Diagnostic Studies: Labs: To rule out hypothyroidism as a suppositional factor in her depressive symptoms, the thyroid stimulating hormone, and free T4 will be assessed as labs can simulate or contribute to mood disorders (Yang et al., 2022). Basic metabolic panel will determine the state of renal functioning since she is on ACE inhibitors, and HbA1c will redefine the level of diabetes management. Diabetes monitoring Lipid panel will be acquired according to the standard guidelines. Vital levels of vitamin B12 and folate will also be ordered because deficiencies may cause depressive symptoms. PHQ-9 baseline records will be used to track treatment response.

Pharmacological Treatment: Selective serotonin reuptake inhibitors have been proven to be effective and show good side effects to the body, which is why sertraline 50mg per day should be suggested as the initial therapeutic approach to major depressive disorder (Liu et al., 2025). Education of the patient will focus on the fact that antidepressants need 4-6 weeks to reach the full effect of treatment and medication adherence. At the start of the therapy, she will be closely observed regarding side effects and treatment response after every two weeks.

Non-Pharmacological Interventions: Cognitive behavioral therapy is recommended since it is supported by evidence to use combination therapy to treat moderate to severe depression (Liu et al., 2025). Her major sleep disturbances will be addressed through sleep hygiene education, which will include the suggestion of regular sleeping schedule, a limited screen time pre-sleep, and avoiding the use of alcohol before sleeping. The change in lifestyle, such as regular exercise and dietary counseling, will be promoted to facilitate mood changes and management of comorbid medical conditions (Liu et al., 2025).

Patient Education: Intensive education on depression occurred which focused on the point that depression is a medical condition and should be treated and not seen as a weakness. Red flags that needed immediate medical intervention, such as manifestation of suicidal ideation, pronounced worsening of the symptoms, or adverse medication side effects, were checked. Diabetes and hypertension self-management strategies were reinforced to ensure optimum management of chronic diseases.

Follow-up and Monitoring: The patient will come back after two weeks to monitor medication safety and symptoms and in six weeks to evaluate the reaction to treatment and optimize her dosage. The chronic disease management and full re-assessment of depression will be tackled after three months. Psychiatry referral will be considered in case no significant improvement has been detected during 8-12 weeks or when the symptoms are increasing.

Goals of Care: In the short-term (4-6 weeks), the goals will be related to bettering sleep habits, stabilizing mood, and patient safety. The medium-term objectives are between 3-6 months, and they aim at remission of the depressive symptoms and optimization of the chronic medical conditions management. The long-term objectives are older than 6-12 months and focused on the continuation of a stable mood, relapse prevention, and the general health and quality of life improvement due to the further treatment compliance and change in lifestyle.