ANSWER
Together with a well-organized conversation on diagnostic and treatment planning, below is a targeted SOAP note form following the described guidelines.
Note from SOAP
Patient’s Name: J.C.
82 is your age.
Male: Gender
Date: [Insert date]
Chief Complaint (CC): “I’ve been feeling weak, tired, and not myself.”
J.C. notes in three months abdominal pain, loss of appetite, and inadvertent weight loss of about 10 lbs. Rated 4/10 in severity, he characterises the ache as dull and consistent, sometimes linked with nausea. He denies constipation, diarrhoea, or vomiting. His everyday activities have been greatly affected by symptoms; he is unable to follow his customary schedule involving light gardening and weekly community events.
Psychiatric History: None mentioned.
Family History: Psychiatric diseases not run in my family.
Social History: J.C. is retired and resides with his wife. He contests using alcohol, tobacco, or illegal drugs.
Review of systems (ROS):
general: weight reduction, tiredness.
Gastrointestinal: Regular nausea; ongoing dull stomach pain.
Psychiatric: Says they struggle to focus and feel despondent.
aim:
Physical Examining:
Generally: Looks tired and rather cachectic.
Mental Status Analysis (MSE)
Looks: well groomed but clearly weightless.
Mood or affect: nervous, subdued.
Thought Process: Slowed but logical.
Mild trouble focusing; orientated to time, place, and person.
Speech: calm but cogent.
Behaviour: friendly, suitable eye contact.
Psychiatric Notes: None of psychosis or mania evident here.
Assessment: Differential Diagnoses
Major Depressive Disorder, or MDD:
DSM-5: Tragic Present are criteria of persistent sad mood, notable weight loss, tiredness, and reduced capacity for concentration.
Rationale: J.C. excludes symptoms related to a medical condition; her symptoms fit the MDD criteria.
Loss of appetite, weight loss, tiredness, despondency are some pertinent positives.
Important Negatives: There is no past of mania or psychotic episodes.
Adjustment Disorder with Depressed Mood:
DSM-5 TR Emotional reaction to a stressor within three months; distress above the expected range.
J.C.’s symptoms could be connected to recent life events (like changes in health).
Rule-Out: Symptoms show more ubiquity and satisfy MDD criteria.
Generalised anxiety disorder (GAD) is
DSM-5-TR: Criteria: Extreme anxiety more days than not for at least six months; accompanied by tiredness and trouble focusing.
J.C shows anxiety, but his depressive symptoms are more noticeable, hence GAD is not the main diagnosis that fits.
Major depressive disorder, mild, one single episode is the diagnosis.
Psychotherapy:
Start Cognitive Behavioural Therapy (CBT) to help with dysfunctional thinking and advance coping mechanisms. twelve weeks’ weekly meetings.
Pharmacologic Treatment:
Start 25 mg daily, titrate to 50 mg depending on tolerance two weeks. Reason: With little influence on cardiovascular comorbidities, sertraline is good for elderly people suffering with depression.
Nonpharmaceutical Treatment:
Promote modest physical exercise such walking to boost appetite and mood.
Use relaxation strategies include guided meditation to control stress.
Promoting health:
To help J.C. with weight loss, teach her the advantages of a balanced diet and support little, frequent meals with nutrient-dense foods.
patient instruction:
Describe Sertraline’s possible adverse effects—such as nausea and dizziness—as well as the need of following both medicine and psychotherapy.
Follow-Up:
Plan a two-week follow-up visit to evaluate Sertraline’s therapeutic response and tolerance.
Notes for Reflections:
How would you change things? If I could go back over this session, I would include a closer examination of J.C.’s coping strategies and support network to help me to appreciate his resiliency. Given his age, I too would look for minute indicators of cognitive deterioration.
In follow-up meetings, concentrate on assessing J.C.’s reaction to therapy, modifying the medication dosage if needed, and keeping an eye on suicidal thoughts—a risk factor in older persons with depression.
Legal/ethical considerations:
Think about the ethical ramifications of treating depression in an older adult with medical complexity by juggling pharmacological treatment with possible side effects.
By addressing any stigma J.C. could have related with mental health treatment, especially in his demography, guarantee culturally responsive therapy.
Promoting health and preventing diseases:
Talk about ways to prevent depression’s effects, including keeping social contacts to help to lower isolation.
Emphasise the need of regular medical visits to monitor diseases including diabetes and hypertension that coexist.
References:
American Psychiatric Association, 2022. Fifth edition of the Diagnostic and Statistical Manual of Mental Diseases (text revision). American Psychiatric Media.
National Institute for Health and Care Excellence (NICE). 2022 Adults’ depression: management and treatment. downloaded from https://www.nice.org.uk.
Lenze, E. J. and Reynolds, C. F. 2018. Older adult depression treatment: clinical guidelines Jama, 320(24), 2550–2556. 10.1001/jama.2018.19288 https://doi.org/10.1001
QUESTION
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, and list them 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 were able to 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).