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Week 4 Assignment 1: Focused Soap Note on Major Depressive Disorder

Week 4 Assignment 1: Focused Soap Note on Major Depressive Disorder


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(1). Major depressive disorder can easily be misdiagnosed as Bipolar disorder.  What is your take?

(2). What other psychotropic medication could be used in managing a patient with severe major depressive disorder comorbid with anxiety?

(3). One crucial blood work to do when patients present with depressive symptoms is the TSH. What is the rationale? Week 4 Assignment 1: Focused Soap Note on Major Depressive Disorder



CC (chief complaint): Patient States, “ I want to try medication since therapy did not help for my depressed mood and anxiety.

HPI: BA is a 25-year-old Hispanic female who presents for initial psychiatric evaluation for symptoms of depression and anxiety. She reports she has been going for psychotherapy, which has not been effective for her depressed mood and anxiety, and was referred to the clinic by her therapist. The patient endorsed feeling depressed, sad, irritable, fatigued, insomnia, lost appetite, low energy, poor concentration, lack of motivation, helplessness, worthlessness, hopelessness, and guilt. She states, “I am not doing well and not where I should be. I feel guilty about many things in my childhood, including being physically and sexually abused and having a child in high school.” The patient states, I am a stepchild and feel I am always left out.” She reports that her symptoms started in 12th grade, but she did not realize what it was or seek help. However, symptoms have been worsening since January this year, affecting her relationship with her family, and she sought therapy. She reported suicidal ideation early this year with no plan or intention.

Ms. BA also reports excessive worries, muscle tension, restlessness, shortness of breath, trembling, and hot feelings. She reports that the anxiety symptoms became troubling two weeks ago, occurring almost daily, and have been increasingly worsening and impacting her functioning at work. The patient denies abdominal pain/discomfort or any tingling sensations. She reports no auditory or visual hallucinations, delusions, or episodes of high or low energy but reports shopping online for things that are not necessary. BA denies nightmares and flashbacks.  Week 4 Assignment 1: Focused Soap Note on Major Depressive Disorder


Psychotherapy or or psychiatric Disgnosis: The patient reports she started therapy in January 2023 when she was diagnosed of depression which she reports was ineffective and she stopped two weeks ago.


Substance Current Use: The patient reports drinking coffee at least a cup every other day. She reports no past or current use of illicit drugs, including marijuana, cocaine, heroin, or amphetamines. She denies tobacco use and alcohol use.

Psychosocial History: Ms. BA is a 25-year-old female who lives with her mother, step-father, and step sister. She was raised by both her mom and step dad and had a son when she was in high school. She reports she was abuse physically and sexually in her childhood and did not seek for therapy. She reports her relationship with her mother is not cordial.She is working in a dental office as a receptionist.

Medical History: The patient has a history of Overactive bladder but is not on any medication.

  • Current Medications: The patient is not on any medications, including OTC.
  •     Allergies:The patient reports no allergy to medication, cats, pollen, food, or dust.
  • Reproductive Hx: The patient reports having a 28-day menstrual cycle, and the last menstrual period was in August 2023. She reports she had a child while in high school. She reports she is heterosexual, sexually active, has a boyfriend, and engages in safe sex practices. She denies any history of sexually transmitted diseases or use of contraceptives. Week 4 Assignment 1: Focused Soap Note on Major Depressive Disorder


GENERAL: Patient reports fatigue, weight loss, and insomnia. She denies any fever, chills, or general body weakness.

  • HEENT: Eyes: Patient does not use reading glasses or contact lenses. No vision loss, double vision, blurred vision, yellow sclerae, cataracts, eye pain, or eye surgery.Ears: Patient reports no hearing loss,  hx of ear infection, or use of hearing aids. Nose: Patient denies sneezing, running nose, chronic sinusitis, or epistaxis. Throat: No reports of sore throat or use of dentures or dental implants.
  • SKIN: The patient reports no dry skin, rashes, itching, or any skin lesion.
  • CARDIOVASCULAR: Patient denies chest pain, discomfort, or pressure. She endorsed palpitation when feeling anxious.
  • RESPIRATORY: Patient reports no shortness of breath, dyspnea on exertion, hemoptysis, or history of TB.
  • GASTROINTESTINAL: The patient reports a change in appetite and has lost six pounds unintentionally in the last two months. She denies nausea, vomiting, anorexia, abdominal pain, diarrhea, constipation, or hematemesis.
  • GENITOURINARY: The patient reports occasional urgency related to the overactive bladder but denies dysuria, frequency, and incontinence. No vaginal discharge, itching, or dyspareunia reported.
  • NEUROLOGICAL: The patient denies recurrent headaches, seizures, dizziness, tingling, or syncope. She reports no balancing or coordination problems.
  • MUSCULOSKELETAL: Ms. B reports no joint pain, back pain, stiffness, muscle aches, joint swelling, or hx of arthritis.
  • HEMATOLOGIC: Patient has no history of blood transfusion, anemia, or blood dyscrasias.
  • LYMPHATICS: She reports no enlarged glands and no history of splenectomy.
  • ENDOCRINOLOGIC: Ms. B reports no polyuria, polydipsia, polyphagia, excessive sweating, or heat or cold intolerance. Week 4 Assignment 1: Focused Soap Note on Major Depressive Disorder


Vital Signs: T – 97.0, P- 94, R – 20, B/P – 126/71, O2 Sat – 98%, Pain – 0/10. Height- 5’2” Weight – 115 Pounds, BMI –  20.1.

Physical Examination:

General: Ms. BA is good historian, alert and oriented and answers questions appropriately. Although guarded at the start of the interview, she became relaxed and open during the course of the interview.

Head to Toe assessment was done and revealed no significant data.

Lab – CBC, CBP, Thyroid panel, and Vitamin D: Results pending

Diagnostic results:

1). The Patient Health Questionnaire – 9 (PHQ-9): PHQ-9 is a simple and quick evidence-based tool that is reliable and effective in screening, evaluating, and monitoring the severity of MDD (Sun et al., 2020). A score between 20-27 indicates severe MDD (Sun et al., 2020), and the patient under study scored 20, which indicates severe Major depressive disorder

(2). Generalized Anxiety Disorder – 7 Items (GAD-7): The 7-item generalized anxiety disorder screening instrument is a standard tool used in many psychiatric practice settings to diagnose GAD (Kroenke et al., 2016). It is a reliable and validated tool (Kroenke et al., 2016) with a total score of 21, and a total score greater than 15 indicates severe generalized anxiety disorder. Ms BA scored 15, indicating severe Generalized anxiety disorder.


Mental Status Examination: BA is a 25-year-old Hispanic female who ambulates with no difficulty to the clinic and looks appropriate for her stated age. She appears neat and well-groomed, dressing appropriately for the weather in black short-sleeved scrubs. She makes minimal eye contact, is guarded when answering questions in a soft, low-tone voice, and her speech is clear and coherent. The mood is sad and affects constricted, congruent to her mood. Thought processes is organized, coherent, and logical with no delisions or paranoia. She exhibits negative though contents including, helplessness, worthlessness, hopelessness, and guilt. No hallucinations, suicidal ideation, or homicidal ideation present. She is alert and oriented to person, place, situation, and time. Insight to illness is intact, and judgment is not impaired.  Week 4 Assignment 1: Focused Soap Note on Major Depressive Disorder

Diagnostic Impression:

(1). Major Depressive Disorder (MDD) Severe (F32.2 ) with Anxious Distress Specifier.

Major depressive disorder is a common and disabling mood disorder associated with depressed or sad mood or anhedonia occurring more days than not for two consecutive weeks and impairing social, occupational, or any other important life function. Symptoms may also include fatigue, poor concentration, sleep disturbance, change in appetite, helplessness, worthlessness, hopelessness, guilt, suicidal ideations or attempts, low esteem, and irritable mood ( American Psychiatric Association (APA), 2013).

The criteria for diagnosing MDD according to DSM-5-TR require the presence of at least five depressive characteristic symptoms, which must include low mood or anhedonia (Zimmerman et al., 2015) in addition to fatigue, insomnia, poor concentration, weight loss, change in appetite, sleep disturbance, the feeling of worthlessness or guilt, or suicidal ideation with symptoms present during the same two-week period, occurring more days than not and impairing important area of life functioning. (APA, 2013).

The patient under review reports low mood and more than five other depressive symptoms occurring almost every day and impairing her functioning with her family. Thus, she meets the DSM-5 criteria for the diagnosis of Major depressive disorder. Her PHQ-9 score was 20, indicating a Major depressive disorder, Severe ( Sun et al., 2020). The patient reports anxiety symptoms such as restlessness, poor concentration, and tension, which meet the criteria for anxious distress as the specifier (Zimmerman et al., 2019; APA, 2013).  Week 4 Assignment 1: Focused Soap Note on Major Depressive Disorder

(2). Generalized Anxiety Disorder (GAD) (F41.1), Severe 

Generalized Anxiety Disorder (GAD) is the most common mental disorder affecting over 6.8 million US adults, with females twice as affected as men (Jothi & Husain, 2021). It is a disorder associated with excessive and irrational fears or worries about life events (Jothi & Husain, 2021). Other symptoms include restlesslessness or feeling on edge, fatigue, concentration difficulty, irritability, muscle tension, and sleep disturbance (DeMartini et al., 2019; APA, 2013).

According to DSM-5 criteria for the diagnosis of GAD, there should be uncontrollable excessive and uncontrollable anxiety and worry about life events and activities with at least three additional anxiety symptoms, occurring more days than not for at least six months and impairing daily life functioning (APA, 2013). In addition to worry and anxiety, anxiety symptoms include restlessness or feeling on edge, fatigue, irritability, muscle tension, poor concentration, and sleep disturbance (APA, 2013; DeMartini et al., 2019).

The patient under study reports excessive worries, muscle tension, restlessness, poor concentration, irritability, fatigue, insomnia, and shakiness, which have been occurring every day and are increasingly getting worse. Per the patient, the duration of symptoms is two weeks. Her GAD-7 total score was 15, which indicates severe generalized anxiety disorder. Since the duration of her anxiety symptoms is less than six weeks, the patient does not meet the DSM-5 criteria for the diagnosis of GAD at this time.

(3). Bipolar II Disorder, Most recent episode depressive (F31.81) 

Bipolar II disorder is a disabling chronic mood disorder that impacts the overall quality of life. It is a disorder characterized by a major depressive episode with depressive symptoms lasting consistently for two weeks and present for at least six months and a hypomanic episode lasting for four days (McIntyre et al., 2020). Week 4 Assignment 1: Focused Soap Note on Major Depressive Disorder. Symptoms of the depressive episode include anhedonia or depressed mood in addition to sleep disturbance, fatigue, agitation or retardation, loss of appetite, loss of weight, the feeling of guilt, worthlessness, or concentration, and suicidal ideation (APA, 2013; McIntyre et al., 2020)The patient must have at least five or more of the symptoms to meet the depressive episode criteria.

Hypomanic symptoms of bipolar disorder include persistently elevated mood or irritable mood lasting consistently for four days, high energy, grandiosity, decreased need for sleep, talkativeness, attention deficit, flight of ideas, irrational behaviors or activities such as shopping sprees or sexual indiscretions (McIntyre et al., 2020). The hypomanic symptoms are not severe enough to impair social or occupational functioning (APA, 2013).

As indicated by McIntyre et al. (2020), Bipolar II disorder is diagnosed by carrying out a detailed clinical assessment and by getting information from family members (McIntyre et al., 2020). Although Ms. BA reports symptoms of depressive episodes, she did not report any past or current hypomanic episodes or symptoms. For Bipolar II disorder criteria according to DSM-5 to be met, there must be at least one past or current episode of hypomania and no manic episode (McIntyre et al., 2020). Hence, the diagnosis of Bipolar II disorder is ruled out currently.

Reflections: During the assessment, the patient was asked if she has any history of abuse, and she said she was abused physically and sexually as a child. When asked if she brought it up during therapy, she responded no that the therapist had not asked her about any history of abuse. That left me wondering how detailed the therapist who had the first encounter with the patient was in her evaluation and the therapeutic bond between her and the therapist.

The American Psychiatric Association practice guidelines for psychiatric evaluation recommend that a patient’s initial psychiatric evaluation be comprehensive and include the patient’s trauma history (Silverman et al., 2015). What I would have done differently is to verify the therapeutic relationship between her and her therapist and, if not cordial, to advocate and discuss options for another therapist. When the therapeutic bond between the patient and the therapist is not strong, trust, respect, and exchange of information are jeopardized, resulting in a lack of confidence, poor adherence to treatment, dissatisfaction, or poor patient outcome (Crits-Chrisoph et al., 2019). During the follow-up visit, I will explore with the patient how comfortable she is with her therapist and if she prefers to continue therapy with another therapist. Week 4 Assignment 1: Focused Soap Note on Major Depressive Disorder

Case Formulation and Treatment Plan:

Based on the symptoms presented, the primary diagnosis for Ms BA is Severe Major depressive disorder with anxiety distress. The precipitants include, having a child in high school who she is stressing to take care of emotionally and financially that has  led to the worsening of her depressive symptoms over the years. Psychotherapy as a monotherapy was ineffective. Patient also has self-guilt related to her childhood trauma (physical and sexual abuse) which has strained her relationship with her mother.  She strength is that  she has good rapport and support from her step-dad and step-sister which is her strength. The short-term goal of treatment for Ms BA is to reduce symptoms,  minimize adverse effects, and improve daily functioning while The long-term goal is to achieve remission and improve quality of life ( American Psychological Association (APA), 2019).

Recent evidence-based clinical practice by American college of physicians recommends that a patient who did not respond to initial monotherapy treatment with either medication or psychotherapy be treated with pharmacotherapy and psychotherapy combined for  Severe MDD (Gartlehner et al., 2023). The first line psychothropic management recommendation by APA for severe MDD is the use of second-generation antidepressants which are which has been proved to reduce depressive symptoms with less adverse effects profile (APA, 2019). Depression-focused psychotherapy such as Cognitive behavioral therapy (CBT), behavioral therapy, interpersonal therapy that restructures negative thoughts, change behaviors, and develop coping skills are strongly recommended (APA, 2019).

Treatment Plan:

  • We explored options, and with informed consent, the patient agreed to the following:
  • Start Lexapro 5 mg PO daily for depression and anxiety. Escitalopram (Lexapro) is FDA-approved for the treatment of Major depressive disorder and off-label use for the treatment of anxiety disorder (APA, 2019).
  • Restart Psychotherapy: Cognitive behavioral therapy lasts 45 -60 minutes weekly for 15-20 sessions. CBT is an evidence-based treatment used as a combined therapy with antidepressants for severe MDD or as a second-step therapy.
  • Complementary and Alternative Medicine (CAM) therapy: The patient is educated on daily exercise’s importance to improve her mood. Yoga, which involves physical postures, meditation, and breathing techniques, is an adjuvant therapy recommended to promote mental and physical well-being (Gartlehner et al., 2023).
  • Refer to the Social worker to assist patient with information on community resources that will address the patient’s economic instability which is the social determinant of health that impacts Ms. BA.’s mental health.  Such recources may include financial assistance, job resources, and support groups.
  • Encourage the patient to join the Depression and Anxiety support group to gain information and support.
  • Refer to PCP to manage Overactive bladder.  Week 4 Assignment 1: Focused Soap Note on Major Depressive Disorder
  • Educate patients on the 911/ER Crisis helpline for medical or mental health emergencies.
  • Return to the clinic for two weeks for follow-up on medication effectiveness ( consider increasing Lexapro to 10 mg PO daily) and to review CBC, CMP, Vitamin D, and TSH lab results. CBC and CMP results are essential to know the baseline before initiating psychotropic medication. The results of TSH are required to rule out hypothyroidism or hyperthyroidism, which can mimic depression or anxiety, and low Vitamin D levels, which can prolong the remission of depression.


I confirm the patient used for this assignment is a patient that was seen and managed by the student at their Meditrek approved clinical site during this quarter course of learning.


Preceptor signature: ________________________________________________________


Date: ________________________




American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Publishing.

American Psychological Association. (2019). Clinical practice guideline for the treatment of depression across three age cohorts.

Crits-Christoph, P., Rieger, A., Gaines, A., & Gibbons, M. B. C. (2019). Trust and respect in the patient-clinician relationship: preliminary development of a new scale. BMC psychology7(1), 1-8.

DeMartini, J., Patel, G., & Fancher, T. L. (2019). Generalized anxiety disorder. Annals of internal medicine170(7), ITC49-ITC64.

Gartlehner, G., Dobrescu, A., Chapman, A., Toromanova, A., Emprechtinger, R., Persad, E., … & Wagner, G. (2023). Nonpharmacologic and pharmacologic treatments of adult patients with major depressive disorder: a systematic review and network meta-analysis for a clinical guideline by the American College of Physicians. Annals of Internal Medicine176(2), 196-211.

Jothi, N., & Husain, W. (2021). Predicting generalized anxiety disorder among women using Shapley value. Journal of infection and public health14(1), 103-108.

Kroenke, K., Wu, J., Yu, Z., Bair, M. J., Kean, J., Stump, T., & Monahan, P. O. (2016). The patient health questionnaire anxiety and depression scale (PHQ-ADS): Initial validation in three clinical trials. Psychosomatic medicine78(6), 716.

McIntyre, R. S., Berk, M., Brietzke, E., Goldstein, B. I., López-Jaramillo, C., Kessing, L. V., … & Mansur, R. B. (2020). Bipolar disorders. The Lancet396(10265), 1841-1856. Week 4 Assignment 1: Focused Soap Note on Major Depressive Disorder

Silverman, J. J., Galanter, M., Jackson-Triche, M., Jacobs, D. G., Lomax, J. W., Riba, M. B., … & Yager, J. (2015). The American Psychiatric Association practice guidelines for the psychiatric evaluation of adults. American Journal of Psychiatry172(8), 798-802.. B. (2020). Bipolar disorders. The Lancet396(10265), 1841-1856.

Sun, Y., Fu, Z., Bo, Q., Mao, Z., Ma, X., & Wang, C. (2020). The reliability and validity of PHQ-9 in patients with major depressive disorder in psychiatric hospital. BMC psychiatry20, 1-7.

Zimmerman, M., Ellison, W., Young, D., Chelminski, I., & Dalrymple, K. (2015). How many different ways do patients meet the diagnostic criteria for major depressive disorder?. Comprehensive psychiatry56, 29-34.

Zimmerman, M., Martin, J., McGonigal, P., Harris, L., Kerr, S., Balling, C., … & Dalrymple, K. (2019). Validity of the DSM‐5 anxious distress specifier for major depressive disorder. Depression and anxiety36(1), 31-38.


Please respond to this question twice.


(1). Major depressive disorder can easily be misdiagnosed as Bipolar disorder.  What is your take?

(2). What other psychotropic medication could be used in managing a patient with severe major depressive disorder comorbid with anxiety?

(3). One crucial blood work to do when patients present with depressive symptoms is the TSH. What is the rationale? Week 4 Assignment 1: Focused Soap Note on Major Depressive Disorder









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