SOAP Notes: Major Depressive Disorder

SOAP Notes: Major Depressive Disorder
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Identifying data: This is a case of B.B.B., an 18-year-old female, who came to the clinic for her second outpatient follow-up psychiatric check-up. Interval history: The patient was diagnosed with major depressive disorder with no psychotic symptoms two weeks ago and was on Escitalopram 10mg/tablet, one tablet once a day at bedtime. The patient was last seen two weeks ago. Subjective: Chief complaint:             The patient stated, "I felt much better when taking the medication. I feel less lonely. However, I noticed an increased appetite, and I feel sleepy in the morning." According to the family, the patient smiles and converses more than last month, and the patient goes out for recreational activities compared to the previous month. However, the family members noticed an increase in the patient’s appetite and weight. Objective: History of Present Illness:             Four months before consultation, the patient fought with her best friend, who backstabbed her, resulting in insults from their other common friends. This made the patient feel lonely, resulting to suicidal thoughts and intentions to harm oneself. The patient also lost her appetite and willingness to do previously enjoyable activities. The patient felt this for most days of the month. Due to this, the patient went to consult last month and was prescribed Escitalopram 10/mg tablet, one tablet once a day at bedtime, and was enrolled in cognitive behavioral therapy. The patient was also advised for a follow-up check-up every two weeks.             The patient noted in her journal that she had improved her overall mood since her last visit two weeks ago. The patient noted that she was able to converse more and was able to reconcile with her friends. The patient also had no suicidal thoughts or intention to harm oneself or others for the past two weeks. Additionally, the patient noted an increase in appetite and an increase in weight of 2 kilograms. Moreover, the patient stopped smoking and took alcoholic beverages, soft drinks, or chocolates. She also had enough sleep ranging from 6 hours to 8 hours of continuous sleep per night. Lastly, the patient noted compliance with medications and attended cognitive behavioral therapy sessions weekly. Vital Signs:

• BP: 110/60mmHg
• HR: 88 bpm
• RR: 20 cpm
• Temp: 36.9 deg C orally taken
• SpO2: 98% at room air

Physical Examination:

• General: Conscious, coherent, oriented to time, place, and person, not in cardiopulmonary distress
• Integumentary: White and fair skin color, no lesions, no pallor, no jaundice, no cyanosis
• HEENT:
• Head: Normocephalic with evenly distributed hair, no alopecia, no palpable mass or lesion, no tenderness
• Eyes: non-sunken eyeballs, anicteric sclera, pink palpebral conjunctivae, no abnormal discharges, PERRLA
• Ears: symmetrical and equally set ears, no scars or lesions, no abnormal discharge
• Nose: nas...