Soap Note Essay on Mental Health

Comprehensive Soap Note Essay on Mental Health

Subjective:

CC (chief complaint): “My mother says I am losing my mind.”

ZC is a 14-year-old Asian-American male. ZC has been checked in for counselling in the mother’s company and is obsessed with the moon. Every night he has to stay outside for a long watching the moon. He believes he lived on the moon in his “past life.” During the full moon, he takes longer hours outside than during other moon phases. “My mother thinks I am losing my mind, but I believe watching the moon is therapeutic. I wonder who lives there. They must be beautiful and smart people like me.” ZC tends to be hungry at anyone who interrupts him, watching the moon. His obsession with the moon is getting worse. “Previously, he could ask me to take him out to watch the mood, and I even bought him binoculars. However, he has become so obsessed, goes out alone and remains outside for several hours”, says the mother. He prefers watching the moon than eating. Sometimes he does not bathe. He keeps mentioning that he will go to the moon when he dies. Since childhood, he has liked sticking out his tongue, twitching, and jerking his head. Sometimes he does not finish his homework and gets hungry when reminded about it. His performance is slowly declining, and he has concentration difficulties in class. During breaks, he secludes himself and sits watching the sky. He was diagnosed with major depressive following his father’s death in a road accident two years ago. He was also diagnosed with tic disorder aged five years.(Comprehensive Soap Note Essay on Mental Health)

HPI: Past Psychiatric History:

Hospitalizations: Hospitalized for a common cold four years ago.

Medication trials: None.

Psychotherapy or Previous Psychiatric Diagnosis: Diagnosed with MDD 2 years ago and tic disorder five years ago.

Psychosocial History:

Substance Current Use and History: None.

Family Psychiatric/Substance Use History: Father abused alcohol.

Social History: Has two siblings, an older brother and a younger sister.

Home Environment: Live with the mother and two siblings.

Educational Level: Grade 9.

Hobbies: Watching earth documentaries.

Legal history: None.

Lifestyle: Sleeps 4-5 hours. Poor eating habits.

Medical History:

Current Medications:  Pimozide 2 mg PO qDay to manage tics.

Allergies: None

Reproductive Hx: Not sexually active.

ROS

GENERAL: No fever or chills. 2lbs weight loss in the last two months.

HEENT:

Head: No headache.

Eyes: No visual changes

Ears/Nose/Throat: No hearing loss. No nasal congestion. No sore throat.

ENDOCRINOLOGIC: Reports decreased appetite. No cold/heat intolereance.

CARDIOVASCULAR: No history of syncope. No palpitations, chest pain, or palpitations.

GASTROINTESTINAL: No abdominal pain, nausea, or vomiting.

GENITOURINARY: No urination hesitance. No polyuria or dysuria.

LYMPHATICS: No bruising or petechiae.

INTEGUMENTARY: No dryness or rash.

NEUROLOGICAL: No numbness, weakness, or tremor.

MUSCULOSKELETAL: No joint, muscle, or back pain.

PSYCHOLOGICAL: Anxious and depressed.

RESPIRATORY: No breath pain, cough, wheeze, or sputum production.

Objective:

Vital Signs: BP: 97/68, HR: 83, R: 21 O2: 98, Pain: None, Ht:4’0′ Wt: 55 lbs BMI: 16.8 kg/m² (32%, Healthy weight)

Diagnostic results:

Beck Depression Inventory (BDI): 45

Moods and Feelings Questionnaire for Suicidal Ideation (MFQ-SI): 25

Assessment:

Mental Status Examination: The patient is alert and oriented in all spheres. He is well groomed. Appears to be in no acute psychological distress. He is calm, with warm behaviour and comments. Makes good eye contact. Has a normal and expansive emotional range. Affect is congruent with the stated mood of “sadness.” Poor insight and judgment. Normal cognition, and memory, with difficulty in abstract thought. Denies active thought of wanting to harm himself or others. The patient shows no immediate risk to himself or others.(Comprehensive Soap Note Essay on Mental Health)

Differential Diagnoses:

1. Obsessive-Compulsive Disorder (OCD), 3 (F42). The patient’s symptoms suggest OCD with absent delusional beliefs as the primary diagnosis. The essential clinical features of OCD include compulsions or obsessions characterized by persistent thoughts and the inability to ignore these thoughts (American Psychological Association [APA], 2019). Individuals are driven to perform repetitive behaviours to prevent anxiety or reduce distress. The obsessions are time-consuming and are associated with significant impairment of other areas of functioning. Such symptoms must not be explained by other mental disorders or substance abuse. Moreover, individuals with OCD tend to avoid people, places, or events that trigger the obsessions.(Comprehensive Soap Note Essay on Mental Health)
2. Persistent (Chronic) Motor or Vocal Tic Disorder, 22 (F95.1 ). The patient’s symptoms suggest a persistent tic disorder characterized by multiple/single vocal or motor tics (APA, 2019). Although the tics may wax and wane, a persistent tic disorder should be experienced for more than one year and diagnosed before 18 years. Tic disturbances must not be attributed to other mental health conditions or substance abuse.(Comprehensive Soap Note Essay on Mental Health)
3. Major Depressive Disorder (MDD), moderate recurrent episode 296.32 (F33.1). The patient’s symptoms suggest MDD is characterized by loss of pleasure or depressed mood (APA, 2019). Individuals with MDD experience a depressed mood most of the day with marked diminished pleasure in doing routine activities. Other significant clinical features include insomnia, thoughts of death, inability to concentrate, worthlessness, and psychomotor agitation. These symptoms are associated with clinically significant distress and impairment in functioning areas. Such symptoms must not be attributed to other medical conditions or substance abuse.(Comprehensive Soap Note Essay on Mental Health)

Reflections

The patient’s symptoms strongly suggest OCD, primarily characterized by obsessions and recurrent performance of specific activities and presented in the history of the present illness. Tic disorders and MDD are comorbid conditions in this case, and further investigations are necessary to determine the association between the conditions. Given this case scenario, I would have a session with the patient in the mother’s absence to create an environment for free expression from the patient. The ethical considerations, in this case, include informed consent, confidentiality, and autonomy. Written and informed consent is necessary for any intervention, as patients have the right to refuse treatment (Jonnalagadda, 2021). Patient information should be handled equally to uphold patient data privacy and autonomy.(Comprehensive Soap Note Essay on Mental Health)

Treatment Plan

Pharmacological Interventions #99204:

Start sertraline  50 mg PO QID. 25-250 mg of sertraline per day is effective for OCD and MDD (Tini et al., 2022). Sertraline is well tolerated with a positive response in continued treatment.    (Comprehensive Soap Note Essay on Mental Health)

Non-Pharmacological Interventions #90834:

Start family cognitive-behavioural therapy (CBT). CBT solved behavioural and cognitive distortions from the presenting condition (Avasthi et al., 2019).(Comprehensive Soap Note Essay on Mental Health)

Education #98960:

Discuss with the client and the mother the side effects of medication. Provide the client with the relevant emergency call lines:

Referral: Psychologist for CBT.

Follow-up: After two weeks.

Table 1: Medical Decision Making Table

CPT Code	Level of MDM	Number and Complexity of Problems	Amount and/or Complexity of Data to be Reviewed and Analyzed (Comprehensive Soap Note Essay on Mental Health)	Risk of Complications and/or Morbidity/Mortality of Patient Management
99214	Low	Low Obsessive-Compulsive Disorder with a history of MDD and tic disorder.	Cartegory 1: Tests and Documents Ordering of the Beck Depression Inventory (BDI) and Moods and Feelings Questionnaire for Suicidal Ideation (MFQ-SI) tests (Comprehensive Soap Note Essay on Mental Health)	Low Risk New patient seen for counselling

References

American Psychiatric Association. (2019). Diagnostic and statistical manual of mental disorders  (7^th ed.). American Psychiatric Publishing, Inc.   (Comprehensive Soap Note Essay on Mental Health)

Avasthi, A., Sharma, A., & Grover, S. (2019). Clinical practice guidelines for the management of obsessive-compulsive disorder in children and adolescents. Indian Journal of Psychiatry, 61(Suppl 2), 306. (Comprehensive Soap Note Essay on Mental Health)https://doi.org/10.4103%2Fpsychiatry.IndianJPsychiatry_554_18

Jonnalagadda, V. R. (2021). Ethical Considerations in Substance Use Disorders Treatment. Psychiatric Clinics, 44(4), 579-589. https://doi.org/10.1016/j.psc.2021.08.009(Comprehensive Soap Note Essay on Mental Health)

Tini, E., Smigielski, L., Romanos, M., Wewetzer, C., Karwautz, A., Reitzle, K., … & Walitza, S. (2022). Therapeutic drug monitoring of sertraline in children and adolescents: A naturalistic study with insights into the clinical response and treatment of obsessive-compulsive disorder. Comprehensive Psychiatry, 115, 152301. https://doi.org/10.1016/j.comppsych.2022.152301(Comprehensive Soap Note Essay on Mental Health)

FAQs

How do you write a mental health SOAP note?

A guide to crafting a mental health SOAP note involves structuring patient records to encompass their emotional well-being and therapeutic journey. The “S” pertains to Subjective, encapsulating the patient’s self-expressed feelings and experiences. Under “O,” record Objective details like measurable data and clinical observations. The “A” covers Assessment, where the clinician offers insights into the patient’s condition, and “P” encompasses the Plan, outlining proposed treatments and future actions. This systematic framework ensures methodical documentation and communication of mental health evaluations and interventions.(Comprehensive Soap Note Essay on Mental Health)

How do you start a mental health essay?

To initiate an essay addressing mental health, one should start by underlining the relevance of this subject within contemporary culture. Commence by elucidating the concept of mental health and providing a concise survey of its extensive effects on both individuals and communities. Shift the focus toward the primary elements you intend to examine, including the value of consciousness, mitigation of prejudice, existing interventions, and the wider repercussions for societal well-being. This initial segment should establish a basis for the forthcoming probe into the intricate facets of mental health.(Comprehensive Soap Note Essay on Mental Health)

What is the Objective part of the SOAP note mental health?

The Objective component of a SOAP note in mental health care involves offering quantifiable and observable details regarding the patient’s state. This encompasses essential signs, physical evaluations, findings from diagnostic assessments, and any concrete information garnered throughout the interaction. It lays a factual groundwork for comprehending the patient’s mental well-being, allowing medical professionals to make knowledgeable choices concerning diagnosis, therapy, and advancement monitoring.(Comprehensive Soap Note Essay on Mental Health)

What is a comprehensive SOAP note?

A detailed SOAP note is a structured documentation approach prevalent in medical and healthcare contexts. The acronym stands for Subjective, Objective, Assessment, and Plan. This framework aids medical practitioners in methodically recording patient data and facilitating communication within the healthcare team. The note initiates with the patient’s subjective information, followed by objective clinical data, an evaluation of the patient’s status, and wraps up with a strategy for ongoing treatment, interventions, or future steps.(Comprehensive Soap Note Essay on Mental Health)