NUR 676 Module 2 SOAP Note Example

SOAP Note: A New Diagnosis of Major Depressive Disorder in a 34-Year-Old Man

[Student Name]

Southern New Hampshire University

NUR 676: Primary Care for Mental Health

Module Two SOAP Note

[Instructor Name]

[Date]

The organization, setting and figures below are a composite written as a model document. No real employer, client, colleague or patient is described.

SOAP Note: A New Diagnosis of Major Depressive Disorder in a 34-Year-Old Man

Depression turns up constantly in primary care, and many patients who have it present with fatigue, poor sleep or physical complaints rather than sadness. A positive screening score is only a starting point. Before prescribing an antidepressant, the clinician must confirm the diagnosis, rule out medical causes, screen for bipolar disorder, which an antidepressant alone can worsen, and ask about suicidal thoughts and substance use. The note below records a first depression visit for a 34-year-old man and makes the case that a structured assessment followed by an evidence-based treatment choice and a plan to measure response gives the patient the best chance of recovery and avoids common errors.

Subjective

Chief concern: "I'm just tired all the time and nothing feels worth doing."

History of present illness: Marcus is a 34-year-old warehouse supervisor who reports six weeks of feeling down most of the day nearly every day, losing interest in basketball and video games he used to enjoy, waking around four each morning with no way back to sleep, feeling exhausted, having trouble concentrating on schedules at work and feeling guilty that he is letting his team down. His appetite is slightly reduced, and he has lost about 2 kg. The symptoms began after his father's death three months ago, but he says the grief has turned into something different, a flatness that does not lift. He cannot recall any stretch of days when he felt unusually high, needed little sleep yet had surplus energy or spent money recklessly. He denies thoughts of death or suicide when asked directly. His alcohol use is limited to a few beers on Saturdays, and he takes no other drugs.

Past history: no prior psychiatric diagnoses or treatment. No chronic medical illness. Medications: none. Family history: mother treated for depression; no known bipolar disorder or suicide. He lives with his partner, who is supportive.

Objective

Vital signs normal. Body mass index 27. He appears tired, with slowed speech and a flat affect; thought process is linear and there is no evidence of psychosis. PHQ-9 score 16, with item 9 scored 0. Mood Disorder Questionnaire negative, with two positive items and no reported impairment. AUDIT-C score 3. Laboratory tests: thyroid-stimulating hormone and complete blood count normal. Physical examination unremarkable.

Assessment

1. Major depressive disorder, single episode, moderate. Kroenke et al. (2001) validated the PHQ-9 in primary care and obstetrics patients, setting thresholds at 5, 10, 15 and 20 to separate increasing levels of severity, and that a score of 10 or more had good sensitivity and specificity for major depression. Marcus's score of 16 falls in the moderately severe range, and the interview confirms at least five of the nine criteria for at least two weeks with functional impairment. Although his symptoms began after a bereavement, their severity, duration and pervasive flatness, along with guilt and functional decline, support a diagnosis of major depression rather than uncomplicated grief.

2. Bipolar disorder screened and unlikely. Hirschfeld et al. (2000) developed the Mood Disorder Questionnaire, a brief self-report screen that asks about symptoms of mania or hypomania, whether several occurred together and whether they caused problems, and found it had good specificity for bipolar spectrum disorder in psychiatric outpatients. His negative screen, together with no history of elevated mood and no family history of bipolar disorder, makes an antidepressant appropriate.

3. Low-risk alcohol use; no suicidal ideation.

Choosing Treatment

For moderate depression, antidepressant medication, psychotherapy or both are appropriate, and patient preference matters. Marcus wanted to start medication and was willing to see a therapist. Cipriani et al. (2018) conducted a network meta-analysis of randomized trials comparing 21 antidepressants in adults with major depression. All were more effective than placebo, but they differed in efficacy and in acceptability, measured by how many patients stopped treatment. Escitalopram was among the drugs with both relatively higher efficacy and better acceptability, as was sertraline, and both are inexpensive generics. Escitalopram was chosen because of its once-daily dosing, few drug interactions and favorable balance in that analysis, after discussing common side effects such as nausea, headache, sleep changes and sexual side effects.

Plan

Escitalopram 10 mg daily, with the explanation that improvement usually begins within two to four weeks and full benefit may take six to eight. Referral to the clinic's behavioral health clinician for cognitive behavioral therapy, with the first appointment within two weeks. Sleep hygiene advice and encouragement to resume physical activity, starting with short walks. He was advised to limit alcohol, which can worsen mood and sleep. The care manager will call at two weeks to check side effects and adherence and repeat the PHQ-9. A visit at four weeks will review the score; if the score has dropped by less than a quarter at six to eight weeks, the dose will be increased to 20 mg or the plan revised. The goal is response, a 50% reduction in the PHQ-9, within two to three months, then remission, a score below 5. Once he is well, the medicine should continue for six months to a year.

Safety and Education

Marcus and his partner were told that any thoughts of self-harm, worsening agitation or new restlessness should prompt an immediate call to the clinic or the 988 Suicide and Crisis Lifeline, and he was given the number. He was told not to stop escitalopram abruptly, since discontinuation symptoms can occur. He was also told that feeling some benefit before full recovery is common and that the plan will be adjusted if he does not improve. He repeated the key points back accurately.

Conclusion

Marcus's fatigue and loss of interest reflected moderately severe major depression. A structured assessment confirmed the diagnosis, ruled out medical causes and bipolar disorder and documented his safety. Escitalopram, chosen with evidence from a large network meta-analysis, together with psychotherapy and PHQ-9 checks at defined points, gives him a clear path toward remission and a plan for adjusting treatment if he does not respond.

References

Cipriani, A., Furukawa, T. A., Salanti, G., Chaimani, A., Atkinson, L. Z., Ogawa, Y., Leucht, S., Ruhe, H. G., Turner, E. H., Higgins, J. P. T., Egger, M., Takeshima, N., Hayasaka, Y., Imai, H., Shinohara, K., Tajika, A., Ioannidis, J. P. A., & Geddes, J. R. (2018). Comparative efficacy and acceptability of 21 antidepressant drugs for the acute treatment of adults with major depressive disorder: A systematic review and network meta-analysis. The Lancet, 391(10128), 1357-1366. https://doi.org/10.1016/S0140-6736(17)32802-7

Hirschfeld, R. M. A., Williams, J. B. W., Spitzer, R. L., Calabrese, J. R., Flynn, L., Keck, P. E., Lewis, L., McElroy, S. L., Post, R. M., Rapport, D. J., Russell, J. M., Sachs, G. S., & Zajecka, J. (2000). Development and validation of a screening instrument for bipolar spectrum disorder: The Mood Disorder Questionnaire. American Journal of Psychiatry, 157(11), 1873-1875. https://doi.org/10.1176/appi.ajp.157.11.1873

Kroenke, K., Spitzer, R. L., & Williams, J. B. W. (2001). The PHQ-9: Validity of a brief depression severity measure. Journal of General Internal Medicine, 16(9), 606-613. https://doi.org/10.1046/j.1525-1497.2001.016009606.x