Mrs. J.N. Soap Note

Mrs. J.N. Soap Note

Patient Information

Name: Mrs. J.N

Age: 46 years

Gender: Female

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Nationality: African American

Method of Referral: referral by primary care physician (Involuntary)

Marital status: Married

Occupation: public school driver

Informant: the patient.

Chief Allegations:

“I feel depressed and stressed most of the time for the past one year and am anxious for the past one year.”

History of Presenting Illness: the patient is Mrs. J.N, A 46-year-old African American female presenting to the clinic as a referral from the PCP. She presents with complaints of depressed mood, being stressed, and feeling anxious for the past year. The depressed mood was preceded by a misunderstanding in her workplace that led to her suspension from work and the loss of her mother later. Being the breadwinner of the family since her husband suffered a stroke, she did not have any source of capital to facilitate the education of her three children. Even after reinstatement in her job, she has never felt better. She, later on, lost her mother 6 months ago following a tragic road accident. She has since lost energy and interest in her work. She feels disinterested in her work and nearly caused an accident. Furthermore, she has trouble getting sleep, is guilty of reduced attention, lost appetite, decreased weight, and often feels pessimistic. She has once tried committing suicide by hanging but was rescued by her neighbors.  On the other hand, she is persistently being anxious for no known reason that she becomes easily distracted, fatigued, restless, irritable, impaired concentration, and can barely control her anxiety.

Past Psychiatric History: there is no previous visit to the psychiatric clinic. No previous mental illness.

Past Medical/Surgical History: she was diagnosed with hypertension two years ago and has been using lifestyle modifications to manage her symptoms. No previous history of surgery or blood transfusion.

Treatment and Medications History:  no previous prescription for any conditions. She is neither taking supplements nor herbal medications.

Allergies: no known drug, environmental, or food allergies.

Reproductive History: menarche at 13 years. First pregnancy at 25 years, while the last pregnancy was at 37 years. Her last menstrual period was on 12/05/2022. Average 3 days, no dyspareunia. She has used combined oral contraceptives in the past but stopped.

Substance use: she often uses alcohol. No history of smoking cigarettes or intravenous drug abuse.

Family History:

Father:  Michael, 82 years, alive, has hypertension, a retired accountant.

Mother:  Jane, 74 years, died; was a retired teacher, had diabetes mellitus, and was diagnosed with major depressive illness.

She is the first born in a family of three. Others are listed below

Second born: Mary, 38 years, alive and well; studied at university; teacher.

Third born: Felix, 35 years, alive and well; university; electrical engineer.


Social/personal History

Education: She studies up to university; holds a bachelor’s degree in mechanics.

Relationships: she is currently living with her husband who is paralyzed. Her recent mood has made her get into arguments with his partner. No previous history of abuse.

Religion: a Christian. Not obsessed with religiosity.

Family and social support: she is the breadwinner of her family. She gets little support from her extended family.

Living Arrangements: lives with her husband in a rental apartment.

Hobbies: traveling and making new friends.

Forensic History: no previous encounter with police. No history of suspension from school.

Premorbid History: calm and lovely.

Review of Systems

constitutional: she reports reduced appetite and loss of weight. she denies nausea, vomiting, fever, or chills

HEENT: Head: she denies head injury. Eyes: she denies blurry vision, tearing, or reduced vision. Ears: she denies tinnitus, pain, or earache. Nose: she denies epistaxis, pain, congestion, or rhinorrhea. Throat: she denies dysphagia, odynophagia, or neck pain.

Respiratory: she denies chest pain, cough, shortness of breath, or hemoptysis.

Cardiovascular: she denies edema, orthopnea, paroxysmal nocturnal dyspnea, or breathlessness.

Gastrointestinal: she denies abdominal pain, vomiting, diarrhea, or constipation.

Genitourinary: she denies dysuria, lower abdominal pain, increased frequency, or urine incontinence.

Skin: she denies itchiness, rashes, or easy bleeding.

Physical Examination

On general examination, she is a middle-aged female, well-groomed, not in distress, with no pallor, jaundice or cyanosis, lymphadenopathy, or edema.

Vital signs: temperature 97.6 F, BP 143/90mmHg, heart rate 86 b/min, SPO2 99%, respiratory rate 20breaths/min.


Systematic Examination

Respiratory: chest moves with respiration, bilateral equal expansion, clear air entry, bronchial breath sound, and resonant percussion.

Cardiovascular: the precordium is normoactive with the apex beat present at the fifth intercostal space. S1 and S2 heard. No added sounds or murmur. No peripheral edema.

The other systems were essentially non-remarkable.

Mental Status Exam

Appearance and Behavior: a middle-aged African American female, appearing appropriate for her age, well-kempt, easily distracted, and not maintaining eye contact. Her face is gloomy.

Speech: soft speech, clear articulation, spontaneous, and mutes occasionally.

Mood and Affect: affect is depression and sadness. The mood is irritable.

Thought: her thought content is anxious with no known reference. Her thought content is coherent.

Perception: she has depersonalization with visual hallucinations about her late mother.

Cognition: she is alert and oriented to time, place, person, and situation. The abstract is appropriate; well equipped with general knowledge; arithmetic skills are intact; judgment is appropriate, and intact distant and recent memory.

Insight: she has insight; she knows she has a problem and would like to be helped.

Diagnostic Formulation

J.N, a 46-year-old African American female, presents with a one-year history of depressed mood, feeling stressed, and being anxious. There is also lost interest in her work, reduced energy, has pessimistic feelings, is fatigued, restlessness, has trouble getting sleep, excessive guilt, reduced attention, lost appetite, and reduced weight. Furthermore, she is anxious, easily distracted, fatigued, restless, irritable, impaired concentration, have suicidal ideation, and can barely control her anxiety. Her symptoms are attributed to the stressful working environment, paralyzed partner, and the loss of her mother through a tragic accident. Her mother was diagnosed with a major depressive illness before her demise. She has no previous history of psychiatric treatment. However, she often drinks alcohol. Upon performing a mental status examination, she expresses features of depression including depressed mood, easily distracted, irritability, avoids eye contact, muting often, and depersonalization.

Multiaxial Diagnosis Formulation.

Axis I: major depressive illness with a differential diagnosis of generalized anxiety disorder.

Axis II: No mental retardation or personality disorder.

Axis III: hypertension.

Axis IV: Not applicable.

DSM V Diagnostic Criteria

Major depressive illness

            The DSM criteria provide guidelines for a depressive disease. Major and minor allegations are used to classify depression into mild, moderate, and severe. The major symptoms include depressed mood, loss of energy, and loss of interest. (Dhandapani et al., 2021). Minor criteria on the other hand include disturbed sleep, excessive guilt, suicidal ideation, reduced concentration, diminished appetite, pessimistic views, and reduced self-esteem. The symptoms must have lasted for a minimum of two weeks with no systemic disorder attributed to symptoms (Munir & Takov, 2022). Any combination of two major symptoms and two minor is classified as mild; moderate has two major symptoms with any three minor symptoms; severe has all the three major symptoms plus at least four minor symptoms. Based on this classification, the patient has a severe depressive episode as confirmed by three major and more than four minor symptoms. She has a depressed mood, lost interest in activities, and anergia; plus, guilty, pessimistic thoughts, suicidal ideation, sleep disturbances, weight loss, and reduced appetite. These symptoms have lasted for more than two weeks and are not attributed to any physical illness.

Neurobiology: regarding depression and genetics, there is a correlation in incidences. Notably, first-degree relatives of patients with depression have a four-fold increased risk of depression as compared to the general population (Munir & Takov, 2022). In the pathophysiology of depression, various neurotransmitters including monoamines, neurotransmitters, and GABA are implicated. A drop in the level of these neurotransmitters is attributed to depressive symptoms. Regarding neuroanatomy, metabolic dysfunction in the prefrontal cortex leads to reduced blood flow, decreased neuronal metabolism, and neural activity (Pan et al., 2019).

In defining the symptoms of depression, various theories are stipulated. Such include the neuroendocrine theory which suggests an endocrine disorder such as hypothyroidism and cortisol deficiency as a cause of depression; the biological theory that suggests occurrence of depression in first degree relatives of depressed individuals; and biochemical theory that suggest deficiency of neurotransmitters in the pathophysiology of depression (Roomruangwong et al., 2018). In several studies there is difference in presentation of depression across cultural practices. Factors including gender, age of onset, time of diagnosis, and substance abuse determine the comorbidities that vary in various cultures (Pan et al., 2019). Therefore, it is prudent that clinicians perform a comprehensive clinical exam of every patient while identifying various cultural differences that impact patient health.

Differential Diagnosis

General Anxiety disorder (GAD)

            For accurate diagnosis of GAD, DSM V provides criteria as follows. In criteria (a) there must be persistent, uncontrollable, and excessive worry lasting for more than 6 months; (b) the patient struggles to control worries; (C) a minimum of three symptoms from the following: restlessness, disturbed sleep, irritability, disturbed sleep, impaired concentration, and fatigue; (d) no other psychiatric illness attributes to symptoms; (e) no substance attributed to symptoms; and (f) there is impairment in social or personal functioning attributed to symptoms (Pan et al., 2019).  The patient J.N has excessive anxiety, restlessness, fatigue, disturbed sleep, and inability to control anxiety. No medical illness attributed to her symptoms.

Neurobiology: there is a strong genetic linkage to GAD. Among first degree relatives of patients with GAD, there is a 15-20% risk of anxiety disorder than general population (Peyrovian et al., 2019). The pathogenesis of anxiety has been attributed to GABA inhibition with activation of the excitatory receptors. This explains the use of benzodiazepines in managing anxiety. Other neurotransmitters including serotonin, dopamine, and norepinephrine are attributed to anxiety. Regarding neuroanatomy, various systems, including the limbic system, prefrontal cortex, and locus coeruleus form the basis. Various theories have been used to explain anxiety including the psychodynamic, behavioral, and biological (Roomruangwong et al., 2018). Psychoodynamic theory attributes anxiety to psychological disturbances;  behavioral attributes anxiety to reaction to painful stimuli or heat; while biological theory attributes the effects of neurotransmitters to anxiety. Finally, the variability in culture differentiates somatic from cognitive symptoms.


Management Plan

            Appropriate management of the patient requires carrying out some investigations to rule out other systemic conditions that could cause patient symptoms. In J.N`s case, checking for vital signs is appropriate to measures the blood pressure since the patient has hypertension. In addition other tests including complete blood count to rule out infections, thyroid function test to rule out thyroid disorders, and liver function test to rule out liver pathology would be appropriate. In terms of medications, the patient would benefit from fluoxetine for depressive episodes and alprazolam for anxiety.

Fluoxetine is a selective serotonin reuptake inhibitor that increases serotonergic transmission and increasing serotonin levels. Increased serotonin levels counters the depressive episodes. Few of its side effects include diarrhea, nausea, insomnia, and anorexia (Peyrovian et al., 2019). It is contraindicated in breastfeeding, hypersensitivity, and concurrent intake with thioridazine.   On the other hand, alprazolam has an inhibitory effect on GABA thus relieving anxiety symptoms. It works by reducing anxiety but concurrently cause drowsiness, headaches, and light-headedness as side effects (Roomruangwong et al., 2018).  Due to risk of respiratory depression and sedation, it should be administered with opioids as they can synergistically combine to cause deleterious effects.  Furthermore, there is absolute contraindication to use alprazolam in case of acute narrow angle glaucoma, concurrent administration with itraconazole, and hypersensitivity.  Finally, patient`s hypertension should be monitored and the need for antihypertensive medication should be assessed.


The patient will require monthly follow-up at the clinic. Treatment with fluoxetine will require gradual adjustment of dose by 20mg/day; the maximum dose is 80mg/day (Peyrovian et al., 2019). Incase of worsening symptoms with increase grief, irritability, and suicidal ideation; the patient should come immediately to the clinic or call the emergency number 911. Next visit in one two weeks.



Dhandapani, A., Soundararajan, S., Simiyon, M., Zachariah, V., & Sambhi, R. (2021). An audit of admission clerking of patients in Heddfan, Adult Mental Health Unit in BCUHB – north Wales. BJPsych Open7(S1), S75–S75.

Munir, S., & Takov, V. (2022). Generalized anxiety disorder. In StatPearls. StatPearls Publishing.

Pan, Z., Park, C., Brietzke, E., Zuckerman, H., Rong, C., Mansur, R. B., Fus, D., Subramaniapillai, M., Lee, Y., & McIntyre, R. S. (2019). Cognitive impairment in major depressive disorder. CNS Spectrums24(1), 22–29.

Peyrovian, B., Rosenblat, J. D., Pan, Z., Iacobucci, M., Brietzke, E., & McIntyre, R. S. (2019). The glycine site of NMDA receptors: A target for cognitive enhancement in psychiatric disorders. Progress in Neuro-Psychopharmacology & Biological Psychiatry92, 387–404.

Roomruangwong, C., Simeonova, D. S., Stoyanov, D. S., Anderson, G., Carvalho, A., & Maes, M. (2018). Common environmental factors may underpin the comorbidity between generalized Anxiety Disorder and mood disorders via activated Nitro-oxidative pathways. Current Topics in Medicinal Chemistry18(19), 1621–1640.





Upon your assessment write SOAP NOTE, make a Diagnosis based on DSM-5 and Treatment Plan: Definitive diagnosis, Differential diagnosis: and Include neurobiology of disorder(s). (Include genetics, neurotransmitters, neuroanatomical changes, current theories of causation, cultural factors); Rationale for each part of management plan (labs; meds: why this med, what is neurochemistry action of med, side effects to monitor, expected benefits, contraindications; counseling-goals, rationale for this type of therapy, expected benefits, teaching, referrals, follow-up).

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