Subjective (S):
  • Chief Complaint (CC): “Sadness, hopelessness, and sudden weight gain.”
History of Present Illness (HPI): JA is a 31-year-old Hispanic female who presents with feelings of sadness, hopelessness, and recent weight gain. She reports that these symptoms began after breaking up with her fiancé of five years, who had an affair with a coworker. Following the breakup, she moved back to her childhood home with her mother. JA was previously active in social groups, including an intramural soccer league, but has since withdrawn from all activities except for work. She has been written up at work multiple times for tardiness and major mistakes due to lack of concentration, leading to a loss of clients. JA has been coming home from work with fast food daily and rarely leaves her room except to use the restroom. She cries almost every day and has gained 15 lbs over the last few weeks. JA reports feeling tired all the time despite sleeping more than usual. She expresses feelings of worthlessness and guilt, believing the breakup was her fault for not meeting her fiancé’s needs and missing signs of his infidelity. JA also feels guilty about burdening her mother financially by moving back home. Although she has had thoughts of taking her own life by using her mother’s prescription pills, she feels guilty about stealing from her mother. Allergies:
  • NKDA (No known drug allergies)
  • No known food, latex, or seasonal allergies
  • Immunization Status: All up to date. Received the flu shot last month.
  • Past Medical History (PMHx):
    • Tonsillitis
    • Influenza A
    • Right foot sprain
Surgical History (SHx):
  • Tonsillectomy and adenoidectomy
Social History (Soc Hx): JA works at an Interior Design office Monday through Friday. She was previously active in intramural soccer with friends on Wednesday nights and had a large social friend group, often spending weekends out. However, she has recently stopped attending the gym due to fatigue and lack of motivation. JA used to eat a well-balanced diet, including vegetables, protein, and smoothies, while avoiding fast food. Since moving back with her mother, she has gained 15 lbs and now consumes fast food daily. She typically sleeps 8-10 hours per night but has been sleeping 12-14 hours lately. JA was in a romantic relationship but is currently going through a rough breakup. Although she usually drinks socially on weekends, she has recently started drinking vodka every night. JA is a non-smoker and denies illicit drug use. She has never previously considered suicide but has recently thought of ending her life by taking her mother’s prescription drugs. Family History (Fam Hx):
  • Mother: Cholecystectomy, hypertension, hypothyroidism
  • Father: Alcohol abuse, type 2 diabetes mellitus
  • Paternal Grandfather (PGF): Hypertension, type 2 diabetes mellitus, otherwise unknown
  • Paternal Grandmother (PGM): Hypertension, otherwise unknown
  • Maternal Grandmother (MGM): Died 4 years ago from non-Hodgkin lymphoma (NHL)
  • Maternal Grandfather (MGF): Chronic obstructive pulmonary disease (COPD), obesity, arthritis
  • No psychiatric history in family or immediate family members
Review of Systems (ROS):
  • Constitutional Symptoms: Reports fatigue and increased appetite. Denies chills or night sweats.
  • HEENT:
    • Eyes: Denies visual issues. No glasses or corrective lenses. Last eye exam was in 2018, with 20/20 vision.
    • Ears, Nose, Throat: Denies hearing loss or changes, nasal congestion, throat or swallowing issues. Last dental visit was 4 months ago.
  • Neurologic: Occasional headaches. Denies weakness, numbness, tingling, memory issues, involuntary movements, tremors, syncope, or seizures.
  • Cardiovascular: Denies history of murmur, chest pain, palpitations, activity intolerance, or edema.
  • Respiratory: Denies history of respiratory infections, shortness of breath, wheezing, or difficulty breathing.
  • Gastrointestinal: Increased appetite. Denies heartburn, bloating, nausea, vomiting, diarrhea, constipation, abdominal or epigastric pain, change in bowel habits.
  • Genitourinary: Denies urinary issues.
  • Musculoskeletal: Lower lumbar pain. Denies swelling, muscle pain or cramps, neck pain or stiffness, changes in range of motion (ROM). History of right foot strain from soccer 4 years ago, with no residuals.
  • Integumentary: Denies any current issues. No moles, rashes, or itching.
  • Psychiatric: Reports increasing anxiety and nervousness, with suicidal thoughts present. Denies nightmares, homicidal thoughts, or excessive anger. Loss of interest in activities, seems depressed, changes at work and socialization. Reports periods of waking during the night, sleeping excessively, and feeling apathetic.
  • Endocrine: Denies cold/heat intolerance, polydipsia, polyphagia, polyuria, changes in skin, hair, or nail texture. Denies unexpected changes in facial or body hair.
  • Hematologic/Lymphatic: Denies unusual bleeding or bruising, lymph node enlargement or tenderness, history of anemia, or blood transfusions.
Objective (O):
  • Vitals:
    • Temperature: 98.5°F
    • Blood Pressure (BP): 126/88 mmHg
    • Heart Rate (HR): 85 bpm
    • Respiratory Rate (R): 16 breaths per minute
    • O2 Saturation: 100%
    • Height: 62 inches
    • Weight: 150 lbs
    • Body Mass Index (BMI): 27.4
  • General Appearance: Healthy-appearing, obese, and well-developed. No acute distress. Affect is flat.
  • HEENT:
    • Eyes: Sclera white, conjunctivae pink. Pupils equal, round, reactive to light and accommodation (PERRLA), 3 mm bilaterally. Extraocular movements intact.
    • Ears: Tympanic membranes pearly gray, no redness, fluid, or bulging noted. Hearing intact.
    • Nose: Normal appearance, no mucus, inflammation, or lesions present. Nares patent. Septum midline.
    • Throat: Oral cavity pink, moist, intact. No missing or decayed teeth. Throat pink, moist, intact. No tonsils. No lesions, ulcers, masses, or exudate present.
  • Neurologic: Grossly oriented x3. Speech clear and articulate. Flat affect with some eye contact. Patient seems preoccupied with phone. Attention and concentration appear distracted. Sensation and deep tendon reflexes (DTR) intact in all extremities.
  • Cardiovascular: S1, S2 noted with an apical heart rate (AHR) and pulses regular and rhythmic. Radial and pedal pulses 2+ bilaterally. No murmurs, gallops, or rubs heard. Carotid arteries have normal pulses bilaterally with no bruits. No cyanosis, clubbing, or edema in extremities. Capillary refill < 2 seconds in all extremities.
  • Respiratory: Respirations even and unlabored. Clear to auscultation (CTA) bilaterally, with no wheezes, rales, or rhonchi noted.
  • Gastrointestinal: Abdomen soft and non-tender to palpation, non-distended. No rigidity, guarding, or masses present. Bowel sounds present in all four quadrants.
  • Genitourinary: Denies dysuria or hematuria. Voids 6-8 times per day. No bladder distention, suprapubic pain, or costovertebral angle (CVA) tenderness.
  • Musculoskeletal: Active range of motion (AROM) normal in all extremities with no tenderness to palpation.
  • Skin: No scaling or breaks on skin, face, neck, or arms. No rashes, lesions, or discoloration noted throughout skin. No open areas. Good turgor.
  • Lymphatic: No lymphadenopathy. No tenderness or masses present.
  • Psychiatric: Insight and knowledge of right and wrong intact. Patient has flat affect. Thinking is rational and logical. No pressured speech. Patient is pleasant, anxious, and cooperative and responds to questions appropriately. Patient appears sad and unsure. JA stated she has thoughts of harming herself but denies plans or thoughts of harming others.
  • Hematologic: No bruises or bleeding noted.
This detailed SOAP note provides a comprehensive overview of JA’s mental health status, capturing her symptoms, social and family history, and objective findings from the physical exam. The information gathered is crucial for diagnosing her condition and developing an appropriate treatment plan