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: nasal septum is at midline, no nasal or sinus congestion, no abnormal nasal discharge
• Throat / Mouth: moist lips and moist buccal mucosa, no circumoral cyanosis, no tonsillar pharyngeal wall congestion
• Neck: no neck mass, no thyroid gland enlargement, non-palpable and non-tender lymphadenopathy
• Chest and lungs: No retractions, no lagging, symmetrical chest wall expansion, resonant, transparent, and equal breath sounds
• Heart: Adynamic precordium, point of maximal impulse at the 5th ICS LMCL, no heaves, no murmurs, no thrills, normal rate, regular rhythm
• Abdomen: Flat, with normoactive bowel sounds, tympanitic, and non-tender upon light and deep palpation
• Extremities: No gross deformities, no edema, with full and equal peripheral pulses, and < 2 seconds capillary refill
• Neurologic examination:
• Deep tendon reflexes: Bilateral biceps, triceps, knee, and ankle jerks are graded 2+
• Sensory examination: All dermatomes are 100% intact regarding light touch, pain, and pressure.
• Cerebrum: Awake, conscious, coherent, and oriented to time, place, and person
• Cerebellum: No tremors, no nystagmus, no ataxia, no dysdiadochokinesia
• Cranial Nerves: All the bilateral cranial nerves are tested and intact.

Laboratory/Diagnostic Tests:

• Anthropometric measurement:
  • Height: 160cm
  • Weight: 46 kg
  • BMI: 18.0 kg/m2
  • Waist circumference: 29cm
  • Hip circumference: 32 cm
  • Waist-hip ratio: 0.906 (Normal)
  • Thyroid function tests

Table 1. Thyroid function tests results of patient B.B.B.

	Patient’s Results	Normal Values	Interpretation
TSH	0.40 - 4.50 mIU/mL	3.0 mIU/mL	Normal
T4	7.0 ug/dL	5.0 – 11.0 ug/dL	Normal
FT4	1.5 ng/dL	0.9 - 1.7 ng/dL	Normal
T3	150 ng/dL	100 - 200 ng/dL	Normal

              Nuguru et al. (2022) explained that imbalances in the thyroid hormones could result in many mood disorders. Specifically, a decrease in thyroid hormones, as in the case of hypothyroidism, clinically presents as depression. Thyroid hormone release is regulated by the hypothalamic-pituitary (HPT) axis. In depression, serotonin insufficiency suppresses the release of thyroid-stimulating hormones from the HPT axis. Hence, this results in subclinical depression. Mental Status Examination:

• Appearance: The patient is well-groomed, looks the same as her age, and is dressed neatly and appropriately to age, weather, situation, and gender identity.
• Behavior: The patient is cooperative and elaborates on the answers to the questions. She does not appear agitated and maintains eye-to-eye contact with the interviewer.
• Motor activity: Motor activity is generally typical, with no restlessness or agitation. There is no noted bradykinesia, hyperkinesia, tardive dyskinesia, tics, or parkinsonian-like symptoms. 
• Speech: The pa...