Soap Note on Mental Health

SOAP Note on Mental Health


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SOAP Note on Mental Health

Patient Initials: P.S. Age: 21; is a Hispanic male who visits the clinic unaccompanied and seems to be a reliable historian.


CC: “I am feeling depressed.”

HPI: The patient is a 21-year-old male Hispanic college student. He has complaints of feeling depressed. He says that ever since he broke up with his girlfriend two months ago, he has had a broadly depressed attitude and has not been enjoying life to the fullest possible extent. He also reports having trouble sleeping on occasion. He is frequently anxious and overthinks the possibility of ever finding true love. He is now failing exams and scoring poor grades. He denies night sweats, fever, chills, fatigue, nausea, or vomiting.

Past Medical History

Chronic illness: None

Medication: None

Allergies: No known allergies

Surgeries: None

Social History

· He is a college student

· Broke up with his girlfriend 2 months ago

· Drinks alcohol 1 bottle of beer per day since he broke up with his girlfriend.

· Smokes cannabis daily since he broke up with his girlfriend.

· Denies smoking tobacco

Family History

· His father died in a tragic road accident.

· Mother has no known chronic illness

· PGF alive has hypertension

· PGM diseased, no known chronic illness

· MGF diseased, no known chronic illness

· MGM diseased, no known chronic illness

Review of Systems

Constitutional: Denies chills, fever, chest pain, or weight loss.

Head: Denies unconsciousness or head trauma.

Eyes: No eye irritation, color blindness, dryness, or copious tears reported. Denies using

corrective lenses.

Ears: Denies experiencing ear pain, ear ringing, discharges, or hearing loss.

Nose: No nosebleed, loss of smell, nasal congestion, or pain reported.

Mouth: Does not experience bleeding gums or mouth wounds.

Throat: No sore throat and hoarseness reported.

Skin: Denies skin rashes, bruises, color changes, or lesions.

Respiratory: He denies having any symptoms of coughing, wheezing, difficulty breathing, or

chest pain.

Cardiovascular: Denies heart palpitations and denies having chest pain or tachycardia.

Genitourinary: Denies having pain, abnormal penile discharge, or urination frequency changes.

Musculoskeletal: Denies having joint pain, muscle pain, or swelling.

Heme/Lymph/Endo: He denies experiencing excess sweating. He denies a history of blood


Neurologic: No dizziness, headaches or tremors, or syncope have been reported.

Psychological: Denies suicidal thoughts or memory loss. Reports depression and anxiety.


Vital Signs

Blood Pressure: 125/74mmHg Pulse 82. Temperature: 98.5F Respiration 18. SaO2: 99% Height: 5’5” Weight: 148lbs BMI 24

General appearance: The patient is conscious, oriented, and well-groomed. He seems disturbed.

Head: normocephalic, symmetric, atraumatic

Ears: T.M. intact and pearly gray with the cone of light bilat. Pinna clean, no exudate noted.

Eyes: Normal PERRLA findings. Anicteric sclera.

Nose: No maxillary sinuses, lesions, or bleeding. The mucous membrane is moist.

Throat: No lesions, exudate, or inflammation.

Skin: Soft, warm, supple, and dry. There are no rashes, bruising, or changes in skin color.

Cardiovascular: Normal S1 and S2 sounds. Regular heartbeat.

Gastrointestinal: No palpable masses. Soft, non-distended, and non-tender abdomen.

Respiratory: Lung auscultation indicates no abnormalities. No wheezes

Musculoskeletal: No joints or muscles that are inflamed or stiff.

Extremities: No discernible edema.

Neurological: Gait is normal, and balance is stable. Clear communication with a clear tone of voice.

Psychiatric: He is cooperative, alert, and has a pleasant disposition and conduct.


1. Depression (F33.1)– Depression is characterized by persistent sadness and lack of motivation. Depression, also known as major depressive disorder, can cause a variety of emotional and physical challenges (SAMHSA, 2021). At times, a person may feel that life has no purpose and find it hard to perform daily tasks (SAMHSA, 2021). This is the most likely differential diagnosis as evidenced by symptoms of feeling sadness from the previous breakup, frustration, smoking cannabis and drinking alcohol.

2. Attention deficit hyperactivity disorder (ADHD) (F90.9)- is one of the most prevalent childhood neurodevelopmental disorders (Cabral et al., 2020). It is most commonly diagnosed in childhood but can last into adulthood if left untreated. Patients with ADHD may struggle to pay attention, control their impulsive behaviors, or engage in an excessive activity (Cabral et al., 2020). The possibility of this diagnosis is due to school inattentiveness and poor grades. However, the differential diagnosis is ruled out because he began scoring low grades after a loss of concentration due to a breakup with his lover.

3. Substance use disorder ( F19. 10) – is a mental condition that impacts both the brain and behavior of a person, resulting in that person’s inability to exercise self-control regarding the consumption of substances like alcohol, drugs or medications (Kalin, 2020). Likely differential diagnosis is evidenced by the use of cannabis and alcohol consumption (Kalin, 2020). Ruled out by DSM-5 criteria.

Final Diagnosis: Depression

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