Case study according to SOAP format
Mr. A is a pleasant, 17 year old, white, and male.
S (Subjective):
Chief complaint: Medication change for depression.
HPI: Patient states that he has not been feeling the same over the past few weeks. He has no
desire to complete daily activities and does not want to get up out of bed. Patient stays that he is
always tired. He can not think of any life changes that occurred prior to this change in behavior.
Nothing increases his energy levels or makes him feel better. The patient complains of no pain.
His mother believes that he needs to have his medication switched to Celexa because that is what
she takes for her depression.
Allergies: NKA
Current Mediation: Effexor 50mg BID.
Childhood Illnesses Medical & Surgical: Broken right tibia as a child.
Psychiatric: Depression
Health Maintenance, Immunizations: Immunizations up to date. Health maintenance not
addressed.
Family History: Mother Depression, Father Heart disease, and only child.
Social History: Patient lives with his mother and his aunt and uncle. The patients father does
not live with the patient or have much communication with him. They share one car between the
four of them. The patient does not drink alcohol or use drugs.
Exercise & Diet: Not assessed.
Safety Measures: Wears seat belt. No guns in the household.
ROS: Denies headache, weight gain or loss sleep disturbances, guilt, change in memory, change
in speech, no delirium, psychomotor retardation or agitation. Patient complains of fatigue, loss of
appetite, interest deficit, concentration deficit, and worthless. Mother reports that the patient has
become increasingly short tempered. Patient has not attempted suicide previously, but has a plan
to cut his wrists. He states that he is not tried it before because he does not like blood. Patient
does not have any homicidal thoughts.
O (Objective)/Physical Exam
VS BP: 118/68, HR: 86, RR: 16, Temp 98.6, weight: 151, height: 64 inches, BMI: .
Mr. A is alert, awake, oriented x 3. Patient is clean and dressed appropriate for age. Flat affect,
anxious, depressed, withdrawn, and responses to questions are extremely short. Patient thought
processes and content are abnormal with suicidal thoughts and a plan. Patient insight into mental
status changes in intact, accepts judgment. Speech and language is clear and understandable. No
flight of ideas, obsessions, compulsions, delusions, illusions, or hallucinations.
A (Assessment)
Problem #1 Change in mental status.
Most Likely Diagnosis: Depression along with suicidal ideations. This diagnosis was chosen
because the patient has multiple risk factors including current suicidal plan, availability of lethal
means, and male gender.
P (Plan)
Testing: None.
Therapy/Treatment: Immediate referral to the local health department psychiatric department
that takes walk in emergencies. Patient and mother agree that they will go tomorrow. Mother
agrees that she will remove all knives from the house when they return home. The patient made
a verbal contract that he will not harm himself.
Education: Suicide is the 13th leading cause of death worldwide, with about 1 million deaths
every year due to self-inflicted violence. In people ages 14-44 years, self-inflicted injury is the
fourth leading cause of death and the sixth leading cause of ill health and disability worldwide,
making suicide a significant public health concern. Suicide is more common among males,
resulting from a constellation of psychological, biologic, genetic, social, and environmental
factors. The two most prevalent mental disorders associate with suicide are major depressive
disorder and substance abuse. There are five components to suicide: ideation, intent, plan, access
to lethal means, and history of past suicide attempts. Effective treatment of the patients mental
disorder plays important role in suicide prevention.
Follow-up: Patient and mother informed that if symptoms worsened this evening or prior to
going to the psychiatrist that they are go to the closest emergency room for treatment. Patient
and local health department will be contacted tomorrow by the referral specialist and a nurse to
ensure that the patient followed through with the psychiatric consult.