3 SOAP Note on Mental Health Name xxx United State University Couse xxx Professors xxxx Date xxx Video link 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. Subjective 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 transfusion. Neurologic: No dizziness, headaches or tremors, or syncope have been reported. Psychological: Denies suicidal thoughts or memory loss. Reports depression and anxiety. Objective Vital Signs Blood Pressure: 125/74mmHg Pulse 82. Temperature: 98.5F Respiration 18. SaO2: 99% Height: 5’5” Weight: 148lbs BMI 24 General ...

1. 3
SOAP Note on Mental Health
Name xxx
United State University
Couse xxx
Professors xxxx
Date xxx
Video link
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.
Subjective
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.

2. 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

3. 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
transfusion.
Neurologic: No dizziness, headaches or tremors, or syncope
have been reported.
Psychological: Denies suicidal thoughts or memory loss.
Reports depression and anxiety.
Objective
Vital Signs
Blood Pressure: 125/74mmHg Pulse 82. Temperature: 98.5F
Respiration 18. SaO2: 99% Height: 5’5” Weight: 148lbs BMI 24

4. 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.

5. Assessment
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

6. Plan
Diagnostic Tests
The Diagnostic and Statistical Manual of Mental Disorders,
Fifth Edition (DSM-5) – The DSM-5 defines major depression
and substance use disorder as five or more episodes of despair
within two weeks and disregarding the negative effects of
continued substance use (Dubovsky et al., 2021). The DSM-5
can helps classify and determine the severity of depression or
substance use disorders.
Complete Blood Count (CBC) - In some cases, medical illnesses
such as anemia, autoimmune illness, or vitamin deficiency can
mimic the symptoms of depression. In order to rule out other
medical disorders that could be confused for depression, a
complete blood count can be beneficial (Selph & McDonagh,
2019). In this case, the patient CBC is normal.
Treatment Plan
Depression symptoms may be treated with venlafaxine tablets or
capsules (Bandelow et al., 2022). Patients begin with 75mg/day
and gradually increase their dosage to 375mg/day (Bandelow et
al., 2022). Therefore, it is recommended that the patient take
Venlafaxine 75mg/day ER 1 Tablet twice a day by mouth for
one month. The dose will be increased at the next appointment.
Patient Education:
1. To abstain from the use of cannabis and drinking alcohol.
2. Exercises can improve treatment outcomes for many
depressed patients (SAMHSA, 2021). Encouraged the patient to
have regular exercises, yoga, and meditation.
3. Encouraged to get enough sleep
4. Encouraged to eat a healthy diet (SAMHSA, 2021).
Referral: Referred to a physiotherapist
Follow-up: Return in 14 days for reevaluation, or sooner if
symptoms worsen.

7. Evidence-Based Practice
Introduction
I have chosen this soap note about mental health because there
has been an evident rise in mental health problems on college
campuses over the past few years. This trend is considered to be
a major mental health crisis that calls for quick intervention.
Depression, anxiety, and other forms of behavioral and
cognitive disorders are all part of one's mental health. Students
in their twenties are at especially high risk for developing many
of the symptoms associated with mental illness. This paper
covers three evidence-based articles and practices for
diagnosing, preventing and treating common mental health
issues, which include insight meditation, stress management,
acceptance and therapeutic intervention, behavioral therapy, and
counseling.
Evidence-based articles:
· Dubovsky, S. L., Ghosh, B. M., Serotte, J. C., & Cranwell, V.
(2021). Psychotic depression: Diagnosis, differential diagnosis,
and treatment.
Psychotherapy and Psychosomatics,
90(3), 160–177. https://doi.org/10.1159/000511348
· SAMHSA. (2021).
Prevention and treatment of anxiety, depression, and
suicidal thoughts and behaviors among college students.
https://archive.hshsl.umaryland.edu/handle/10713/16957
· Selph, S. S., & McDonagh, M. S. (2019). Depression in
children and adolescents: Evaluation and treatment.
American Family Physician,
100(10), 609–617.
https://www.aafp.org/pubs/afp/issues/2019/1115/p609.html
Diagnosis
To make a diagnosis of major depressive disorder, the DSM-

8. 5 criteria must be met (Selph & McDonagh, 2019). These
criteria cannot be explained by drug abuse, medication use, or
any other medical or mental condition (Selph & McDonagh,
2019). When a teen tests positive on a formal screening
instrument or appears with symptoms suggesting a possible
depression, the healthcare professional is recommended to
determine whether the complaints are due to a severe depressive
state or another ailment that could manifest with comparable
symptoms. In some cases, medical illnesses such as anemia,
autoimmune illness, or vitamin deficiency can mimic the
symptoms of depression (Selph & McDonagh, 2019). In order to
rule out other medical disorders that could be confused for
depression, a complete blood count or thorough metabolic
profile panel can be beneficial.
Risk factors
In the 10-24 age group, suicide is the second greatest cause of
mortality after unintentional injury (Selph & McDonagh, 2019).
There is a link between depression and suicide, but young
people who are at risk may go unnoticed until they undergo
suicide screening (Selph & McDonagh, 2019). Therefore, these
studies have advocated appropriate interventions to prevent
suicides.
Management
For mild depression that may not last long, active support like
counseling and pharmacotherapy treatment options, helping the
patient take care of their own depression is firstly recommended
before starting pharmacotherapy (Dubovsky et al., 2021).
Depressive symptoms can often be alleviated through physical
activity, and numerous studies have found this to be effective in
achieving this goal (Dubovsky et al., 2021). Participation in
organized exercise has shown potential for relieving depressive
symptoms. Exercise and depression have been linked since the
early 1900s by scholars (Selph & McDonagh, 2019). Case
studies conducted in the past concluded that exercise of
moderate intensity should be useful for depression and should
result in a happy mood for some individuals. As a result of

9. these studies, that is why we recommended the patient practice
regular exercises and refer him to a psychotherapist.
Holistic Approach
A holistic approach to mental healthcare aims to treat the whole
person, not just the disease symptoms, rather than just the
disease itself (Hughes et al., 2021). Mental health professionals
that use a holistic approach to patient care will take a step back
to get a more comprehensive picture of their patient's overall
health (Hughes et al., 2021). Health care providers need to be
aware of a patient's lifestyle and relationships to better treat
them. Before developing a care plan, it is crucial to comprehend
the interrelationships between all physiological systems and
lifestyle factors (Hughes et al., 2021). As part of a
comprehensive approach to mental health, the patient, family,
and community are also supported.
Holistic mental health care offers various advantages to
patients. For instance, some individuals with mental health
concerns may also feel anxious and have insomnia, exhaustion,
and other health problems (Hughes et al., 2021). The treatment
process can become more challenging when these physical
health problems are accompanied by a mental health condition.
Addressing these additional health concerns concurrently
improves patient outcomes in each of these areas.
Other patient advantages of a holistic mental health approach
include dietary and physical exercise enhancements. These
modifications can aid in reducing anxiety, sleeplessness,
sadness, and mood swings (Hughes et al., 2021). Utilizing a
patient's thinking as a healing tool. This is accomplished by
assisting patients in reframing how they see, understand, and
respond to specific circumstances and stimuli. This can be as
successful as psychotropic medication administration. Educating
how to deal with stress. Typically, stress is a cause of a variety
of mental health issues (Hughes et al., 2021). In addition to
being crucial for a patient's overall improvement in health,
stress management plays a crucial role.
Patients can also get many benefits from taking a holistic

10. approach to psychiatric care, which includes paying attention to
how they take care of their spiritual selves. Studies have shown
that a strong sense of spirituality fosters self-esteem, enhances
motivation, and assists individuals in making meaning of
intense interior experiences (Hughes et al., 2021). According to
medical studies, spiritual persons engage in fewer self-
destructive activities such as drug and alcohol abuse, gambling,
and taking unnecessary risks.
Examples How to Collaborate with the Patient's Family and
Other Members and Cultural Factors.
For best care in these complex conditions, both patients and
physicians must be involved in which we involved the patient
and our clinical team, whereby we refer the patient to a
psychotherapist to help the healing (Bombard et al., 2018).
Clinicians provide information and recommendations based on
their scientific knowledge of therapy and intervention options,
as well as their knowledge of prospective outcomes (Bombard et
al., 2018). We should have involved the family and cultural
considerations because it has the first-hand experience with the
benefits and drawbacks of various treatments in light of the
patient's unique set of circumstances and preferences (Bombard
et al., 2018). To choose the appropriate care choice, it is
necessary to gather data from both sources.
Patient-centered treatment does not entail agreeing to every
request. An important part of this process is to interact with the
patient and develop an open line of communication about the
information that is available as well as the decisions that will be
made (Bombard et al., 2018). There are many factors that go
into providing patient-centered care, and it can be difficult and
time-consuming to include everyone who has a stake in the
patient's well-being in that process.
Jean Watson Caring Process Considering our Patient
Jean Watson suggests that compassion regenerates vital energy
and bolsters our capacities (Wei & Watson, 2019). The benefits
are immense and promote both personal and professional self-
actualization. We must also remember that Watson highlights

11. the importance of taking care of oneself in order to take care of
others; self-healing is an essential step for restoring our vitality
and recharging our mental bank (Wei & Watson, 2019). Taking
care of others is a win-win situation for everyone involved:
patients, families, and health caregivers. As a result, we
believed that showing compassion to the patient and
encouraging him to care for himself as a form of self-healing
could help him generate vital energy.
Representative of a Holistic Approach to Our Patient
As a representative of a holistic approach, we used treatment
strategies focusing on energy or movement-based, biological, or
anchored in functional nutrition. We implemented dietary
modifications and nutritional supplements as a change in
lifestyle; we encouraged mind-body exercises like yoga and tai
chi, physical exercise, discussion, art, and massage treatment.
We also involved other clinicians as part of this therapy
whereby we referred our patient to a psychotherapist. In
addition, we should have included the family in the therapeutic
planning process.
In conclusion, both psychotherapy and antidepressants are
common forms of treatment for depressed teens. We also used
the holistic approach strategies, which took everything into
account. Our plan focused on mental, emotional, physical,
spiritual, and social health. We thought that one plan could not
work without the other. That is why, in addition to
pharmacotherapies, we also used exercise management and
counseling. Exercise's antidepressant effects are still up in the
ability to reduce symptoms of depression. During exercise
implementation, follow-up interaction may also be necessary.
Henceforth, motivation and encouragement for exercise activity
can be greatly enhanced.
References
Bombard, Y., Baker, G. R., Orlando, E., Fancott, C., Bhatia, P.,
Casalino, S., Onate, K., Denis, J.-L., & Pomey, M.-P. (2018).
Engaging patients to improve quality of care: a systematic

12. review. Implementation Science: I.S., 13(1).
https://doi.org/10.1186/s13012-018-0784-z
Dubovsky, S. L., Ghosh, B. M., Serotte, J. C., & Cranwell, V.
(2021). Psychotic depression: Diagnosis, differential diagnosis,
and treatment.
Psychotherapy and Psychosomatics,
90(3), 160–177. https://doi.org/10.1159/000511348
Hughes, S., Rondeau, M., Shannon, S., Sharp, J., Ivins, G., Lee,
J., Taylor, I., & Bendixsen, B. (2021). A holistic self-learning
approach for young adult depression and anxiety compared to
medication-based treatment-as-usual. Community Mental Health
Journal, 57(2), 392–402. https://doi.org/10.1007/s10597-020-
00666-9
Kalin, N. H. (2020). Substance use disorders and addiction:
Mechanisms, trends, and treatment implications.
The American Journal of Psychiatry,
177(11), 1015–1018.
https://doi.org/10.1176/appi.ajp.2020.20091382
SAMHSA. (2021).
Prevention and treatment of anxiety, depression, and
suicidal thoughts and behaviors among college students.
https://archive.hshsl.umaryland.edu/handle/10713/16957
Selph, S. S., & McDonagh, M. S. (2019). Depression in children
and adolescents: Evaluation and treatment.
American Family Physician,
100(10), 609–617.
https://www.aafp.org/pubs/afp/issues/2019/1115/p609.html
Wei, H., & Watson, J. (2019). Healthcare interprofessional team
members' perspectives on human caring: A directed content
analysis study. International Journal of Nursing Sciences, 6(1),
17–23. https://doi.org/10.1016/j.ijnss.2018.12.001Cabral, M. D.
I., Liu, S., & Soares, N. (2020). Attention-deficit/hyperactivity

13. disorder: diagnostic criteria, epidemiology, risk factors and
evaluation in youth.
Translational Pediatrics,
9(Suppl 1), S104–S113.
https://doi.org/10.21037/tp.2019.09.08
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