Soap note rubric and sample attached

Any case of mental health adults


SOAP Note: 48-year-old Hispanic Female with Depression with Psychotic Features

Roxana Orta

Florida Atlantic University


SOAP Note: 48-year-old Hispanic Female with Depression with Psychotic Features


MM is a 48-year-old, divorced, a Hispanic female who was brought to the clinic by her son after

been discharge two days ago from a crisis unit after an episode of psychosis.


“Feeling that the FBI is following me, and my parents want to poison me.”


Patient reports that her 67-year-old mother was born in Cuba, she emigrated to the United States

a year ago with her father. Her mother completed high school, and is not currently working; she

does not speak English and relies solely on the patient’s income for support. Mother does have a

history of hypertension and rheumatoid arthritis, also reports a history of depression, which the

patient’s called “un Estado de nervios.” Patient’s 69-year-old father completed high school and

worked as a mechanic in his native country, and he is not currently working because he is

waiting for his work permit. He has a medical history of hypertension, obesity, and benign

prostate hypertrophy. Patient’s father does not have an account of substance or mental health

problems. However, he smokes a pack of cigarettes daily. A patient has one sibling, a younger

sister who was still living in Cuba; her sister is healthy and has no history of substance abuse or

mental health problems. The patient also reports that in her mother side, two of her aunts

suffered from postpartum depression, as well as one of her cousins. She also states that two of

her uncles were alcoholic. In her father side, the patient reports a history of substance abuse by

two of her paternal uncles.



Patient reports having no birth issues, she was born a standard delivery, full term, and with no

complications. The patient also reports completing all the milestones, doing well in school. She

states that the only issues growing up were her father incarceration for ten years as a political

prisoner, which was very traumatic, and she became very fearful after that. Since that time, she

has never been able to speak up her mind. She states,” I rather don’t say anything, even when I

know it is not right.”


The patient does not have health insurance, and the last time she saw a physician was when she

did physical for her employment. Her immunizations are up to date, and she does not have either

a food or medication allergy. She has a history of endometriosis, what she states, “it resolved in

her mid-thirties.” She also injured her back a year ago, and she said that she received injections,

but she does not know the name of the medication. She denies any other problems, except for

occasional cold and sore throat. Which is treated with over the counter medications. Otherwise,

she has never hospitalized, except during childbirth, which was standard delivery. Currently, the

patient is taking multivitamins and sleepy time tea. She has not had a mammography or PAP

smear in the last five years. Her laboratory results show microcity anemia and slightly elevated

LDL. Laboratory results on admission to her hospitalization included thyroid-stimulating

hormone, and thyroxine were all within reasonable limits. Her blood pressure and weight are

within normal limits.



Patient shares a two-bedroom apartment with her mother and father. She reports been married for

two years to the father of her son. Since that time, she has not had any romantic relationships or

sexual relationships because her life was dedicated to her son. She has no friends currently, only

some coworkers whom she frequents. Patient states, “I work from 7 AM to 11 PM, I have to

support my family, I have no time for friends”, She denies having any hobbies or interest. She

enjoys watching Spanish television. She does not smoke, drinks alcohol, or consume any illegal

substances. Patient denies any history of legal problems. Patient only son is a 19-year-old college

student who accompanies the patient to this evaluation. She reports having a great relationship

with her son and that his living to school has been very hard on her.


The patient is a high school graduated, with no history of military service, and has a nursing

assistant certificate. She has two jobs, and she states,” the situations are very demanding, I have

two expend most of the time bathing patients and feeding them.” I have been working steadily

for the past two years without a vacation or a weekend off”. Patient reports that due to her recent

hospitalization, she has reduced her work hours to 40 hours a week.


Patient denies any history of outpatient or psychiatric hospitalization before the admission

described above. She was discharged two days ago from the crisis unit. She was started in

Risperdal 2 mg. At bedtime, Trazodone 100 mg PO HS, and citalopram 20 mg. In the AM.

Patient reports having an episode of depression right after the birth of her son, she denies having

any treatment or follows up for the incident. She states” after giving birth to my son, I felt sad,


tired and had weird thoughts, for months I did not feel any happiness, it lasted about two years,

then it went away.” No history of suicidal or assaultive behavior.


Patient reports feeling nervous since her son left for college back six months ago. In the last three

months, her sleep deteriorates to the point that she was only sleeping for two or three hours at

night.Two weeks ago, after working in the night shift, she thought that people were following

her, she saw lights everywhere and became very frightened. She also reports at that time starting

hearing voices telling her that the FBI was after her. The patient also has lost about 10 pounds,

because she believed that her parents want to poison her. She states,” I was so scared that I

decided to drive my car against a tree.” Patient reports that the symptoms were so frightening

that she stopped her car in the middle of the road and asked a policeman for help. Son says that

his mother has been experiencing lack of sleep and mood swings since moving to the United

States about five years ago. Son reports his mother works all the time, and that at times she

becomes irritable and distant. PHQ-9 was administered, and her score was 25, which indicates

“severe depression.”


a) Anxiety: Anxious, worried, feeling restless, and experiencing muscle tension.

b) Mania: Patient denies periods of increased energy. However, she reports feeling irritable

most of the time.

c) Depression: Reports feeling of sadness and loneliness, unable to concentrate, with lack of

appetitive, sleepless, and with no motivation of joy about anything, she states feeling guilty

about getting sick, she is worried about her parents and son, no pleasure in activities, having


problems with sleep and having issues with eating. Trouble is concentrating most of the days

and having suicidal thoughts. She reports feeling hopeless.

d) Schizophrenia: patient reports hearing command hallucinations. She denies visual

hallucinations but reports that the voices started recently.

e) Panic attacks: No panic attacks reported.

f) PTSD: Patient denies flashbacks, recurrent dreams, or repetitive thoughts about her father,


g) OCD: Denies any anxiety relieving repetitive behaviors.

h) ADHD: Denies any history of inattention or hyper


i) Eating disorders: weight loss experience due to lack of appetite, denies any purging or


j) Personality Disorders: Patient denies a pattern of troubled relationships. She wants to

establish new connections, but she is too preoccupied with her family problems.


a) Appearance: Good grooming and overly dressed for the weather. Good eye contact and

cooperative with the assessment.

b) Behavior and psychomotor activity: No abnormal movements noted

c) Consciousness: Fully alert.

d) Orientation: To a person, place, time, and date.

e) Memory: Through examination, the patient exhibits no deficits in recent, remote, or

immediate retention memory.

f) Concentration and attention: The patient has no deficits in focus and attention during the

examination. Able to follow direction and repeat the 12 months test backward.


g) Intellectual functioning: Appears to be average or above average. Patient speaks articulately

with an excellent vocabulary and above average fund of knowledge.

h) Speech and language: speech is with average volume, regular rate, and rhythm.

i) Perceptions: Command auditory hallucinations of female voices telling her that the FBI is

after her. The FBI wants her fingerprints. However, she understands that those are symptoms

of her disease.

j) Thought processes though is coherent and goal-directed, organized and linear. However,

reports racing thoughts.

k) Thought content: Paranoid delusions of others are trying to hurt her. The patient was

experiencing sad thoughts which she can not share with anybody in her family. She states she

hesitates to speak up because of feelings of hopelessness. She says feeling extreme sadness

after her son left for college. However, at the time, she feels angry because it is all her fault.

l) Suicidality or homicidal: Denies current suicidal or homicidal ideation; however, reports

suicidal thoughts.

m) Mood: “Down.” “Depressed.” She feels no pleasure in life.

n) Affect: Appears depressed, tearful, and anxious.

o) Judgment: Fair wants to go back to work, feels

p) Insight: Fair, understands the present mental state.

q) Reliability: Generally, it seems to be a good historian.


48-year-old Hispanic female with a family history of depression and a personal account of

untreated postpartum depression. Who now presents with auditory hallucinations, paranoid

thinking, sleep disturbances, and loss of interest in daily activities that were aggravated by son


moving to college and working in multiple jobs for about 16 hours a day. Patient under a lot of

stress due by her economic situation, she feels responsible for her parents and son. Patient

presentation is consistent with a recurrent Major depression disorder with psychotic features. The

treatment will be the focus on helping her and her family to decrease the patient stressors, such

as working long hours and loneliness. Psychotic symptoms are associated with numerous social

factors, such as migration and urban upbringing. Isolation is related to positive traits and

depression. Symptoms of paranoia, precisely the impression that other people are giving odd

looks and that other people are not what they seem to be related to loneliness (Jaya, Hillmann,

Reininger, Gollwitzer & Lincoln, 2017). Psychotic symptoms in depression are often associated

with poor social functioning (Sönmez et al., 2016). The patient does not have a social network,

and she does not participate in any leisure activities.

Furthermore, the patient needs to be monitored further some of her symptoms correlated with

bipolar disorder mixed type. Jääskeläinen et al. (2018) systematic review found that psychotic

depression first episode is a marker of later bipolar disorder. Sleep is another issue that needs to

be addressed since sleep is associated with psychotic symptoms and worsening depression

(Koyanagi & Stickley, 2015).


296.34 (F33.3) Major depressive disorder, severe, recurrent episode with psychotic features

According to the DSM5 (American Psychiatric Association, 2013). Patient presents with

more than five of the following symptoms:

1. Depressed mood most of the day, nearly every day, as indicated by either subjective

report (feelings sad, hopeless).


2. Markedly diminished interest or pleasure in all, or almost all, activities most of the day,

nearly every day.

3. Feelings of worthlessness or excessive or inappropriate guilt (which may be delusional)

nearly every day.

4. Recurrent thoughts of death, recurrent suicidal ideation without a specific plan, or a

suicide attempt or a specific plan for committing suicide.

5. The symptoms cause clinically significant distress or impairment in social, occupational,

or other critical areas of functioning.

6. Unreasonable feelings of self‐reproach or excessive and inappropriate guilt.

The patient reports a depressed mood for most days over the past six months. She has

experienced a loss of interest in usual activities and long-standing impairment in social

functioning. She reports having problems with vegetative symptoms such as sleeping, changes in

appetite, most of the days, as well as the loss of energy and low self-esteem (Rice et al., 2019).

These symptoms are causing impairment in functioning as evidenced by an inability work.

Furthermore, results of the PHQ-9 shows a score of 25, which indicates “severe depression.”


296.80 (F31.9) Unspecified bipolar and related disorder

The diagnosis of Bipolar disorder should be considered. According to Grande, Berk, Birmaher &

Vieta (2016) psychosis, depression is a marker of bipolar depression. A history of postpartum

depression is also a risk factor for bipolar disorder. Vieta et al. (2018) also recommend

considering this diagnosis until more information is gathered.

F29. Unspecified Schizophrenia Spectrum and Other Psychotic Disorder


This diagnosis refers to symptoms that are typical of schizophrenia (e.g., delusions,

hallucinations, disorganized thinking and speech, catatonic behavior), that cause substantial

social and occupational distress and impairment, but that do not meet the full criteria for any

specific disorder. For example, a patient may have persistent auditory hallucinations with no

other symptoms, thus not meet the criteria for schizophrenia, which requires two psychotic

manifestations (American Psychiatric Association, 2013).

Psychosocial and environmental factors: Patient symptoms may interfere with her

employment functioning. Furthermore, patient symptoms interfere with physical and social



Safety: Safety preauction because of the risk of suicidality. The anhedonia displayed by this

patient makes the possibility of suicidality. Gabbay et al. (2015) found that anhedonia severity

was associated with more severe clinical outcomes, including higher suicidality scores. This

patient has been depressed for over six months. If her depressive state lasts long, the patient may

start contemplating suicide. (Grande, Berk, Birmaher, & Vieta 2016).

Pharmacological treatment: Patient will continue with Risperdal 2 mg. At bedtime, citalopram

20 mg, and Trazadone 100 mg. At bedtime, the Patient will come back in four to six weeks for

medication management. However, Thompson, Malhotra & Rothschild (2019) evidence-based

review recommends an antidepressant and antipsychotic medication in combination. Preferably,

a combination of fluoxetine and olanzapine. The combination of an antidepressant and

antipsychotic is significantly more effective than either antidepressant monotherapy or

antipsychotic monotherapy for the acute treatment of depressive psychosis.


Psychoeducation: Patient will receive education regarding indication for medication and risks,

benefits, and potential side effects of citalopram due to the risk of suicidality. Provide training on

the FDA Black Box warning about the increased risk of suicidality-associated antidepressant

medications (Cipriani et al., 2016).

Mindfulness and Relaxation: At this patient will benefit from mindfulness and relaxation, and

the patient recognizes that her medication regiment controls her symptoms and her reducing her

stress. The patient was instructed on relaxation and meditation techniques (Moritz et al., 2015).

Referrals: Refer for primary care with recommendations for mammography and Pap smears.



American Psychiatric Association. Diagnostic and statistical manual of mental disorders (5th

Ed). (2013). Washington, DC: American Psychiatric Association.

Cipriani, A., Zhou, X., Del Giovane, C., Hetrick, S. E., Qin, B., Whittington, C., … & Cuijpers,

P. (2016). Comparative efficacy and tolerability of antidepressants for major depressive

disorder in children and adolescents: a network meta-analysis. The Lancet, 388(10047),


Gabbay, V., Johnson, A. R., Alonso, C. M., Evans, L. K., Babb, J. S., & Klein, R. G. (2015).

Anhedonia, but not irritability, is associated with illness severity outcomes in adolescent

major depression. Journal of child and adolescent psychopharmacology, 25(3), 194-200.

Grande, I., Berk, M., Birmaher, B., & Vieta, E. (2016). Bipolar disorder. The

Lancet, 387(10027), 1561-1572.

Jääskeläinen, E., Juola, T., Korpela, H., Lehtiniemi, H., Nietola, M., Korkeila, J., & Miettunen, J.

(2018). Epidemiology of psychotic depression–systematic review and meta-

analysis. Psychological medicine, 48(6), 905-918.

Jaya, E. S., Hillmann, T. E., Reininger, K. M., Gollwitzer, A., & Lincoln, T. M. (2017).

Loneliness and psychotic symptoms: The mediating role of depression. Cognitive therapy

and research, 41(1), 106-116.

Koyanagi, A., & Stickley, A. (2015). The association between sleep problems and psychotic

symptoms in the general population: a global perspective. Sleep, 38(12), 1875-1885.

Moritz, S., Cludius, B., Hottenrott, B., Schneider, B. C., Saathoff, K., Kuelz, A. K., & Gallinat, J.

(2015). Mindfulness and relaxation treatment reduces depressive symptoms in individuals

with psychosis. European Psychiatry, 30(6), 709-714.


Sönmez, N., Røssberg, J. I., Evensen, J., Barder, H. E., Haahr, U., ten Velden Hegelstad, W., …

& Melle, I. (2016). Depressive symptoms in first‐episode psychosis: a 10‐year follow‐up

study. Early intervention in psychiatry, 10(3), 227-233.

Thompson, A. R., Malhotra, A., & Rothschild, A. J. (2019). Advances in the Treatment of

Psychotic Depression. Current Treatment Options in Psychiatry, 6(1), 64-74.

Vieta, E., Berk, M., Schulze, T. G., Carvalho, A. F., Suppes, T., Calabrese, J. R., … & Grande, I.

(2018). Bipolar disorders. Nature Reviews Disease Primers, 4, 18008.

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