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Focused Soap Note on Major Depressive Disorder in a young adult
Student Name:
College of Nursing-PMHNP, Wilkes University
NSG-535
Assignment Due Date:
, NRNP/PRAC 6665 & 6675 Comprehensive Focused SOAP Psychiatric
Evaluation Template
Subjective:
CC (chief complaint): “I have been experiencing insomnia, anger outbursts and have no interest
in studies or work for the past 2 weeks”.
HPI: David Arve, a 23-year-old male presents with persistent symptoms of difficulty sleeping
and constant irritation. D.A reports that he can’t seem to get moving and struggles to concentrate,
especially in class and at work. He also states that he has experienced suicide ideation and fears a
repeat of his previous episode characterized with self-harm and attempted suicide. D.A has
discontinued his medication since the onset of depressive symptoms.
D.A is concerned about his upcoming examinations and failed assignments since his
health condition has highly affected his school attendance and academic performance. He also
reports loosing his job due to absenteeism and incompetency. In addition, the patient notes that
he has dropped out of his weekly soccer games which he previously enjoyed bonding over with
friends. He also reports loosing interest in social interaction and prefers staying indoors alone.
He has also cut off most of his friends and classmates who make efforts to reach out to him. D.A
notes starting unecessary arguments with his family members and constant involvement in anger
outbursts on the slightest provocation. The patient’s mother reports failed efforts to convince him
to seek medical attention until the patient hurt his sibling over a slight argument. The patient’s
health condition has a significant impact on his daily life and that of his close family members
and friends. D.A states, “I need to go back to normal”. The mother hopes to establish an effective
intervention to help D.A cope with examination pressure and resume his normal life.
Page 2 of 13
Focused Soap Note on Major Depressive Disorder in a young adult
Student Name:
College of Nursing-PMHNP, Wilkes University
NSG-535
Assignment Due Date:
, NRNP/PRAC 6665 & 6675 Comprehensive Focused SOAP Psychiatric
Evaluation Template
Subjective:
CC (chief complaint): “I have been experiencing insomnia, anger outbursts and have no interest
in studies or work for the past 2 weeks”.
HPI: David Arve, a 23-year-old male presents with persistent symptoms of difficulty sleeping
and constant irritation. D.A reports that he can’t seem to get moving and struggles to concentrate,
especially in class and at work. He also states that he has experienced suicide ideation and fears a
repeat of his previous episode characterized with self-harm and attempted suicide. D.A has
discontinued his medication since the onset of depressive symptoms.
D.A is concerned about his upcoming examinations and failed assignments since his
health condition has highly affected his school attendance and academic performance. He also
reports loosing his job due to absenteeism and incompetency. In addition, the patient notes that
he has dropped out of his weekly soccer games which he previously enjoyed bonding over with
friends. He also reports loosing interest in social interaction and prefers staying indoors alone.
He has also cut off most of his friends and classmates who make efforts to reach out to him. D.A
notes starting unecessary arguments with his family members and constant involvement in anger
outbursts on the slightest provocation. The patient’s mother reports failed efforts to convince him
to seek medical attention until the patient hurt his sibling over a slight argument. The patient’s
health condition has a significant impact on his daily life and that of his close family members
and friends. D.A states, “I need to go back to normal”. The mother hopes to establish an effective
intervention to help D.A cope with examination pressure and resume his normal life.
Page 2 of 13
