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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.

HP: Patient states that he has not been feeling the same over the past few weeks. e has nodesire to complete daily activities and does not want to get !p o!t of bed. Patient stays that he is

always tired. e can not think of any life changes that occ!rred prior to this change in behavior.

"othing increases his energy levels or makes him feel better. #he patient complains of no pain.

is mother believes that he needs to have his medication switched to $ele%a beca!se that is whatshe takes for her depression.

Allergies& "'A

Current !ediation& (ffe%or )*mg +-.

Childhood llnesses !edical " Surgical& +roken right tibia as a child.

Psychiatric& -epression

Health !aintenance# mmuni$ations: mm!ni/ations !p to date. ealth maintenance not

addressed.

%amily History:Mother -epression, 0ather eart disease, and only child.

Social History:Patient lives with his mother and his a!nt and !ncle. #he patients father doesnot live with the patient or have m!ch comm!nication with him. #hey share one car between the

fo!r of them. #he patient does not drink alcohol or !se dr!gs.

&'ercise " iet& "ot assessed.

Safety !easures& ears seat belt. "o g!ns in the ho!sehold.

OS: -enies headache, weight gain or loss sleep dist!rbances, g!ilt, change in memory, changein speech, no deliri!m, psychomotor retardation or agitation. Patient complains of fatig!e, loss of

appetite, interest deficit, concentration deficit, and worthless. Mother reports that the patient hasbecome increasingly short tempered. Patient has not attempted s!icide previo!sly, b!t has a plan

to c!t his wrists. e states that he is not tried it before beca!se he does not like blood. Patient

does not have any homicidal tho!ghts.

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O (Objective)*Physical &'am

+S +P& 112342, 5& 24, 55& 14, #emp 62.4, weight& 1)1, height& 4 inches, +M& .

Mr. A is alert, awake, oriented % 8. Patient is clean and dressed appropriate for age. 0lat affect,

an%io!s, depressed, withdrawn, and responses to 9!estions are e%tremely short. Patient tho!ghtprocesses and content are abnormal with s!icidal tho!ghts and a plan. Patient insight into mental

stat!s changes in intact, accepts :!dgment. ;peech and lang!age is clear and !nderstandable. "o

flight of ideas, obsessions, comp!lsions, del!sions, ill!sions, or hall!cinations.

A (Assessment)

Problem ,- $hange in mental stat!s.

!ost .i/ely iagnosis: -epression along with s!icidal ideations. #his diagnosis was chosen

beca!se the patient has m!ltiple risk factors incl!ding c!rrent s!icidal plan, availability of lethal

means, and male gender.

P (Plan)

0esting:"one.

0herapy*0reatment: mmediate 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 ho!se when they ret!rn home. #he patient made

a verbal contract that he will not harm himself.

&ducation: ;!icide is the 18th leading ca!se of death worldwide, with abo!t 1 million deaths

every year d!e to self