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Psychiatry Follow-Up SOAP Note

Patient reports that his depressive symptoms have improved but he still feels down at times. He is sleeping better and feels the medication is helping without side effects. Examination shows normal vital signs and affect is improved. Labs are normal. Diagnosis is recurrent major depressive disorder without psychosis. Plan is to continue fluoxetine at current dose and consider increasing after one week if no further improvement, along with continuing counseling and follow up.

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Cordelia Kpaduwa
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863 views1 page

Psychiatry Follow-Up SOAP Note

Patient reports that his depressive symptoms have improved but he still feels down at times. He is sleeping better and feels the medication is helping without side effects. Examination shows normal vital signs and affect is improved. Labs are normal. Diagnosis is recurrent major depressive disorder without psychosis. Plan is to continue fluoxetine at current dose and consider increasing after one week if no further improvement, along with continuing counseling and follow up.

Uploaded by

Cordelia Kpaduwa
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd

Psychiatry follow-up SOAP note

1 week from inpatient care

S- Patient states that he generally has been doing well. Depressive symptoms have improved but he still feels
down at times. He is sleeping better, achieving 7-8 hours of restful sleep each night. He feels the medication is
helping somewhat and without any noticeable side-effects. He has no suicide plan and has not thought about
suicide since the recent attempt. He has no access to prescription medications, other than the fluoxetine. He
believes the classes he participated in while inpatient have helped him with coping mechanisms. He has also
coordinated individual counseling with his case manager.
O- Vitals: T 98.4, P 82, R 16, BP 122/78
General: alert and oriented to person, place, and time. Affect is significantly improved with good range
of emotional expression.
Heart- RRR, no murmurs, no gallops
Lungs- CTA bilaterally
Skin- no lesions or rashes

Labs: CBC, lytes, and TSH all within normal limits

A- Major Depressive Disorder, recurrent, without psychotic features

P- Continue Fluoxetine at 10mg dose. If no further improvement in the next week, we will consider increasing
dose to 20mg. Continue outpatient counseling. Follow-up in one week or earlier if any depressive symptoms
worsen.

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