12.1. Sarah O’Neil iHuman Patient

Complete a SOAP note for the patient using the SOAP note template as a guide. The SOAP note should NOT be in a table format. This assignment should be done in a single-spaced Word document.

Chief Complaint: Depression. “I’ve been so sad almost every day for the past month”

History of Present Illness: Sarah is a 25-year-old married female who was referred by her PCP for evaluation of her depression after a medical evaluation negative for organic causes. Sarah initially presented to PCP after encouragement from her boss for evaluation due to crying episodes at work and decreased work performance. Sarah reports feeling sad daily for the past month and sad “every minute of the day” for the past two weeks. She endorses suicidal ideation but states she would not act on it due to her family and faith. She is experiencing some paranoid ideation and believes her co-workers are trying to get her fired. Additionally, Sarah reports going days without sleeping approximately 6 weeks ago, trying to write a novel, and behaving in a manner that was distinctly out of character for her. She went out alone to a bar, contemplated engaging in an extramarital affair, almost left with a male stranger, and became black-out drunk. Sarah also reports recent weight gain and being unhappy with the way she looks. Her depression is impacting her work and her relationships, putting a strain on her marriage. Sarah reports previous depressive episodes with self-injurious behavior in high school.

Family history significant for mother with schizophrenia and suicide 7 years ago, father with alcohol-use-disorder, and sister with depression.