Ms. A.B., a 39-year-old Hispanic female, presents for a psychiatric medication follow-up

Case Study – Depression
This assignment tasks you with synthesizing the clinical encounter of a 39-year-old female follow-up visit using a structured SOAP note format focused on the Subjective, Objective, and Assessment sections. Use the SOAP Psychiatric template provided in the assignment resources below to assist with this assignment.

Read the provided case study of a 39-year-old female (Ms. A.B.) attending a psychiatric medication follow-up. Using the OLDCARTS-Psychiatric template, craft the Subjective (S) and Objective (O) and Assessment (A) sections in paragraph form with clear headings.

Instructions
Scenario:

Ms. A.B., a 39-year-old Hispanic female, presents for a psychiatric medication follow-up. Ms. A.B. is a recently divorced female, works as an Attorney, and resides alone. She reports experiencing a persistent low mood for several years, which has recently intensified. She describes her mood as “a bit better,” but still experiences “waves of sadness” that occur 2–3 times a week, lasting several hours. These episodes are not associated with specific triggers and are not accompanied by significant changes in appetite or weight. She reports occasional difficulty sleeping, particularly with early-morning awakenings around 4–5 a.m., twice weekly, and experiences mild psychomotor sluggishness in the afternoons. Her concentration is intermittently impaired, especially in the late afternoon, and she occasionally feels self-blame about productivity but denies pervasive guilt.

Ms. A.B. denies any history of mania, psychosis, or suicidal ideation. She has been prescribed sertraline 50 mg daily for the past six weeks, with a partial response noted. Her PHQ-9 score has decreased from 16 to 10, indicating moderate depression. She has no significant medical history and reports no substance use except for occasional social drinking. She lives alone, works full- time in marketing, and has a supportive social network.

Mental status examination reveals a congruent affect with a subjective report of feeling “a bit better,” though she describes her mood as “flat.” Thought processes are logical and coherent, with no evidence of delusions or hallucinations. She denies auditory or visual hallucinations. Cognitively, she is alert and oriented to person, place, and time. Her concentration is mildly reduced, particularly in the late afternoon. Insight and judgment are intact, and she demonstrates good awareness of her treatment needs.

Regarding safety, Ms. A.B. denies current or past suicidal ideation and reports no access to firearms. She has a supportive network of friends and family and is independent in the activities of daily living. Screening tools administered include the PHQ-9, which decreased from 16 to 10, indicating moderate depression, and the GAD-7, which scored 8, suggesting mild anxiety.

Physically, her vital signs are stable: blood pressure is 118/76 mmHg, heart rate is 72 bpm, respiratory rate is 16 breaths/min, temperature is 98.6°F, and oxygen saturation is 98% on room air. Laboratory results, including CBC, CMP, and TSH, are within normal limits.

She has been prescribed sertraline 50 mg daily for the past six weeks, with partial response noted. She denies any known drug allergies and reports no significant medical history. Ms. A.B. lives alone, works full-time in marketing, and has a college education. She denies tobacco, illicit drug, or alcohol use.

Assignment Resources
Use the following resources to help with this assignment:

SOAP Psychiatric Follow-up Download SOAP Psychiatric Follow-up[PDF]
Submit
Ensure your documentation
Reflects changes over time (e.g., “PHQ9 reduced from 16 to 10”).
Notes denials of psychosis (auditory/visual hallucinations) and suicidal ideation
Remains clear, concise, and clinically appropriate.
Length & Format: 3 – 5 pages
Word Document

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