Week 4_ case # 1_ instructions

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NRNP/PRAC 6665 & 6675 Comprehensive Focused SOAP Psychiatric Evaluation Template

Assignment Instructions:

Answer with minumun 2 paragraphs each the following questions based in the bellow clinical case:

1. What other additional differential diagnosis is applicable based on the presention symptoms? explain

2. What additional history is required to confirm the diagnosis?

3. What other medications would be applicable in her situation?

** At least 2 references per question**


CC (chief complaint): “I need help, I feel empty and overwhelmed by sadness”.

HPI: Client MM is a 33-year-old Caucasian female who was referred from the women center after she lost a term pregnancy of twins 13 months ago. She presented for a psychiatric evaluation with her husband in attendance. They both looked very sad. She reported that the reason for referral was because she was very depressed after losing her pregnancy and was having suicidal thoughts. She was started on Zoloft 50 mg pod once a day at the women center. She currently denies any suicidal or homicidal ideation. She is feeling intense sadness. Admits to having rumination thoughts. She is still grieving the loss of her pregnancy. Admits that she has not been able to get back to work after the burying her babies remain. She said she has lost interest in doing things she enjoys doing. Admits to have lost her appetite and is skipping meals. She has poor memory and concentration. Denies any distractibility. She has poor sleep, sleeps 4 to 5 hours per night. Patient endorse hopelessness, helplessness and worthlessness, however, she said she is not suicidal at this time. Reports to be anxious. Admits to racing thoughts and mood swing. Admits to nightmares. Denies paranoia, delusions and hallucination. PHQ-9 score 24.

Past psychiatric history: Denies any previous psychiatric history.

Social history: She was born and brought up in New York, they moved to Florida when she was young and went to school in Florida. She is a college graduate. Reports that her childhood was good and had very supportive parents and extended family. She is the first born in a family of four two sisters and one brother. The rest of her sibling lives with their parents. The two sisters work at the post office and the brother who is the youngest is in the navy. She is married and lives with her husband, they have no children together. She reports to have had two previous miscarriages. Reports that they are experiencing marital issues but she does not want to discuss more on that. She works as a technician in a phone company. Her husband is a teacher. Her parents are alive and well.

Family history of Psychiatric illness: Denies any psychiatric illness in her family.

Substance Current Use: Admits to drinking 2 cups of coffee daily, Denies alcohol, tobacco, recreational drug, narcotic pain medication, or steroids use.

Medical History: Hypothyroidism

Current Medications: Zoloft 50 mg p.o o.d

Synthroid 50 mcg
p.o o.d

Medication trials: none

No know drug allergies

Reproductive Hx:
LMP 12/01/2022 She is para 0 Gravida 3


· GENERAL: 138 pounds has lost 40 pounds unintentionally. Height 5’5. No fever, no chills. Admits to feeling weak and fatigued.

· HEENT: Reports to be having occasional headaches, denies any changes with her eye sight, denies any loss of hearing, No sneezing no nasal congestion no sir throat and enlarged thyroid gland.

· SKIN: No skin discoloration and itching

· CARDIOVASCULAR: Denies any chest pain, tightness, or discomfort.

· RESPIRATORY: no shortness of breath


· GENITOURINARY: no burning, hesitancy, urgency or abnormal color.

· NEUROLOGICAL: admits to having frequent headache

· MUSCULOSKELETAL: Denies any muscle, back, joint pain

· ENDOCRINOLOGIC: denies sweating, cold or hot intolerance.


By the end of this presentation the participant will be able to identify the three differential diagnosis this client is presenting with.

By the end of this presention the participant will be able to identify the key symptoms from the mental status examination the lead to the differential diagnosis.

By the end of this presention the participatants will understand the side effects of Zoloft.

Diagnostic results:

· Thyroid function tests: to retrieve result

· Complete metabolic panel: to retrieve result

· Complete blood count to retrieve result


Mental Status Examination:

Client MM is a 33-year-old Caucasian female, who appears older than the stated age. She was dressed in an oversize T shirt and long pants. She was very tearful with red eyes. She had long black hair held in a pony tail. She looked flushed. Had poor eye contact and her eyes were mostly down cast. She appeared underweight. She was restless and kept changing sitting position. Mood was described as depressed. Affect was flat. Her speech was barely audible and slow. Thought process goal directed but with flight of ideas. Thought content: deny any fixed delusion. Perception: Denies auditory and visual hallucinations. Denies any suicidal or homicidal thoughts at the moment. Cognition: short term memory is poor. Had poor abstract reasoning.

Diagnostic Impression:

1. F43.8 Prolonged grief disorder. According to DSM 5-TR, the patient must have experienced the death of a close relation for at least 12 months to meet the criteria for this diagnosis. Client MM lost her term twin pregnancy 13 months ago and is still mourning the loss (American Psychiatric Association, 2022). She is in intense emotional death. She is unable to revenge in her relationship with her husband or engagement; she reports that she has not been able to report back to work. She reports being emotionally numb. Her duration of mourning exceeds the expected social norms. Mechanism of responding to the stress of loss, there is an increased risk of a mental or physical disorder that requires treatment(Simon et al., 2020).

2. F32.2 Major Depressive disorder severe. According to DSM-5-TR, for patient to meet the classification of Major depressive disorder, they must meet the following five or more of the following symptoms, Depressed mood most of the day, diminished interest in doing things one loved doing, weight loss, Insomnia or hypersomnia nearly every day, psychomotor agitation, Fatigue or lack of energy, Diminished ability to think, and recurrent thoughts of death (American Psychiatric Association, 2022). Client MM has more than six of the above symptoms. The symptoms have also caused significant impairment in her social and occupational functioning. She reports that she has not been able to report to work for 13 months since losing her pregnancy.

3. F41.1 generalized anxiety disorders. The diagnostic criteria for GAD, according to DSM-5 TR, is excessive anxiety and worry happening more days than not for over six months (American Psychiatric Association, 2022). Client MM admits to excessive worry and anxiety for over six months. She also admits to having difficulty controlling worry. Admits to restlessness, being tired all the times, difficulty concentrating, and sleep disturbance which are some of the symptoms of GAD in DSM -5-TR


Client MM is a 33 year old female; she is grieving the loss of her term twin pregnancy. She is a para 0 gravida 3. She has lost a term twin pregnancy. She is feeling hopeless. A lot must be bothering her. Her current situation might even affect her marriage? Will the husband want to be in childless marriage? She is anxious about conceiving and experiencing another miscarriage. She seems lost in thought. Her desire is to feel better.

Case Formulation and Treatment Plan:

Discussed with the client available treatment and non treatment options and the benefits of combining psychopharmacology with psychotherapy. Advised the client on the benefits of taking medication as prescribed and not stopping the treatment abruptly. Agreed to increase the dose of Zoloft and monitor after two weeks.

Patient education on the side effects of Zoloft. Zoloft is an antidepressants. Some of the minor side effects include drowsiness, feeling tired, syncope, anxious, abdominal discomfort, nausea, diarrhea, xerostomia, confusion, female sexual disorder, rhinitis and poor appetite (singh & Saadabadi, 2022). It can also cause adverse side effects like convulsions, headache, confusion, memory problems, severe weakness, racing thoughts (singh & Saadabadi, 2022). Discussed with client MM on using a reliable family planning method to prevent getting pregnant when using Zoloft as it has serious effect on the unborn child, in case of pregnancy or planning to get pregnant to contact the provider. Call and report any adverse reaction.

Increased the dose for Zoloft 100 mg p.o o.d

To try Melatonin 10mg for sleep, if no adequate sleep may try other hypnotic agents.

Psychotherapy individual and family

Marital counseling

Review after two weeks

Instructed to call 911 or 988 suicide and crisis lifeline or go to ER if she experiences a danger to self or others


American Psychiatric Association. (2022). Depressive disorder. In American psychiatric association (Ed.),
Diagnostic and statistical manual of mental disorders Fifth edition text revision DSM-5-TR (5th ed., pp. 177–214). American Psychiatric Association.

Karrouri, R., Hammani, Z., Benjelloun, R., & Otheman, Y. (2021). Major depressive disorder: Validated treatments and future challenges.
World Journal of Clinical Cases,
9(31), 9350–9367.


Simon, N. M., Shear, M., Reynolds, C. F., Cozza, S. J., Mauro, C., Zisook, S., Skritskaya, N., Robinaugh, D. J., Malgaroli, M., Spandorfer, J., & Lebowitz, B. (2020). Commentary on evidence in support of a grief related condition as a DSM diagnosis.
Depression and Anxiety,
37(1), 9–16.


singh, H. K., & Saadabadi, A. (2022).
Sertraline. Statpearls publishing.

© 2021 Walden University

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