SOAP 1 Response
2 days ago 8
SOAP1RESPONSE.docx
SOAP1RESPONSE.docx
SOAP 1 RESPONSE: 250 WORDS with references- Strong, recent (5-7 years), scholarly, peer- reviewed support of topics. No grammar, spelling, and punctuation errors.
Client: CJ
Date: 09/03/2026
Session Type/Length: Complete Evaluation/Intake, 11:00 a.m.–12:00 p.m. VIA telehealth
Duration: 60 minutes
Subjective:
Chief complaint: Patient states that she is having anxiety and depression.
Patient is a 23-year-old Caucasian female reporting that she is experiencing anxiety and depression from a traumatic car accident that she causes six years ago when she was 17 years old when she ran a red light. She reports that people were significantly injured. She reported that this has left her feeling emotionally drained and has altered her life. She describes feelings of feeing not good enough and inadequate. She says that in her first year of college she failed every class for two semesters straight. Before the accident she excelled in school. She says that there are repeated thoughts of self-blame, thinking about the other accident victims and the grief over perceived loss. She reports that the anniversary of the accident was recent and discussing it in therapy today took a toll on her emotionally. She says that she has been suppressing the accident and feels like she has not fully processed the totality of the accident and that it is taking a toll on her mentally.
CJ reports that she has been having worsening depression. She is in an accelerated nursing program and although she was doing well in the program, she says that she has failed two validations during this most recent term despite multiple attempts. She says after failing she has had increasing self-doubt, crying for prolonged periods of time and feeling that she may not be good enough to be a nurse. She says that she feels isolated and does not have family support from her parents because they did not attend college and her mother advised her to get help.
She states that she has difficulty concentrating while she is driving and in school. She says that sometimes she has to pass the intersection where her car accident was and she has flash backs and questions as should she still be driving. She reports she didn’t drive for two years after the accident. She says that her energy level fluctuates and she feels more lows than highs. She says that her sleeping cycle is off due to the demands of the nursing program that she is in. She reports no nightmares
CJ reports that from the age of 19-22 she smoked marijuana daily; she says that smoking went from recreational to being emotionally dependent. She continues to smoke at least three or four times a week now and would smoke more if she was not in school. She expressed a desire to quit smoking and described it as entering substance use disorder territory. CJ reports state her mom has poor mental health and on her father side there is a history of substance abuse and neither has a formal diagnosis.
Past Medical History: Diabetes type 2, depression
Allergies: NKDA
Medications and Supplements:
Metformin--Prescribed for type 2 diabetes—has not taken in the last 6 months, plans to reevaluate with her primary care doctor
Sertraline 25mg, 1 tablet daily for depression- has not taken in the last 6 month
Objective:
Appearance: Patient appears to be well groomed; eye makeup observed.
Behavior: Patient was cooperative, engaged and talkative. Speech was a normal pattern and was willing to elaborate on sensitive topics without hesitation.
Mood: Describes feeling sad, depressed most days but there are days with happiness. Reports self-doubt, not feeling worthy, feeling overwhelmed and having the world on her shoulders.
Affect: Affect appears broad in range, becomes visibly and verbally emotional when discussing the car accident 3 years ago. Seem to block certain aspects of the accident out of her mind.
Thought process: CJ is able to provided detailed events chronologically of her personal history, social history and academic history.
Thought content: Denies any suicidal or homicidal ideation but states that she feels inadequate, has past regrets and has a since of failure when she thinks about her future. Compares herself to her peers states she feels like a failure because most of them have started their careers and she is still in school failing test.
Cognition: CJ is oriented and fully alert. Memory intact, able to recall timelines, dates, events. Self-reported difficulties having trouble staying focused in class and while driving.
Insight: CJ acknowledges her mental health difficulties’; states she needs help. She recognizes her use of marijuana and that the car accident has left her with undealt emotional issues and impact on her self-esteem and self-perception.
Judgement: Patient appears to have good judgement. Patient is also in therapy. Patient expressed positive consideration for medication but has concerns because she has an upcoming trip for her birthday.
Rating scales
PHQ- score 8
Interpretation: Mild depression
Generalized Anxiety Scale – Socre 7
Interpretation: Mild Anxiety
Diagnosis:
Anxiety disorder, unspecified F41.9 (ICD-10)
Post -traumatic stress disorder, chronic F43.12 (ICD-10)
Assessment:
Patient exhibits post-traumatic stress disorder related to the auto accident she caused and anxious features. Nonfatal traffic accidents can negatively affect an individual’s emotional well-being and may contribute to mental health conditions such as post-traumatic stress disorder, depression, and anxiety (Boelen et al., 2022).
She also reports a history of cannabis use as a way of emotionally coping. Cannabis use may also be contributing with her concentration moods and academics. Cannabis intoxication may cause mild to moderate problems in several areas of cognitive functioning. Some of these difficulties may continue even after the immediate effects of cannabis have worn off (Dellazizzo et al., 2022). She appears to have difficulty processing prior accident memories, maladaptive beliefs, self- blame, unworthiness, failure, negative self-concept
Patient will continue to need outpatient therapy treatment. She exhibits symptoms of emotional disorders that interfere with her daily function and unable to alleviate these symptoms on her own and will benefit from medication management.
Plan:
--To start with the following medications:
--Fluoxetine 10mg to take 1 tablet by mouth every day
--Avoid grapefruit juice while taking this medication. Limit alcohol use if decides to drink and to continue therapy. Check in weekly after starting this medication.
--Engage in one enjoyable activity daily
--Continue with talk therapy, focus on self-compassion, and trauma processing
--Practice breathing exercises
--Try to establish a daily bedtime
Cannabis disorder:
--Start taking N-amethystine 600 mg twice daily, increase 1200 mg after 1 week if tolerated
--Gradual try to reduce cannabis use try smoking on non-school days
--Try chewing gum when thinking about smoking or sucking on sugar free candy
--Continue to address cannabis use in therapy
--Patient to schedule an appointment with her primary doctor to address her diabetes.
--Follow up weekly for the next four weeks
References
Boelen, P. A., Eisma, M. C., de Keijser, J., & Lenferink, L. I. M. (2022). Traumatic stress, depression, and non-bereavement grief following non-fatal traffic accidents: Symptom patterns and correlates. PLOS ONE, 17(2), e0264497. https://doi.org/10.1371/journal.pone.0264497
Dellazizzo, L., Potvin, S., Giguère, S., & Dumais, A. (2022). Evidence on the acute and residual neurocognitive effects of cannabis use in adolescents and adults: A systematic meta-review of meta-analyses. Addiction, 117(7), 1857–1870. https://doi.org/10.1111/add.15764
SOAP1RESPONSE.docx
SOAP 1 RESPONSE: 250 WORDS with references- Strong, recent (5-7 years), scholarly, peer- reviewed support of topics. No grammar, spelling, and punctuation errors.
Client: CJ
Date: 09/03/2026
Session Type/Length: Complete Evaluation/Intake, 11:00 a.m.–12:00 p.m. VIA telehealth
Duration: 60 minutes
Subjective:
Chief complaint: Patient states that she is having anxiety and depression.
Patient is a 23-year-old Caucasian female reporting that she is experiencing anxiety and depression from a traumatic car accident that she causes six years ago when she was 17 years old when she ran a red light. She reports that people were significantly injured. She reported that this has left her feeling emotionally drained and has altered her life. She describes feelings of feeing not good enough and inadequate. She says that in her first year of college she failed every class for two semesters straight. Before the accident she excelled in school. She says that there are repeated thoughts of self-blame, thinking about the other accident victims and the grief over perceived loss. She reports that the anniversary of the accident was recent and discussing it in therapy today took a toll on her emotionally. She says that she has been suppressing the accident and feels like she has not fully processed the totality of the accident and that it is taking a toll on her mentally.
CJ reports that she has been having worsening depression. She is in an accelerated nursing program and although she was doing well in the program, she says that she has failed two validations during this most recent term despite multiple attempts. She says after failing she has had increasing self-doubt, crying for prolonged periods of time and feeling that she may not be good enough to be a nurse. She says that she feels isolated and does not have family support from her parents because they did not attend college and her mother advised her to get help.
She states that she has difficulty concentrating while she is driving and in school. She says that sometimes she has to pass the intersection where her car accident was and she has flash backs and questions as should she still be driving. She reports she didn’t drive for two years after the accident. She says that her energy level fluctuates and she feels more lows than highs. She says that her sleeping cycle is off due to the demands of the nursing program that she is in. She reports no nightmares
CJ reports that from the age of 19-22 she smoked marijuana daily; she says that smoking went from recreational to being emotionally dependent. She continues to smoke at least three or four times a week now and would smoke more if she was not in school. She expressed a desire to quit smoking and described it as entering substance use disorder territory. CJ reports state her mom has poor mental health and on her father side there is a history of substance abuse and neither has a formal diagnosis.
Past Medical History: Diabetes type 2, depression
Allergies: NKDA
Medications and Supplements:
Metformin--Prescribed for type 2 diabetes—has not taken in the last 6 months, plans to reevaluate with her primary care doctor
Sertraline 25mg, 1 tablet daily for depression- has not taken in the last 6 month
Objective:
Appearance: Patient appears to be well groomed; eye makeup observed.
Behavior: Patient was cooperative, engaged and talkative. Speech was a normal pattern and was willing to elaborate on sensitive topics without hesitation.
Mood: Describes feeling sad, depressed most days but there are days with happiness. Reports self-doubt, not feeling worthy, feeling overwhelmed and having the world on her shoulders.
Affect: Affect appears broad in range, becomes visibly and verbally emotional when discussing the car accident 3 years ago. Seem to block certain aspects of the accident out of her mind.
Thought process: CJ is able to provided detailed events chronologically of her personal history, social history and academic history.
Thought content: Denies any suicidal or homicidal ideation but states that she feels inadequate, has past regrets and has a since of failure when she thinks about her future. Compares herself to her peers states she feels like a failure because most of them have started their careers and she is still in school failing test.
Cognition: CJ is oriented and fully alert. Memory intact, able to recall timelines, dates, events. Self-reported difficulties having trouble staying focused in class and while driving.
Insight: CJ acknowledges her mental health difficulties’; states she needs help. She recognizes her use of marijuana and that the car accident has left her with undealt emotional issues and impact on her self-esteem and self-perception.
Judgement: Patient appears to have good judgement. Patient is also in therapy. Patient expressed positive consideration for medication but has concerns because she has an upcoming trip for her birthday.
Rating scales
PHQ- score 8
Interpretation: Mild depression
Generalized Anxiety Scale – Socre 7
Interpretation: Mild Anxiety
Diagnosis:
Anxiety disorder, unspecified F41.9 (ICD-10)
Post -traumatic stress disorder, chronic F43.12 (ICD-10)
Assessment:
Patient exhibits post-traumatic stress disorder related to the auto accident she caused and anxious features. Nonfatal traffic accidents can negatively affect an individual’s emotional well-being and may contribute to mental health conditions such as post-traumatic stress disorder, depression, and anxiety (Boelen et al., 2022).
She also reports a history of cannabis use as a way of emotionally coping. Cannabis use may also be contributing with her concentration moods and academics. Cannabis intoxication may cause mild to moderate problems in several areas of cognitive functioning. Some of these difficulties may continue even after the immediate effects of cannabis have worn off (Dellazizzo et al., 2022). She appears to have difficulty processing prior accident memories, maladaptive beliefs, self- blame, unworthiness, failure, negative self-concept
Patient will continue to need outpatient therapy treatment. She exhibits symptoms of emotional disorders that interfere with her daily function and unable to alleviate these symptoms on her own and will benefit from medication management.
Plan:
--To start with the following medications:
--Fluoxetine 10mg to take 1 tablet by mouth every day
--Avoid grapefruit juice while taking this medication. Limit alcohol use if decides to drink and to continue therapy. Check in weekly after starting this medication.
--Engage in one enjoyable activity daily
--Continue with talk therapy, focus on self-compassion, and trauma processing
--Practice breathing exercises
--Try to establish a daily bedtime
Cannabis disorder:
--Start taking N-amethystine 600 mg twice daily, increase 1200 mg after 1 week if tolerated
--Gradual try to reduce cannabis use try smoking on non-school days
--Try chewing gum when thinking about smoking or sucking on sugar free candy
--Continue to address cannabis use in therapy
--Patient to schedule an appointment with her primary doctor to address her diabetes.
--Follow up weekly for the next four weeks
References
Boelen, P. A., Eisma, M. C., de Keijser, J., & Lenferink, L. I. M. (2022). Traumatic stress, depression, and non-bereavement grief following non-fatal traffic accidents: Symptom patterns and correlates. PLOS ONE, 17(2), e0264497. https://doi.org/10.1371/journal.pone.0264497
Dellazizzo, L., Potvin, S., Giguère, S., & Dumais, A. (2022). Evidence on the acute and residual neurocognitive effects of cannabis use in adolescents and adults: A systematic meta-review of meta-analyses. Addiction, 117(7), 1857–1870. https://doi.org/10.1111/add.15764