20 Feb Focused SOAP Note Patient: 15‑year‑old female
1.Adolescent (15 years) Mood and Eating Disorder A 15-year-old female presented with restricted food intake and low mood. CBT for eating disorder initiated; focus placed on body image, mood tracking, and healthy coping mechanisms.
Focused SOAP Note
Patient: 15‑year‑old female Presenting Problems: Restricted food intake, low mood Diagnosis: Mood Disorder (Depressive features), Eating Disorder (restrictive type) Treatment Initiated: Cognitive Behavioral Therapy (CBT) for eating disorder
Subjective
Chief Complaint: “I don’t feel like eating much and I feel sad most of the time.”
History of Present Illness:
Reports restricted food intake over the past several weeks.
Expresses dissatisfaction with body image and fear of weight gain.
Describes persistent low mood, irritability, and decreased interest in social activities.
Denies suicidal ideation or self‑harm behaviors at present.
Psychiatric History: No prior psychiatric hospitalizations.
Family/Social History: Supportive family; academic performance declining due to fatigue and concentration difficulties.
Patient’s Perspective: Believes controlling food intake helps manage stress but acknowledges negative impact on health.
Objective
Appearance: Thin adolescent female, casually dressed, appears withdrawn.
Mood/Affect: Reports depressed mood; affect constricted but appropriate.
Speech: Soft, coherent, goal‑directed.
Thought Process: Logical, organized.
Thought Content: Preoccupation with body image; no psychotic features.
Behavior: Avoids eye contact; hesitant when discussing eating habits.
Cognition: Alert and oriented ×3; concentration mildly impaired.
Physical Exam (limited): BMI below expected for age; no acute medical distress noted.
Assessment
Primary Diagnoses:
Eating Disorder, restrictive type (likely Anorexia Nervosa, pending full evaluation).
Mood Disorder, depressive features (Major Depressive Disorder vs. Adjustment Disorder with depressed mood).
Clinical Impression:
Adolescent presents with restricted food intake and low mood, consistent with early eating disorder and comorbid depressive symptoms.
Risk factors include body image concerns, mood dysregulation, and academic stress.
Protective factors include supportive family and willingness to engage in therapy.
Plan
Psychotherapy:
Continue CBT for eating disorder with focus on:
Challenging distorted body image beliefs.
Mood tracking and journaling.
Developing healthy coping mechanisms (stress management, relaxation techniques).
Incorporate family‑based therapy sessions to support adherence and monitoring.
Medical/Nutritional Monitoring:
Refer to pediatrician/nutritionist for weight, BMI, and lab monitoring.
Establish meal plan with gradual normalization of intake.
Mood Management:
Monitor depressive symptoms weekly.
Consider psychiatric evaluation for pharmacotherapy if mood symptoms persist or worsen.
Safety:
Screen regularly for suicidal ideation or self‑harm.
Provide crisis resources and establish safety plan.
Education:
Psychoeducation for patient and family on eating disorders and mood disorders.
Encourage balanced nutrition, sleep hygiene, and physical activity.
Follow‑Up:
Weekly therapy sessions for CBT.
Monthly multidisciplinary team review (therapist, pediatrician, nutritionist).
Signature/Provider: ___________________________ Date: ___________________________
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