This paper presents a comprehensive focused SOAP psychiatric evaluation of a 14-year-old female presenting with food restriction, severe weight loss, amenorrhea, and distorted body image. The evaluation covers the patient's subjective history, objective diagnostic findings, and a mental status examination. Three differential diagnoses — bulimia nervosa, avoidant/restrictive food intake disorder, and anorexia nervosa — are systematically assessed against DSM-5 criteria, leading to a primary diagnosis of restricting-type extreme anorexia nervosa (F50.0). The treatment plan includes nasogastric refeeding, pharmacotherapy with Fluoxetine and Olanzapine, cognitive-behavioral therapy, motivational enhancement therapy, and family interventions, with attention to medication risks and follow-up care.
This paper demonstrates differential diagnosis reasoning — a core clinical skill in which each competing diagnosis is evaluated against established diagnostic criteria and then accepted or eliminated based on the patient's specific presentation. By citing DSM-5 criteria lettered A, B, and C for each disorder, the writer makes the logic transparent and academically rigorous.
The paper follows the standard SOAP note format: Subjective (chief complaint, HPI, medications, ROS), Objective (diagnostic results), Assessment (mental status exam and diagnostic impression), and Plan (treatment and follow-up). Within the Assessment section, the diagnostic impression functions as a mini literature review that contextualizes the patient's symptoms within DSM-5 definitions. The Reflections section adds brief self-critique, noting a potential gap in screening for comorbid major depressive disorder — a hallmark of graduate-level clinical reflection.
The client is a 14-year-old white female brought in by her parents for refusing to eat, leading to generalized weakness, severe weight loss, and amenorrhea lasting four months. The parents are worried because the client had maintained a regular 26–28 day menstruation cycle since menarche at age 12. They fear she could be pregnant, although three home pregnancy tests have all returned negative results.
The client's parents report that she has been dieting for seven months prior to the visit. The behavior began after her friends teased her about her appetite and weight. In response, she began restricting her food intake, engaging in excessive exercise, and avoiding foods high in fat. She frequently skips breakfast and lunch, and during dinner she secretly places food in a plastic bag and disposes of it in the trash. The client denies inducing vomiting or purging, but perceives herself as "fat." She is unhappy with her self-image and believes she is not attractive.
The client is the oldest of two siblings and describes her parents as overprotective and strict. She feels her father is excessively controlling and never allows her to make independent decisions. She reports being unable to be her true self, as she feels forced to live according to her father's wishes. She acknowledges difficulty communicating with her younger sister and her father, but feels her mother understands her. Her parents describe her as a perfectionist who is highly focused on punctuality and cleanliness. Academically, she performs above average, and the family history shows no mental illness or eating disorders.
A few weeks before the visit, the client experienced epigastric pain accompanied by vomiting, joint aches, headaches, and severe fatigue. Her primary care physician (PCP) prescribed antiemetics and multivitamins, which improved her symptoms. The client denies having a boyfriend or engaging in sexual activity.
Substance Use: None reported.
Medical History:
Current Medications: None. Allergies: No known allergies. Reproductive History: Last menstrual period (LMP) was four months ago.
General: The client denies chills and fever, although clinical tests reveal low blood pressure (hypotension) and bradycardia. Clinical examination reveals a thin girl with a height of 1.47 m, weight of 28 kg, and a BMI of 13 kg/m², reflecting a 13% deficit in weight for her height.
HEENT: No visual loss, blurred vision, double vision, or yellow sclerae. No hearing loss, sneezing, congestion, runny nose, or sore throat.
Skin: No itching or rash, although skin is generally dry.
Cardiovascular: No chest tightness, palpitations, or edema.
Respiratory: No shortness of breath, cough, or sputum.
Gastrointestinal: No stomach cramps, indigestion, constipation, or heartburn.
Genitourinary: No burning on urination, hesitancy, or unusual color.
Neurological: Occasional headaches and dizziness, but no change in bladder or bowel control.
Musculoskeletal: Generalized muscle weakness.
Hematologic: No signs of bleeding, anemia, or bruising.
Lymphatics: Lymph nodes are of normal size.
Endocrinologic: Client denies feeling cold, profuse sweating, or heat intolerance. No polyuria or polydipsia.
An electrocardiogram (EKG) and chest X-rays were ordered to rule out cardiac conditions as potential causes of the client's hypotension (Khairani et al., 2011). A complete blood count (CBC) was also ordered to exclude medical conditions such as anemia and hyperthyroidism, which share similar presentations and could account for amenorrhea, frequent headaches, and dizziness (Khairani et al., 2011). Results of the blood investigation were within normal limits. A urine pregnancy test was ordered and returned a negative result. A pelvic ultrasound was ordered to evaluate for abnormalities contributing to amenorrhea; no abnormalities in the pelvic organs were identified. A gastroscopy was ordered to rule out digestive tract abnormalities such as malabsorption as potential causes of the client's vomiting and nausea (Khairani et al., 2011).
The client is a white female who appears her stated age, although she looks shorter and smaller than her peers. She is alert and attentive throughout the clinical interview and is oriented to time, place, person, and event. Her speech is coherent and rational and does not indicate hallucinations. The client displays a depressed mood but denies illusions, paranoid thought processes, and suicidal or homicidal ideation. Her judgment and insight are both grossly intact. However, she expresses strong denial regarding her body appearance and insists that her body shape is normal.
Three differential diagnoses can be drawn from the subjective and objective information: bulimia nervosa, avoidant/restrictive food intake disorder, and anorexia nervosa.
Bulimia nervosa is an eating disorder characterized by recurrent episodes of binge eating (Criterion A) followed by inappropriate compensatory behaviors to prevent weight gain — such as excessive exercise, use of diuretics, or self-induced vomiting (Criterion B) — and excessive concern about body shape and weight (Criterion C) (APA, 2013). The presenting client is overly concerned about her body shape and repeatedly refers to herself as "fat" despite a BMI of 13 kg/m² (Criterion C). Although she admits to excessive exercise, she denies inducing vomiting, and there is no evidence of binge eating as required by Criterion A. Accordingly, bulimia nervosa is the least likely of the three diagnoses.
The APA (2013) defines avoidant/restrictive food intake disorder (ARFID) as an eating or feeding disturbance manifested by a persistent failure to meet nutritional or energy needs, associated with one or more of the following: significant weight loss, significant nutritional deficiency, dependence on nutritional supplements, or significant interference with psychosocial functioning. The disturbance is not better explained by cultural practices or lack of available food, and is not attributable to a concurrent medical condition (APA, 2013). The client demonstrates a primary eating disturbance — skipping meals and avoiding certain foods — resulting in a low body weight and BMI of 13 kg/m². However, Criterion C of the DSM-5 states that the eating disturbance must not be better explained by excessive concern about body shape or weight (APA, 2013). Because the client is markedly preoccupied with her body image — perceiving herself as "fat" and unattractive — and engages in food avoidance specifically to address these concerns, ARFID is an unlikely diagnosis.
The most likely diagnosis is anorexia nervosa, characterized by: (a) restriction of energy intake leading to a significantly low body weight; (b) intense fear of gaining weight and persistent engagement in behaviors that prevent weight gain; and (c) undue influence of body weight and shape on self-evaluation, and a lack of recognition of the seriousness of the low body weight (APA, 2013). The client presents with a BMI of 13 kg/m², reflecting a 13% weight deficit for her height (Criterion A). She is excessively concerned about gaining weight and engages in excessive exercise and food avoidance to prevent it (Criterion B). Finally, she does not recognize the seriousness of her condition and insists that her body shape is normal (Criterion C). The most likely diagnosis is restricting-type extreme anorexia nervosa (F50.0).
Always verify citation format against your institution’s current style guide requirements.