Focused SOAP Note and Patient Case Presentation

Subjective

The patient is a 21-year-old African American female who was seen today for her initial evaluation via telehealth session with her consent obtained. The patient stated, "I'm seeking a psychiatrist because my primary care physician suggested for me to see a psychiatrist to help me with my anger issues”. She stated that she has not being diagnosed for any mental problem before and not on any medication. The patient stated that she gets angry very quickly, depressed, and very anxious, sometimes without any reason she would lash out on people. “I just had my birthday, and I went out for a dinner with my friends, and I had a good time”. “I hear voices, but not that type of crazy voices that tell you to do somethings”. “It is just from my inner thought, maybe thinking in my head and talking out loud to myself”. She said she just gets irritated here and there from some people. She denies suicidal or homicidal ideation or intent presently. She also denies delusional or hallucination presently.

Objective

The patient is alert and oriented x 4 to person, place, time, and the situation. The patient was seen today in the clinic for initial evaluation via telehealth. The patient appeared very clean and dressed neatly. She has normal eye contact with normal psychomotor activity. Her attention is intact and very cooperative. Her speech is normal, her thought process is goal-directed, and her thought contents are circumstantial. Perceptions, insight, and judgment are good, intact cognitive, and language is normal and appropriate. She has euthymic and euphoric moods, and the affect is congruent to her mood. Memory intact denies suicidal or homicidal ideation or intent. She denies delusions and hallucinations. The patient scored 15/27 on the PHQ scale.

Assessment

The patient reported doing good and working two jobs to support herself. She said that she works as a pharmacy technician Monday through Friday and works as a concierge on weekends. The patient stated that she grew up with both parents but now they are divorced. She now lives with her mother and her siblings. The patient stated that she is seeking a psychiatrist because her primary care physician suggested for her to see a psychiatrist to help her to manage her anger issues. She stated that she has not being diagnosed for any mental problem before and not on any medication. The patient stated that she gets angry very quickly, depressed, and very anxious, sometimes without any reason she would lash out on people. She said that her siblings get on her nerves sometimes and she gets irritated especially when they are together for so long. The patient stated that she completed high school and graduated. She said that she was never bullied, nor sexually assaulted. She said that she gets very anxious most of the time. The voices she hears are from her inner thought, and not that type of crazy voices that tells you to do something. She stated that she has a poor eating habit and that she overeats most of the time. She said that she sleeps about 6 hours a day. She stated that she used to be sexually active but not in any relationship now. She said she is not married and has no children. She has few friends. The patient stated that the grandmother on her mother's side has depression, and now she is having dementia as she is getting older. She said she verbally lashes at people sometimes for no reason. Upon assessment, her PHQ-9 scale score is 15/27. She stated that she weighs 200lbs and her height is 5’4’’. Upon assessment, the patient is diagnosed with schizoaffective disorder and anxiety disorder. The patient is not on any medication presently. The patient is referred to a psychotherapist and will be scheduled to see a therapist weekly. The patient is encouraged to engage in exercise to build up her serotonin. She is also encouraged to be taking deep breathing, not eat after 7 pm, and keep electronics away at bedtime. Also, she encouraged to keep a journal of her daily activities and will review it next appointment in 4 weeks. She is encouraged to call a suicide hotline or call 911 or call the psychiatrist's office when wants to talk. She verbalized understanding.

Plan of care:

The patient will have decreased feelings of depression and anxiety over the next 90 days.

The patient is educated on the use of positive coping skills like exercising, deep breathing, and journaling daily.

The patient is referred to a psychotherapist weekly.

Follow up in 4 weeks on 5/17/22.

Call 911 for suicidal or homicidal ideation.

“I just had my birthday, and I went out for diner with my friends, and I had a good time”.