Focused SOAP Note and Patient Case Presentation

The Patient Evaluation Information

Objective:

The patient is alert and oriented x 4, to person, place, time, and his situation. He was seen today for an initial evaluation via telehealth with his consent obtained. The patient appearance is clean and very neat. His mood is euthymic, and affect is congruent to his mood. His thought process is logical, and goal directed. She has good judgement and insight. She denies suicidal or homicidal ideations currently. She denies visual but report auditory hallucinations currently

General Appearance: Neat & clean.

Eye contact: Normal.

Psychomotor Activity: Normal.

Orientation: Person. Place. Time. Situation.

Attention: Intact.

           

BEHAVIOR: Cooperative.

SPEECH: Normal.

MOOD: Euthymic. Euphoric.

AFFECT: Appropriate.

THOUGHT PROCESS: Goal Directed, Logical.

THOUGHT CONTENT: Intact.

PERCEPTIONS: Good.

INSIGHT: Good.

JUDGMENT: Good.

COGNITION: Intact.

Language. WNL. Abnormal

MEMORY: None. Immediate. Recent. Remote.

C-SSRS (CURRENT)

1. WISH TO BE DEAD:

have you wished you were dead or wish you could go to sleep and not wake up? NO

if yes, describe:

2. NON-SPECIFIC ACTIVE SUICIDAL THOUGHTS:

have you had any thoughts of killing yourself? Yes.

if yes, describe:

3. ACTIVE SUICIDAL IDEATIONS WITH ANY METHODS (NOT PLAN) WITHOUT INTENT TO ACT

have you been thinking about how you might do this? No

if yes, describe:

4. ACTIVE SUICIDAL IDEATIONS WITH SOME INTENTS TO ACT, WITHOUT SPECIFIC PLAN

have you had these thoughts and had some intentions of acting on them? No

if yes, describe:

5.ACTIVE SUICIDAL IDEATIONS WITH SPECIFIC PLAN AND INTENT

have you start to work out or worked out the details of how to kill yourself? No

if yes, describe:

C-SSRS (LIFETIME)

1. WISH TO BE DEAD.

have you wished you were dead or wish you could go to sleep and not wake up? No

if yes, describe:  

2. NON-SPECIFIC ACTIVE SUICIDAL THOUGHTS: In the past, not now.

have you had any thoughts of killing yourself? YES

if yes, describe:

3. ACTIVE SUICIDAL IDEATIONS WITH ANY METHODS (NOT PLAN) WITHOUT INTENT TO ACT

have you been thinking about how you might do this? No

if yes, describe: Pills

4. ACTIVE SUICIDAL IDEATIONS WITH SOME INTENTS TO ACT, WITHOUT SPECIFIC PLAN.

have you had these thoughts and had some intentions of acting on them? YES

if yes, describe: Opened window and thought of jumping out of the window

5.ACTIVE SUICIDAL IDEATIONS WITH SPECIFIC PLAN AND INTENT: NO

have you start to work out or worked out the details of how to kill yourself? No

if yes, describe:

PROTECTIVE FACTORS: Family (Father and stepmother)

RISK ASSESSMENT: Low

SAFETY PLAN RECOMMENDATIONS: TO CALL 911 IF FEELING SUICIDAL

Psychosis: Y/N No

Diagnosis Formulation: Bipolar Disorder.

Score on Administered Screening Tool: PHQ score 10/27

Subjective

The patient is an 18-year-old male in for an initial psychiatric evaluation with consent. He is accompanied by his father and stepmother for the evaluation. Marc reports feeling good right now; he states, " I was diagnosed with ADHD and Bipolar disorder, I am taking Seroquel 50mg and stopped taking Adderall 3 years ago". They report wanting to with a new psychiatrist because the other did not have counseling services.

Assessment

The patient is in for an initial psychiatric evaluation; he reports a previous diagnosis of bipolar disorder and ADHD, and actively taking Seroquel 50mg at night. Patient reports feeling good and having no concerns but wanting continuation of care due to lack of available therapy at his previous provider.

Patient reports a troubled upbringing with divorced parents, expulsion from middle school, bullying, arguments with his mother, and occasional thoughts of suicide in the past.

He reports auditory hallucinations stating where he would see a window and think about jumping out of the window but did not act on the hallucination. A recommendation to increase his prescribed Seroquel to 75mg based on his reported auditory hallucinations and poor sleep was made to patient, however, he declined to increase the dosage stating he is okay. He is educated that if these auditory hallucinations persist and cause him to enact harm on himself or others, he should call 911.

Patient will continue Seroquel 50 mg nightly, and a referral for psychotherapy will be escalated. He is educated on medication compliance to improve his mood symptoms. He is educated on medication side effects and adverse effects. Education is provided on positive coping mechanisms to improve his mood.

A discussion was held with Marc's father who is present during the interview. He expresses his wish to start patient back on his Adderall as he is about to enter college. The father is educated that Adderall will not be prescribed at this time because patient may be able to make behavioral adjustments through psychotherapy sessions and increased engagement in other activities. A reevaluation will be needed to diagnose patient with ADHD. Otherwise, his father is encouraged to continue actively supporting and maintaining open communication with patient.

Plan of Care:

Client will have decreased mood symptoms within 90 days

Client is referred for psychotherapy sessions weekly

Client will continue Seroquel 50mg at bedtime

Client is educated on medication side effects and adverse effects

Follow up in 2 weeks on 3/29/22

Call 911 for suicidal or homicidal ideations