SOAP Power point

Patient’s Chief Complaint (CC): "I started noticing how my neighbor started following the same route I was taking while jogging at the park. I think this is very true, and I can get some proof".

History of the Present Illness (HPI)/ Demographics;

HP is 22 years old college student, white, Caucasian, male, and about five weeks ago, he started noticing how his neighbor seemed to be following him. He mentioned that he “started noticing how my neighbor started following the same route I was taking while jogging at the park. I think this is very much true, and I can get some proof". It was also about this time when he lost broke up with a long-time girlfriend, his childhood sweetheart. He found out she was cheating on him with his best friend. Since then, he has felt unfortunate and lonely because of the betrayal and the loss of his girlfriend and best friend. He also lost his appetite and found it hard to sleep at night. He experienced feelings of hopelessness and worthlessness. He felt tired and had little energy during the day. That also caused him to miss some of his college classes. Ever since starting college, he has walked every morning from his apartment to the park. It helped clear his head. He started noticing how his neighbor, who usually took a different route to the park, was following his way. He also observed that before going to work, his neighbor would glance at his apartment room window. He also believes he heard him referring to him while conversing with someone on his phone. Two weeks ago, he also felt a bit euphoric and energized. He felt the urge to rearrange his apartment and take up art classes. He also felt lucky, so he went on a weekend trip to a hotel casino and used some of his college money to play poker. Unfortunately, he lost all his money. Now, he is back to feeling glum and suspicious of what he describes as his dodgy neighbor. What usually made his symptoms worse were stressful situations, including when he ran into his ex and best friend together. What relieved his symptoms were instances when he would go home to his family and spend time with them. He also found that playing video games helped him relax and forget his worries. When asked to rate his feelings of sadness and loneliness (depression), he rated it at 9/10. When asked to rate his feelings of euphoria and hyperactivity, he rated it at 8/10.

Review of Systems:

General: HP denies feeling any fever and having any chills. He does admit to feeling fatigued and weight loss

HEENT: He denies any changes in his hearing, smell, taste, or his vision. HP denies sinus pressure

Neck: HP denies neck and throat pain

Lungs: HP denies experiencing any shortness of breath. He denies coughing, sneezing, or wheezing.

Cardiovascular: HP denies having had any chest pain. He denies having experienced any edema. He denies palpitations.

Breast: HP denies having experienced any breast pain or tenderness. He denies having felt any breast lumps.

GI: He denies abdominal pain, blood in stool, diarrhea, constipation, and heartburn. He denies experiencing any nausea and vomiting. He admits to the loss of appetite.

Male/female genital: HP denies experiencing any pain or tenderness in his penis and or testicles.

GU: HP denies experiencing any pain or burning sensation when urinating. He denies having an excessive amount of urine when peeing and denies any changes in the frequency of urination.

Neuro: HP denies having experienced any dizziness, numbness, weakness, seizures, or tremors. He denies having experienced any headaches.

Musculoskeletal: HP denies having experienced any back pain, joint pain, joint swelling, and neck pain.

Activity & Exercise: HP admits to walking 30 minutes to one hour daily in the morning.

Psychosocial: Admits to feelings of anxiety and depression

Derm: HP denies having observed any hives, rashes, lesions, or mole changes on his skin

Nutrition: HP eats eggs, bread, chicken, chocolates, fruits, vegetables, chips, and water daily. Lately only been eating chips, water, and bread.

Sleep/Rest: 2-3 hours a day

STI Hx: HP denies having had a history of STI

O= Objective data:

Medications

Current psychotropic medications:  

None

Current prescription medications:  

None

OTC/Nutritionals/Herbal/Complementary therapy:

None

Substance use : (alcohol, marijuana, cocaine, caffeine, cigarettes)

Marijuana (smokes a joint with friends once a month); does not smoke; drinks about three bottles of beer once a month with friends; drinks 2-3 cups of coffee a day

Allergies: No known allergies, no food allergies, no medication allergies, no latex allergies, no allergies to herbals

Past medical history:

1. Major/Chronic Illnesses: None

1. Trauma/Injury: None

1. Hospitalizations: ER visit 6 months ago due to food poisoning; ER visit due to mild COVID-19 symptoms

Family history: Hypertension (father side); Type 2 diabetes (mother side)

Past surgical history: None

Psychiatric history: None

Family Psychiatric history: Parents and both sets of grandparents have no known history of any psychiatric disorder or suicide. Siblings also have no general history of any psychiatric illness or suicide.

Social history:

Lives: Alone in a small apartment

Marital Status: Single Employment Status: None Current/Previous occupation type: Summer job at a summer camp

Exposure to: Smoke: None; ETOH: Occasionally (once a month, 3 beers); Recreational Drug Use: Marijuana (occasional, about once a month when out drinking with friends; one joint)

Sexual orientation: Heterosexual Sexual Activity: Currently not Contraception Use: Yes, condoms

Family Composition: Family/Mother/Father/Alone : Parents and siblings back home

Other: (Place of birth, childhood hx, legal, living situations, hobbies, abuse hx, trauma, violence, social network, marital hx):

Place of birth: Jacksonville, Florida

Childhood Hx: Relatively happy childhood; raised by his father and mother in the suburbs, grew up with two other siblings (brother and sister), is the middle child

Living situations: Currently living in a small apartment, goes home to parents at least once a month for a weekend.

Hobbies: Playing video games, playing basketball, walking

Abuse: None

Social network: Is close with family; has numerous close friends; socializes atleast once a month with them

Marital Hx: Never been married

Labs and screening tools: No labs were reviewed during the consult

Vital signs: BP: N/A TPR: N/A HR: N/A RR: N/A Ht. 5’11” Wt. 145 BMI ( percentile) 20.2

Pain: No pain.

Physical exam (Focused)

General: HP is alert and oriented to time, person, and place. He is also not in acute distress. He looks like he recently lost weight. He does not appear well-groomed, as his hair is uncombed, and he seems like he is wearing pajamas.

HEENT: N/A

Neck: N/A

Pulmonary: N/A

Cardiovascular: N/A

Breast: N/A

GI: N/A

Male/female genital: N/A

GU: N/A

Neuro: N/A

Musculoskeletal: N/A

Derm: N/A

Psychosocial: HP’s mood and affect are dysphoric. He has feelings of suspicion and distrust. His guilt and a lot of anxiety. His long- and short-term memory are intact. His judgment and insight are somewhat lacking

Misc.

Mental Status Exam

Appearance: HP appears slightly unkempt, with his hair uncombed and pajamas as his choice of clothes. The session is via telehealth, though, so he may have felt he did not need to dress up. He has no visible tattoos, scars, or piercings.

Behavior: HP maintains eye contact during the consult. He sometimes fidgets and sometimes is uncomfortable talking about his ex and best friend. He is nevertheless cooperative and friendly and can be engaging for the most part.

Speech: HP’s tone is well-modulated. His words are clear, and the volume of his voice is sufficiently moderated. It is quiet and soft enough. His pronunciation is also evident. He tends to be guarded at times, especially when he thinks his accounts about his neighbor are not being taken seriously. When asked to talk more about his neighbor and ex-girlfriend, he tends to be more monosyllabic.

Mood: HP’s mood is sad and anxious. He rates his sadness at 8/10 and his anxiety at 8/10 as well.

Affect: HP's effect mostly shows sadness and general distrust. Regarding the intensity of emotions, what can be observed is worthlessness and suspicion. HP does not find it hard to show and initiate emotional reactions. He does show difficulty in relaxing and letting go of his suspicions. He is tense and highly strung. He does not show much amusement or gaiety with life or with his current situation.

Thought Content: HP does have preoccupations about his neighbor. He does not want to let go of the notion that his neighbor is following him. He does not have suicidal or homicidal thoughts. At present, he is uncomfortable with crowds and being in other people's company. There are extraordinary delusions in her thoughts and beliefs.

Thought Process: HP could be more organized in how he talks about his experience and his current situation. He responds to questions a bit distractedly and suspiciously. He can be incoherent, and his thoughts have a flight of ideas. He can be evasive, especially when discussing his suspicions about his neighbor.

Cognition/Intelligence: He is oriented to person, place, and time. He is aware of who he is and who I am. He also knows he is having a mental health consult with me as a mental health professional via teleconference. He is mindful of the current time and date. His orientation is good. His remote memory is intact, and he can recall childhood events and important happenings in his life. He can remember his birthday, birthplace, address, and where he went to school. His remote memory is good. His recent memory is also good. He knows what he ate and what he did yesterday. He can also recall three words I told him and asked him to recite. He can sometimes lose his focus on the question or topic we are on. He has a bit of a short attention span. But he does respond when his attention is called.

Clinical Insight: HP’s insight is not that good. He is aware that he is depressed and possibly bipolar, but he does not believe he is being delusional about his neighbor. He is aware he needs help and that there may be negative consequences of not getting timely and appropriate mental health care services.

Clinical Judgment: HP’s understands socially conforming behavior and the possible consequences of not conforming socially. I asked him what he would do if he was crossing the street and a car was speeding towards him. He said he would run for safety, doing his best to avoid the car.

A= Assessment:

Primary Diagnosis:

1. Schizoaffective disorder. This can be observed in the patient's symptoms of psychosis and mood disorder (Hartman et al., 2019). He currently has delusions and has symptoms associated with bipolar disorder (depression and mania, disjointed thoughts, sadness, insomnia, loss of appetite, the feeling of worthlessness, and a bit euphoric at times).

P= Plan:

Pharmacologic: Antipsychotic and mood stabilizer (Hattab et al., 2021)

Antipsychotic: Invega, 6 mg, once daily per orem for 6 weeks

Mood stabilizer: Lithium, 600 mg, 2 times a day per orem for 6 weeks

Non-pharmacologic treatment plan: Talk therapy and family intervention (Sutijono et al., 2022)

Talk therapy at least once or twice a week; his family can also be guided in helping him recover from his current mental health issues.

Diagnostic testing/screening tools: None ordered at this time

Patient/family teaching:

· Teach patients and families about self-management of symptoms (Hedlin, 2023).

· The patient can recover from this disorder if provided with assistance at the soonest possible time.

· Teach the patient and family to identify his triggers (Hedlin, 2023)

· Encourage the patient to establish a routine for his activities and stick to the same

· Encourage the family to be a strong support system for the patient.

· Avoid drugs and alcohol (Hedlin, 2023)

· Teach the family to communicate with the patient

· Encourage the family to react to the patient calmly at all times (Hedlin, 2023).

Another primary diagnosis:

2. Generalized anxiety disorder (as noted from his anxiety and avoidance of crowds and people)

Pharmacological: Antidepressant, SSRI (Escitalopram), 10 mg per orem daily, for six months

Non-Pharmacological: Cognitive behavioral therapy, once a week for six months

Diagnostic testing: None at this time

Patient teaching:

· Teach patient relaxation techniques (deep breathing techniques, music therapy, etc.)

· Encourage the patient to try out new hobbies.

· Encourage family members to spend more time with the patient at this crucial time in his mental health.

· Encourage the patient to avoid drugs and alcohol.

Referral: Psychotherapist for his talk therapy

Follow-up: After 30 days or earlier if symptoms are persistent.

Differential Diagnosis

1. Schizophrenia (DSM V); ICD 10 F201 (Disorganized schizophrenia)

2. Bipolar Disorder (DSM V); ICD 10 F31

References

Hattab, S., Qasarweh, L., Ahmaro, M., Atatre, Y., Tayem, Y., Ali, M., & Jahrami, H. (2021).

Prescribing patterns of psychotropic medications in psychiatric disorders: a descriptive study from Palestine.  International Journal of Clinical Pharmacy, 1-8.

Hartman, L. I., Heinrichs, R. W., & Mashhadi, F. (2019). The continuing story of schizophrenia

and schizoaffective disorder: one condition or two?  Schizophrenia Research: Cognition,  16, 36-42.

Hedlin, M. (2023). The Collected Schizophrenias—Narrative Insights Into Schizoaffective

Disorder.  JAMA,  329(2), 109-110.

Sutjiono, B., Ahmad, S. F., & Jaya, E. S. (2022). Feasibility and Benefit of Cognitive

Behavioral Therapy for Psychosis via Teleconsultation in Indonesia: A Case Study of a 40-Year-Old Schizoaffective Disorder Patient.  Behavior Change, 1-14.