Care Across the Lifespan I

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Soap Note Case

K.G

25 y Male

Chief complaint

Individual seen in clinic face to face for medication management and follow up. He is accompanied by mother.

Follow Up Visit

Follow Up Visit

Individual reports that he has started back drinking and smoking marijuana. He reports that he smokes and drinks everyday. Mother reports that he drinks until he passes out. "I'm taking medication. I need an outlet like work." Individual reports that he has been sleeping well. Individual reports that he rates life 5/10, with 10 being total happiness.

Medications

paliperidone ER 6 mg tablet,extended release 24 hr, Take one tab nightly  

Assessment

Schizoaffective disorder, bipolar type (disorder) (F25.0/295.70) Schizoaffective disorder, bipolar type 

Substance abuse (disorder) (F19.10) Other psychoactive substance abuse, uncomplicated

Difficulty sleeping (Z72.820/V69.4) Sleep deprivation 

ROS

Psychiatric: (+)change in mood, (+)depression, (-)sadness interfering with function, (+)anxiety, (-)nervousness, (-)sleep disturbance, (-)suicidal ideation, (+)hopelessness, (+)worthlessness, (-)delusions, (-)hallucinations

Care plan

Continue all medication as ordered. Individual instructed to refrain from smoking and drinking due to severe side effects. Visit AA meetings, and Focus on Recovery. Follow up in 4 weeks. Individual and mother verbalize understanding of treatment plan.

ALLERGIES

No allergy history has been documented for this patient.

History

DETAIL

LAST UPDATED

DETAIL

LAST UPDATED
Past Medical History (PMHx)

· Comments: *HIV (+)- 2018, dyslexia, ADHD

15 Nov 2021

09:32 AM
Past Surgical History (PSHx)

· No past surgical history has been documented for this patient

·

Family History (FHx)

· Comments: Mother- (living)- Anxiety Dad (liver)- Bipolar Paternal aunt (living)- Schizophrenia Maternal grandfather (deceased)- alcoholism, hallucinations

15 Nov 2021

09:35 AM
Social History (SHx)

· Birth Gender: Male

· Drug Abuse: Illicit drug use - marijuana

· Safety: Wear seatbelts

· Sexual Activity: Sexually active / Exposure to STI

· Tobacco: Heavy tobacco smoker - Black and Milds- daily / Current every day smoker

15 Nov 2021

09:36 AM
Hospitalizations / Procedures

· No hospitalizations / procedures have been documented for this patient

·

Long Term Care Facility

· No Long Term Care Facilities have been documented for this patient

·

Hospice

· No hospices have been documented for this patient

·

Implantable Devices

· No implantable devices have been documented for this patient

Vitals

Height : 69 in

Weight: 179.5

BMI : 26.51

BP : 112/66 mmHg

Temperature : 98.7 °F

Pulse : 89 bpm

Respiratory rate: 18 bpm

O2 Saturation

Pain

Head Circumference