3
Soap Note
Student’s Name
Institutional Affiliation
Professor
Course
Date
Subjective
Patient Verification
Name: D.M.
DOB: 12/3/2000
Demographics: 25-year-old
Gender Identifier Note: Male
Chief Complaint (CC): “I hear voices that won’t stop, and sometimes I feel like people are watching me.”
History of Present Illness (HPI): The patient is a 21 year old male college student, his history was one of schizoaffective disorder, which came to diagnosis at age 19. Though he adheres to his medication, he continues to have persistent auditory hallucinations that have been getting worse over the past month. The voices are derogatory and instructive, though it has not resulted in self-harm or aggressive behavior. He also talks about a bout of intermittent paranoia that had him convinced that his classes were spying on him. In addition, J.R. is prone to mood instability, as he can switch from low energy, low motivation, and depressive episodes to episodes of extreme irritability and impulsivity.
Currently, the patient is prescribed olanzapine 10 mg at night and fluoxetine 20 mg daily. He acknowledges that he sometimes fails to take his medication because he experiences side effects, such as drowsiness and weight gain. No recent hospitalizations or suicide attempts.
Pertinent History:
· Reports frequent low energy and lack of motivation during depressive episodes.
· During elevated mood states, he experiences racing thoughts, impulsivity, and decreased need for sleep.
· Denies current suicidal or homicidal ideation.
Sleep and Appetite: He reports excessive drowsiness due to medication and increased appetite leading to weight gain.
Energy and Concentration: Low energy during depressive episodes and also distractibility and difficulty completing tasks.
Psychiatric Symptoms:
· Auditory hallucinations (command and derogatory voices).
· Paranoia about being watched or followed.
· Mood instability with periods of irritability and impulsivity.
SI/HI/AV: Denies suicidal ideation, but acknowledges past thoughts, no homicidal ideation and reports auditory hallucinations but denies visual hallucinations.
Allergies: No known drug or food allergies (NKDFA).
Past Medical History: Mother diagnosed with major depressive disorder. No known family history of schizophrenia or bipolar disorder.
Substance Use History: Occasional cannabis use, denies tobacco or alcohol use.
Family History: Father diagnosed with ADHD. Mother has mild anxiety disorder. No history of substance abuse in the family.
Social History: Lives alone in an apartment. Studies computer science, but struggling with coursework due to symptoms. He has few close friends and limited social interaction. He was previously hospitalized twice for acute psychosis.
Review of Systems (ROS)
·
Constitutional: No fever; fatigue occurs during depressive phases.
·
Eyes: No noticeable vision disturbances.
·
ENT: No issues with hearing or throat discomfort.
·
Cardiac: No reports of chest discomfort or irregular heartbeat.
·
Respiratory: Breathing is normal; no coughing or shortness of breath.
·
GI: No complaints of nausea or vomiting; bowel movements remain regular.
·
GU: Urinary function is unchanged and unremarkable.
·
Musculoskeletal: No muscle or joint discomfort or stiffness.
·
Skin: No visible rashes, sores, or abnormalities.
·
Neurologic: No history of headaches or seizure activity.
·
Endocrine: Appetite has noticeably increased.
·
Hematologic: No tendency for excessive bruising or abnormal bleeding.
Objective
Vital Signs and Measurements
·
Temp: 98.2°F
·
BP: 128/80 mmHg
·
HR: 75 bpm
·
R (Respiratory Rate): 16 breaths/min
·
O2 Saturation: 98% on room air
·
Ht (Height): 178 cm
·
Wt (Weight): 85 kg
·
BMI: 26.8
Laboratory Findings
·
LABS:
· Lab findings within normal limits (WNL).
· Toxicology Screen: Negative for all substances.
· Alcohol Screen: Negative.
· HCG: Not applicable (N/A).
Physical Exam:
·
General Appearance: Well-groomed, appears slightly anxious.
·
Skin: Warm, dry, no rashes or lesions.
·
HEENT: Eyes clear, no abnormalities in nasal or throat examination.
·
Cardiovascular: Regular heart rate, no murmurs.
·
Respiratory: Lungs clear bilaterally.
·
GI: No tenderness, normal bowel sounds.
·
Musculoskeletal: Normal range of motion, no tenderness.
·
Neurologic: Alert and oriented, no focal deficits.
·
Psychiatric:
· Appears anxious and distracted.
· Speech normal in rate but occasionally tangential.
· Thought process disorganized with mild paranoia.
· Auditory hallucinations present.
MSE (Mental Status Exam):
·
Appearance: Well-groomed, appropriate hygiene.
·
Behavior: Cooperative but appears distracted.
·
Mood/Affect: Mood fluctuates, affect mildly anxious.
·
Speech: Normal rate but slightly pressured at times.
·
Thought Process: Mildly disorganized, occasional paranoia.
·
Cognition: Intact but struggles with sustained focus.
·
Insight/Judgment: Fair insight into illness, moderate judgment impairment due to paranoia.
Assessment
Diagnosis (DSM-5 and ICD-10 Codes):
Schizoaffective Disorder, Bipolar Type
· DSM-5 Code: 295.70
· ICD-10 Code: F25.0
Differential Diagnoses:
·
Bipolar I Disorder with Psychotic Features (ICD-10: F31.2)
· Mood instability could indicate bipolar disorder, but persistent hallucinations outside mood episodes support schizoaffective disorder.
·
Schizophrenia (ICD-10: F20.9)
· Continuous hallucinations suggest schizophrenia, but mood symptoms align more with schizoaffective disorder (Pavlichenko et al., 2024).
·
Major Depressive Disorder with Psychotic Features (ICD-10: F32.3)
· Patient’s manic symptoms and persistent paranoia rule out major depressive disorder alone.
Plan
1.
Pharmacologic Interventions:
· Increase olanzapine from 10 mg to 15 mg once nightly to reduce excessive hallucinations and paranoia (Florentin et al., 2023).
· If manic symptoms persist, consider adding a mood stabilizer (such as lithium or valproate).with a low dose and adjusting as needed.
2.
Non-Pharmacologic Interventions:
· Cognitive-Behavioral Therapy (CBT) is recommended for psychotic symptoms and mood regulation (Pavlichenko et al., 2024)..
· Psychoeducation on medication adherence and side effect management
3.
Patient Education:
· Explain the importance of continued medication even when there is improvement in symptoms.
· Give strategies to cope with paranoia and hallucinations.
4.
Safety Planning:
· Educate the patient to contact if symptoms get worse.
· Emergency contact plan in place for crisis situations.
5.
Follow-Up:
· Report back in 2 weeks for symptom and medication review..
6.
Referrals:
· Referral to a psychiatrist for medication management.
· Referral to therapy for CBT and psychoeducation.
Time spent counseling and coordinating care: 60 minutes
Total visit time: 90 minutes
Date: 02/13/2025
Time: 10:00 PM
References
Florentin, S., Reuveni, I., Rosca, P., Zwi-Ran, S. R., & Neumark, Y. (2023). Schizophrenia or schizoaffective disorder? A 50-year assessment of diagnostic stability based on a national case registry.
Schizophrenia Research,
252, 110-117.
Pavlichenko, A., Petrova, N., & Stolyarov, A. (2024). The modern concept of schizoaffective disorder: a narrative review.
Consortium Psychiatricum,
5(3), 42.
