Focused SOAP Note and Patient Case Presentation

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QUESTION
Assignment 2: Focused SOAP Note and Patient Case Presentation
For this Assignment, you will document information about a patient that you examined during the last 3 weeks, using the Focused SOAP Note Template provided. You will then use this note to develop and record a case presentation for this patient. SEE CASE SCENARIOR 1 BELOW
• Create a Focused SOAP Note on this patient using the template provided in the Learning Resources. There is also a completed Focused SOAP Note Exemplar provided to serve as a guide to assignment expectations.
Please Note: You must submit your SOAP note using SafeAssign.
• Include at least five scholarly resources to support your assessment, diagnosis, and treatment planning.
• Ensure that you have the appropriate lighting and equipment to record the presentation.
• Present the full complex case study. Include chief complaint; history of present illness; any pertinent past psychiatric, substance use, medical, social, family history; most recent mental status exam; current psychiatric diagnosis including differentials that were ruled out; and plan for treatment and management.
• Report normal diagnostic results as the name of the test and “normal” (rather than specific value). Abnormal results should be reported as a specific value.
• Be succinct in your presentation, and do not exceed 8 minutes. Specifically address the following for the patient, using your SOAP note as a guide:
 Subjective: What details did the patient provide regarding their chief complaint and symptomology to derive your differential diagnosis? What is the duration and severity of their symptoms? How are their symptoms impacting their functioning in life?
 Objective: What observations did you make during the psychiatric assessment?
 Assessment: Discuss their mental status examination results. What were your differential diagnoses? Provide a minimum of three possible diagnoses and why you chose them. List them from highest priority to lowest priority. What was your primary diagnosis, and why? Describe how your primary diagnosis aligns with DSM-5 diagnostic criteria and supported by the patient’s symptoms.
 Plan: What was your plan for psychotherapy (include one health promotion activity and patient education)? What was your plan for treatment and management, including alternative therapies? Include pharmacologic and nonpharmacologic treatments, alternative therapies, and follow-up parameters, as well as a rationale for this treatment and management plan.
 Reflection notes: What would you do differently with this patient if you could conduct the session over? If you are able to follow up with your patient, explain whether these interventions were successful and why or why not. If you were not able to conduct a follow up, discuss what your next intervention would be.
CASE SCENARIOR 1
Patient is a 27-year-old Caucasian male who is alert and oriented to person, place, time and situation.
Patient presented for follow up treatment of Schizophrenia Spectrum and Other Psychotic Disorders, Alcohol Use (Severe), Cannabis Use Disorder. Patient has had problems with mood since 2013 when he attempted suicide by jumping out a moving car. He had disorganized and tangential thinking, feeling he could not be “controlled”, and plans to go skating, bungee jump, and fly a helicopter. In 2007 he was diagnosed with schizophrenia due to paranoia and both auditory command hallucinations and visual hallucinations of animals and shadows. Patient also has a long history of cannabis use. He has had multiple arrests due to substance use and violence.
Today he again reported feeling “good”. He has chronic difficulty coping with others and stays at home to avoid interactions. He denied suicidal or homicidal ideation. He has been hearing voices and seeing animals and shadows, but the hallucinations have been infrequent thanks to meds. He has chronic difficulty falling asleep and his sleep has been interrupted. He has been having more frequent nightmares and he has not been feeling rested when he wakes up. Energy has decreased. He has chronic difficulty with concentration, but he denied problems with short-term memory. Weight has been increasing due to increased calories intake. Last reported marijuana use was April 1st 2022. Last reported PCP use last week. Last reported alcohol use was last weekend. Patient prefers medication in liquid form except otherwise. No immediate safety issues warranting involuntary hospitalization.
Substance Hx: Pt reports alcohol history- “3 to 6 beers a month then I have a blackout and do stuff that I don’t remember the next day. Pt states that he smokes about 4-5 tobacco cigarettes monthly; caffeinated products: Occasional cup of caffeinated coffee.
Family Hx: Father died from cancer in 1980.
Weight: 260 pounds, Height: 5′ 4”, B.P (Sitting): 140 / 72, Resp: 18, Pulse (Sitting): 97 BPM
Past Medical History: Diabetes, HTN and hyperlipidemia.
Allergies/Adverse reactions: PCN, molds, trees, perfumes
Plan/Recommendations:
1. Discussed the effects of alcohol, cannabis, PCP, and other substances and advised patient to avoid substance use.
2. Continued quetiapine 300mg every night.
3. Reordered fluphenazine elixir 5mg (10mL) every morning.
3. Follow up in 4 weeks.
4. Call or return sooner as needed for worsening symptoms.
5. Seek immediate professional assistance and get to an ER for thoughts of suicide or of harming others.

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