Focused SOAP Note and Patient Case Presentation

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Week (week # 9): (Enter assignment title)
Subjective:
CC (chief complaint): The patient complains of having extreme difficulties in coping and interacting with other people. He states that he has been facing infrequent hallucinations, where he sees shadows and animals or hears strange voices. Similarly, his sleep pattern has been interrupted, thus, causing him to have a chronic struggle when falling asleep. He claims that he does not feel rested when he wakes up because of the sleep interruptions and recurrent nightmares that he has been experiencing lately. Moreover, he notes that he has a severe concentration problem and a decrease in energy. Besides, his weight has been rising significantly, due to an increase in his calorie intake.
HPI: P.T. is a 27-year-old Caucasian male that presents to the clinic for follow-up treatment of Schizophrenia Spectrum, severe alcohol use, and cannabis use disorder, among other psychotic conditions. The patient was diagnosed with Schizophrenia Spectrum in 2007 because of paranoia and both visual and auditory command hallucinations of shadows and animals. He also has an extended history of cannabis use and has been arrested multiple times due to violence and substance abuse. Similarly, he has been having mood problems since 2013 and has tried to commit suicide by jumping out of a moving vehicle. Furthermore, he has had tangential and disorganized thinking, where he felt out of control and had plans to fly a helicopter, bungee jump, and go skating. He is currently under psychotropic medications.
Substance Current Use: P.T. reports a history of marijuana and alcohol use. His last usage of marijuana was on 1st April 2022, and alcohol was last weekend. He claims to take 3 to 6 beers a month, after which he blacks out and does things that he cannot recall the following day. P.T. also suggests that he smokes about 4 to 5 cigarettes per month and takes an occasional cup of caffeinated coffee.
Medical History:

Current Medications: Quetiapine 300mg every night and fluphenazine elixir 5mg (10mL) every morning.
Allergies: The patient is allergic to perfumes, molds, trees, and PCN.

Reproductive History: None.

REVIEW OF SYSTEM:

GENERAL: Reports weight gain, sleep disturbance, hallucinations, decreased energy, and chronic concentration problems.
HEENT: No blurred vision, visual loss, yellow sclerae, or double vision. No sneezing, hearing loss, running nose, sore throat, or congestion.
SKIN: No itching or rashes.
CARDIOVASCULAR: No chest discomfort, pressure, or pain. No edema or palpitation.
RESPIRATORY: No cough, sputum, or shortness of breath.
GASTROINTESTINAL: No vomiting, nausea, diarrhea, or anorexia. No blood or abdominal pain.
GENITOURINARY: No odor, hesitancy, odd color, or burning on urination.
NEUROLOGICAL: No dizziness, numbness, headache, syncope, ataxia, paralysis, or tingling in the extremities. No change in bladder control or bowel movement.
MUSCULOSKELETAL: No stiffness, muscle pain, joint pain, or back pain.
HEMATOLOGIC: No history of splenectomy or enlarged nodes.
LYMPHATICS: No bruising, bleeding, or anemia.
ENDOCRINOLOGIC: No reports of heat intolerance, cold, or sweating. No polydipsia or polyuria.

Objective:
Diagnostic results: No X-rays or lab reports.
Assessment:
Mental Status Examination: P.T. is a 27-year-old Caucasian male who looks older than his stated age. He seems alert and oriented to time situation, and place. He is cooperative and dressed appropriately. He has also not shown any symptoms of abnormal motor activity. His speech is coherent, clear, and normal in tone and volume. His thought processes are logical and goal-oriented. Similarly, there is no evidence of flight of ideas or looseness of association. The patient appears to be excited and in a good mood. He, however, complains of auditory and visual hallucinations of shadows and animals. P.T. has a history of delusional thinking, where he felt out of control and planned to fly a helicopter, go skating, and bungee jump. Nevertheless, he denies any current homicidal or suicidal ideation. Moreover, he has good insight and his recent memory seems to be intact. The client has a severe problem with concentration.
Diagnostic Impression: Substance-induced Psychotic Disorder, Schizoaffective disorder, Bipolar.

My primary diagnosis for the patient is Substance-Induced Psychotic Disorder. This is a mental health disorder that occurs as a result of substance use or abuse (Lysaker et al., 2018) In this case, P.T. has a long history of severe alcohol and Marijuana use. He has also been experiencing signs and symptoms that are commonly associated with the ailment including both visual and auditory hallucinations, decreased energy, loss of interest in socializing activities, history of disorganized thinking, severe sleep, and concentration problems. He also meets the DSM-5 diagnostic criteria for Substance-Induced Psychotic Disorder (Pearson & Berry, 2019). For instance, his current symptoms developed during the period of substance use and can be linked to Marijuana and alcohol abuse (Pearson & Berry, 2019). Similarly, the effects of the disease are affecting the relationships and the general health of the patient. The other differential diagnosis, therefore, do not meet all the requirements of the DSM-5 guidelines.
Reflections: P.T seems to have a serious problem with alcohol and Marijuana abuse which has significantly affected the quality of his life. His symptoms have also worsened compared to the results of his last appointment. I would, thus, conduct more tests and evaluations if given another opportunity to ascertain the patient’s current health condition. I would also want to determine his triggers for substance abuse and walk closely with the client to help him overcome his drug addiction and promote his health outcomes (Lysaker et al., 2018). My next intervention will, thus, include a follow-up and a treatment plan that will focus on minimizing his symptoms and promoting his wellbeing.
Case Formulation and Treatment Plan:
I have recommended the patient to receive substance abuse counseling and join a health support group, where he will be monitored closely to facilitate his mental health and promote positive health outcomes. I have also discussed with him the significance of taking his medications as prescribed and their potential side effects. For instance, he is likely to experience dizziness, general body weakness, vomiting, and constipation from taking quetiapine (Shader, 2019). Similarly, taking fluphenazine elixir might cause him to suffer from insomnia, weight changes, restlessness, rash, and endocrine effects, among other adverse reactions (Shader, 2019). P.T is advised not to stop medication or treatment abruptly without the knowledge or consent of a healthcare provider. Discussed the dangers of combining medication with alcohol, cannabis, herbal, and OTC drugs. Highlighted the effects of his alcohol addiction and Marijuana on his physical and mental health. Encouraged the client to minimize his beer intake and receive therapy to help him adopt healthy habits (Shattock et al., 2018). P.T to continue taking fluphenazine elixir 5mg (10mL) every morning and quetiapine 300mg each night to help minimize and manage his symptoms. The client is also encouraged to continue with treatment and case management to ensure his welfare and facilitate his recovery.
The client is provided with emergency numbers and instructed to call 911 or go to the nearest ER if they experience any adverse effects from the medication or become actively homicidal or suicidal. Reviewed therapist and hospital records for collaborative data and information (Hastings, 2019). Patient is allowed time for questions and provided with appropriate answers. In this case, he appears to comprehend the discussion and agrees to adhere to the treatment plan as recommended. P.T is also advised to come for a follow-up in four weeks and continue with his treatment to prevent the need for additional or higher levels of care.
 
 

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