For this Assignment, you will complete a focused SOAP note for a patient in a case study who has either a schizophrenia spectrum, other psychotic, or medication-induced movement disorder.
Patient: John Doe
Age: 35
Gender: Male
Chief Complaint: Delusions and hallucinations
History of Present Illness: John Doe is a 35-year-old male who presents with a chief complaint of delusions and hallucinations. He reports hearing voices that no one else can hear and believes that people are plotting against him. He also reports feeling paranoid and afraid of leaving his house. These symptoms have been present for the past two weeks and have been progressively worsening. APA
Medical History: John Doe has a history of schizophrenia and has been non-compliant with his medication regimen for the past year. He has a history of substance abuse, including alcohol and marijuana. Medication-induced movement disorder.
Current Medications: None
Allergies: None
Vital Signs: BP 130/80, HR 85, RR 16, T 98.6 F
Mental Status Examination:
Appearance: John Doe appears disheveled and unkempt.
Behavior: John Doe appears agitated and fidgety.
Speech: John Doe’s speech is rapid and pressured.
Mood/Affect: John Doe’s mood is anxious, and his affect is constricted.
Thought Process/Content: John Doe’s thought process is disorganized, and his thought content is dominated by paranoid delusions and auditory hallucinations.
Insight/Judgment: John Doe lacks insight into his condition and has poor judgment.
Assessment:
John Doe is a 35-year-old male with a history of schizophrenia who presents with worsening symptoms of delusions and hallucinations. He has been non-compliant with his medication regimen for the past year and has a history of substance abuse.
Plan:
- Admit John Doe to the psychiatric unit for stabilization and treatment of his psychosis.
- Initiate antipsychotic medication and monitor for side effects.
- Implement a structured daily routine and activities to promote stability.
- Conduct individual therapy to address John Doe’s delusions and hallucinations.
- Refer John Doe to a substance abuse treatment program.
- Consult with a social worker to assist with John Doe’s discharge planning and follow-up care.
Follow-Up:
John Doe will be monitored closely for improvement in his symptoms and potential side effects of his medication. A treatment plan will be developed to address his ongoing needs, including medication management, therapy, and support services. Discharge planning will involve coordination with community resources to ensure continuity of care.
