Focused SOAP Note
Patient Information:
S.T, 53, M, White
S.
CC (chief complaint): Forgetfulness, seeing imaginary things and sounds, and losing touch of reality. These symptoms have been increasingly concerning to both the patient and his family.
HPI: S.T is a 53-year-old patient who is brought to the clinic by his sister due to the worsening symptoms of seeing and hearing imaginary people and sounds. His sister reports that these symptoms have significantly impacted his daily functioning. He believes some people are spying on his life and he cannot remember the day correctly. This belief has caused him considerable distress and confusion. The symptoms have been persisting for weeks. Despite the duration, he has not sought medical attention until now. He has a history of smoking and taking marijuana. This substance use may be contributing to his current mental state.
Current Medications: No current medication. The absence of medication suggests that his symptoms are not being managed pharmacologically.
Allergies: No known drug allergies. This information is crucial for considering future treatment options.
PMHx: The patient reports he has been hearing imaginary sounds and people for weeks. This persistent auditory hallucination is a key symptom in his presentation.
Soc and Substance Hx: The patient has a history of smoking and abusing marijuana. His substance use history may be relevant to his psychiatric symptoms. He denies history of cocaine. This denial helps narrow down potential substance-related causes.
Fam Hx: Lives with the sister. His living situation may provide some support but also stress.
Surgical Hx: No history of surgical operations. This lack of surgical history simplifies his medical background.
Mental Hx: Mother reports a history of suicide. This family history may indicate a genetic predisposition to mental health issues. Denies history of suicide. His denial suggests he may not have personal suicidal ideation at this time.
Violence Hx: The father was rough on the siblings until his death. This history of familial violence could have long-term psychological effects.
Reproductive Hx: No history of children or marriage. This may impact his social support network.
ROS:
GENERAL: A 53-year-old male who is having imaginary sounds and voices addressing people. These hallucinations are a significant part of his current condition. He cannot tell the exact day of the week or month. This disorientation is concerning for his cognitive function.
HEENT: No hearing problems. This suggests that his auditory hallucinations are not due to a primary hearing issue.
SKIN: No lesions or itching. His skin condition appears normal.
CARDIOVASCULAR: No chest discomfort or pain. This indicates no immediate cardiovascular concerns.
RESPIRATORY: No shortness of breath or sputum. His respiratory system seems unaffected.
GASTROINTESTINAL: No vomiting, diarrhea, or nausea. His gastrointestinal health is stable.
GENITOURINARY: No burning on urination. This suggests no current genitourinary issues.
NEUROLOGICAL: No dizziness or numbness. His neurological symptoms are primarily psychiatric.
MUSCULOSKELETAL: No muscle pain or stiffness. His musculoskeletal system is not contributing to his symptoms.
HEMATOLOGIC: No bleeding or anemia. His hematologic status is normal.
LYMPHATICS: No enlarged lymph nodes. This indicates no apparent lymphatic issues.
PSYCHIATRIC: Cannot comprehend exact day or location. This cognitive impairment is significant. The patient sees imaginary people, hearing imaginary sounds. These hallucinations are central to his psychiatric presentation. Mother reports a history of suicide. This family history is relevant to his risk assessment. Denies history of suicide. His denial is important for current safety planning.
ENDOCRINOLOGIC: No polyuria. His endocrine function appears normal.
ALLERGIES: No known drug allergies. This is important for future treatment considerations.
Diagnostic results:
Labs: There is no lab test to evaluate for Schizophrenia. This highlights the need for a clinical diagnosis. An experienced mental health professional will be required to examine the patient’s behavior and medical history. This evaluation is crucial for accurate diagnosis. A complete blood count and urine tests are effective in ruling out the conditions that can cause hallucinations and symptoms related to schizophrenia. These tests help exclude other medical causes.
A.
Mental Status Examination: The patient is a 53-year-old patient who presents to the clinic under the recommendation of the sister. His sister’s involvement suggests family concern. He is cooperative during the clinic, but he does not have a touch of reality. His cooperation is positive, but his disconnection from reality is concerning. His memory of time and date is not clear. This memory issue is a significant cognitive symptom. He sees things that others cannot see and hears voices that other people cannot hear. These hallucinations are key symptoms of his condition. He has a history of smoking and abusing marijuana. This history may be relevant to his symptoms. The speech is clear and coherent and answers questions effectively. His speech clarity is a positive sign. The recent and remote memory is not intact. This memory impairment is concerning for his cognitive health.
Differential Diagnoses:
F20.9: Schizophrenia, unspecified: Unspecified schizophrenia spectrum can occur alongside other psychotic disorders. This diagnosis considers the broad spectrum of symptoms. The condition affects the life of an individual until they cannot function normally. This impact is evident in the patient’s current state. The symptoms of schizophrenia include delusions, hallucinations, and abnormal behavior (Archibald et al., 2019). These symptoms align with the patient’s presentation. The patient is likely suffering from schizophrenia since he hears voices from people that other people, such as the sister, cannot hear. This auditory hallucination is a classic symptom. For instance, he hears loud music that the sister and other people cannot hear (Archibald et al., 2019). This specific example illustrates his hallucinations. The patient may be suffering from schizophrenia, among other co-occurring disorders. Co-occurring disorders could complicate his diagnosis.
F23: Brief psychotic disorder: The condition involves a display of psychotic behavior that involves delusions and hallucinations. These symptoms are present in the patient. Psychosis involves a lack of touch with reality (Smith et al., 2020). This is evident in the patient’s disorientation. For example, the patient believes some people are after him and have been sent to spy on his life. This delusion is a key symptom. The condition can occur with a possibility of future relapses (Smith et al., 2020). This potential for relapse is important for treatment planning. The patient could be suffering from a brief psychotic disorder due to the behavior of losing touch with reality. This diagnosis considers the acute nature of his symptoms.
F22 Delusional Disorders: Delusion behavior occurs and impairs the cognition of the patients. This impairment is evident in the patient’s presentation. It affects individuals until they cannot differentiate between the imagined and real-world (Miola et al., 2020). This is a significant issue for the patient. The patient could be suffering from delusional disorders due to the conversations about time and place (Miola et al., 2020). His confusion about time and place supports this diagnosis. For instance, the person claims that some people are out to get him and harm him. This specific delusion is a key symptom.
F31.2 Bipolar I Disorder with psychotic features: The condition involves a combination of mania, depression, hallucination, lack of touch with reality, and disordered thinking. These symptoms overlap with the patient’s presentation. Individuals with bipolar disorder can experience a hard time due to the hallucinations (Trisha et al., 2018). This could explain some of the patient’s symptoms. In some cases, severe mania and depression can lead to dangerous behavior. This risk is important for safety planning.
Plan:
The patient should start psychotherapy sessions immediately. Early intervention is crucial for managing his symptoms. The psychotherapists will use cognitive behavior therapy to address the delusions and hallucinations. This therapeutic approach is evidence-based for psychotic symptoms. The psychotherapists can take 10-12 sessions. This structured approach provides a timeline for treatment. A session with the sister or a significant member of the family is critical to enhancing family support. Family involvement can improve treatment outcomes. A combination of the medication to address the hallucinations and delusions can be recommended depending on the outcome and health of the patient (Trisha et al., 2018). Medication may be necessary if symptoms persist. The patient should take therapy sessions each week and homework assignments to be completed at home. This regular schedule helps reinforce therapeutic gains. It is vital to report every week for review. Regular reviews allow for monitoring progress. It is critical to educate the patient to avoid drugs that can trigger hallucinations, such as marijuana. Substance avoidance is important for symptom management.
Reflection:
If I conducted the treatment interview again, I would ask questions about past psychiatric treatment. This information could provide insights into previous interventions. I would ask the patient about their experience when they take drugs such as marijuana. Understanding the effects of substances on his symptoms is crucial. I would ask the patient about the severity of the hallucinations. This would help gauge the impact on his daily life. I will also seek to interview the sister, who will explain the severity of the condition. Her perspective could provide additional context. The sister will explain any intervention they have made at home and the patient’s behavior at home. This information is valuable for understanding the home environment. I will also order urine tests to examine if the patient is abusing other drugs that could be causing hallucinations. This could help rule out substance-induced psychosis. I will ensure I follow up with the patient to ensure they are making improvements. Follow-up is essential for ongoing care. I would combine both therapy and medication to enhance the positive results. This combination approach is often more effective. During the provision of care, I will ensure I observe confidentiality by avoiding sharing information with third parties without the patient’s permission. Confidentiality is a fundamental ethical principle. I will observe veracity by telling the truth, such as the effect of marijuana on hallucinations (Rainer et al., 2018). Honesty is crucial for building trust. I will observe justice and fairness by ensuring the patient is treated kindly and professionally without bias. Fair treatment is essential for ethical care. It will be critical to ensure non-maleficence and beneficence to avoid harm (Rainer et al., 2018). These principles guide ethical decision-making. The decisions made during therapy and prescription of medication should be made professionally and with caution. Professionalism ensures patient safety. The health promotion activities will encourage the patient to avoid drugs and substances that can affect the brain chemicals (Archibald et al., 2019). Education on substance use is a key component of health promotion. For instance, it will be crucial to caution against abusing marijuana and other prescription drugs. This advice is important for preventing relapse. I will encourage the patient to observe an environment free of stress and conducive to allowing the brain to function at optimal levels. A supportive environment can enhance recovery.
