SOAP NOTES

DR. MOORE: Good afternoon. I’m Dr. Moore. Want to thank you for coming in for your appointment today. I’m going to be asking you some questions about your history and some symptoms. And to get started, I just want to ensure I have the right patient and chart. So can you tell me your name and your date of birth? SHERMAN TREMAINE: I’m Sherman Tremaine, and Tremaine is my game game. My birthday is November 3, 1968. DR. MOORE: Great. And can you tell me today’s date? Like the day of the week, and where we are today? SHERMAN TREMAINE: Use any recent date, and any location is OK. DR. MOORE: OK, Sherman. What about do you know what month this is? SHERMAN TREMAINE: It’s March 18. DR. MOORE: And the day of the week? SHERMAN TREMAINE: Oh, it’s a Wednesday or maybe a Thursday. DR. MOORE: OK. And where are we today? SHERMAN TREMAINE: I believe we’re in your office, Dr. Moore. DR. MOORE: OK, great. So tell me a little bit about what brings you in today. What brings you here? SHERMAN TREMAINE: Well, my sister made me come in. I was living with my mom, and she died. I was living, and not bothering anyone, and those people-those people, they just won’t leave me alone. DR. MOORE: What people? SHERMAN TREMAINE: The ones outside my window watching. They watch me. I can hear them, and I see their shadows. They think I don’t see them, but I do. The government sent them to watch me, so my taxes are high, so high in the sky. Do you see that bird? DR. MOORE: Sherman, how long have you saw or heard these people? SHERMAN TREMAINE: Oh, for weeks, weeks and weeks and weeks. Hear that– hear that heavy metal music? They want you to think it’s weak, but it’s heavy. DR. MOORE: No, Sherman. I don’t see any birds or hear any music. Do you sleep well, Sherman? SHERMAN TREMAINE: I try to but the voices are loud. They keep me up for days and days. I try to watch TV, but they watch me through the screen, and they come in and poison my food. I tricked them though. I tricked them. I locked everything up in the fridge. They aren’t getting in there. Can I smoke? DR. MOORE: No, Sherman. There is no smoking here. How much do you usually smoke? SHERMAN TREMAINE: Well, I smoke all day, all day. Three packs a day. DR. MOORE: Three packs a day. OK. What about alcohol? When was your last drink? SHERMAN TREMAINE: Oh, yesterday. My sister buys me a 12-pack, and tells me to make it last until next week’s grocery run. I don’t go to the grocery store. They play too loud of the heavy metal music. They also follow me there. DR. MOORE: What about marijuana? SHERMAN TREMAINE: Yes, but not since my mom died three years ago. DR. MOORE: Use any cocaine? SHERMAN TREMAINE: No, no, no, no, no, no, no. No drugs ever, clever, ever. DR. MOORE: What about any blackouts or seizures or see or hear things from drugs or alcohol? SHERMAN TREMAINE: No, no, never a clever [INAUDIBLE] ever. DR. MOORE: What about any DUIs or legal issues from drugs or alcohol? SHERMAN TREMAINE: Never clever’s ever. DR. MOORE: OK. What about any medication for your mental health? Have you tried those before, and what was your reaction to them? SHERMAN TREMAINE: I hate Haldol and Thorazine. No, no, I’m not going to take it. Risperidone gave me boobs. No, I’m not going to take it. Seroquel, that is OK. But they’re all poison, nope, not going to take it. DR. MOORE: OK. So tell me, any blood relatives have any mental health or substance abuse issues? SHERMAN TREMAINE: They say that my dad was crazy with paranoid schizophrenia. He did in the old state hospital. They gave him his beer there. Can you believe that? Not like them today. My mom had anxiety. DR. MOORE: Did any blood relatives commit suicide? SHERMAN TREMAINE: Oh, no demons there. No, no. DR. MOORE: What about you? Have you ever done anything like cut yourself, or had any thoughts about killing yourself or anyone else? SHERMAN TREMAINE: I already told you. No demons there. Have been in the hospital three times though when I was 20. DR. MOORE: OK. What about any medical issues? Do you have any medical problems? SHERMAN TREMAINE: Ooh, I take metformin for diabetes. Had or I have a fatty liver, they say, but they never saw it. So I don’t know unless the aliens told them. DR. MOORE: OK. So who raised you? SHERMAN TREMAINE: My mom and my sister. DR. MOORE: And who do you live with now? SHERMAN TREMAINE: Myself, but my sister’s plotting with the government to change that. They tapped my phone. DR. MOORE: OK. Have you ever been married? Are you single, widowed, or divorced? SHERMAN TREMAINE: I’ve never been married. DR. MOORE: Do you have any children? SHERMAN TREMAINE: No. DR. MOORE: OK. What is your highest level of education? SHERMAN TREMAINE: I went to the 10th grade. DR. MOORE: And what do you like to do for fun? SHERMAN TREMAINE: I don’t work, so smoking and drinking pop. DR. MOORE: OK. Have you ever been arrested or convicted for anything legally? SHERMAN TREMAINE: No, but they have told me they would. They have told me they would if I didn’t stop calling 911 about the people outside. DR. MOORE: OK. What about any kind of trauma as a child or an adult? Like physical, sexual, emotional abuse. SHERMAN TREMAINE: My dad was rough on us until he died. DR. MOORE: OK. [MUSIC PLAYING] So thank you for answering those questions for me. Now, let’s talk about how I can best help you. [MUSIC PLAYING] Develop a focused SOAP note, including your differential diagnosis and critical-thinking process to formulate a primary diagnosis. Incorporate the following into your responses in the template: • 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 the patient’s mental status examination results. What were your differential diagnoses? Provide a minimum of three possible diagnoses with supporting evidence, and list them in order from highest priority to lowest priority. Compare the DSM-5-TR diagnostic criteria for each differential diagnosis and explain what DSM-5-TR criteria rules out the differential diagnosis to find an accurate diagnosis. Explain the critical-thinking process that led you to the primary diagnosis you selected. Include pertinent positives and pertinent negatives for the specific patient case. • Plan: What is your plan for psychotherapy? What is 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. Also incorporate one health promotion activity and one patient education strategy. • Reflection notes: What would you do differently with this patient if you could conduct the session again? Discuss what your next intervention would be if you were able to follow up with this patient. Also include in your reflection a discussion related to legal/ethical considerations (demonstrate critical thinking beyond confidentiality and consent for treatment!), health promotion, and disease prevention, taking into consideration patient factors (such as age, ethnic group, etc.), PMH, and other risk factors (e.g., socioeconomic, cultural background, etc.). • Provide at least three evidence-based, peer-reviewed journal articles or evidenced-based guidelines that relate to this case to support your diagnostics and differential diagnoses. Be sure they are current (no more than 5 years old).

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