CASE STUDY 2
Psychiatric SOAP Note Template
Criteria Clinical Notes
Subjective Patient name: Justin Johnson
Gender: Male
Age: 19 y/o
Chief
... [Show More] complaint: c/o problems at school
HPI (History of present illness): The patient
(Justin Johnson) is a 19 y/o male who presents
was accompanied by his mother and presented
with c/o problems at school. The patient
reports that he was expelled from college two
months ago for breaking into a building on
campus and shouting that the dean wanted to
steal his intellectual property. The patient’s
mother reports that his behavior started
changing about six months ago after he
stopped taking his medication
(methylphenidate) for Attention-deficit
hyperactive disorder. Additionally, the patient
admits he had stopped attending classes and
began to smoke more marijuana. Moreover, he
states that he was detached from social
interaction and seemed to be “obsessed” with
research, specifically in academic plagiarism.
His mother reports that she had observed
manifestations of paranoid ideation as well as
ritualistic behaviors in the patient over the past
two months while at home, he had neglected
his personal hygiene, slept during the day, and
avoided engaging in activities that were
previously enjoyable. Notably, the patient had
repetitive head-tilting movements, staring
spells, and scratching of the left ear.
Past medical and psychiatric history: The
patient has a h/o childhood asthma (he used an
albuterol inhaler and his last episode of asthma
occurred when he was ten years old) and
ADHD. Additionally, the patient had a single
and brief episode of fear to leave the house and
talking to himself at the age of thirteen years,
which was attributed to the type of ADHD
medication he was using. However, his
behavior returned to normal after his
medication was changed.
Social history: Justin is a male student who
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CASE STUDY 3
was expelled from college recently. He reports
the use of marijuana and detachment from
social interaction.
Family history: Justin’s paternal uncle has a
h/o mental illness and his maternal aunt has a
h/o seizure disorder.
Objective ROS (Review of systems)
General: The patient reports paranoid
delusions, social withdrawal, ritualistic
behaviors, irritability, auditory hallucinations,
he but denies fever, weakness, or weight loss.
Skin: The patient denies rashes or lesions
HEENT: Denies headaches, visual
disturbances, hearing problems, throat
soreness, or nasal congestion.
Neck: Denies neck stiffness or pain.
Lungs: Denies cough or shortness of breath.
Cardiovascular: Denies chest tightness, pain,
or palpitations.
Gastrointestinal: Denies constipation,
abdominal pain, or vomiting.
Genitourinary: Denies polyuria, hematuria, or
dysuria.
Neurological: Denies seizure activity, taste
changes, anxiety, or numbness.
Musculoskeletal: Denies joint pain, back pain,
or joint swelling.
Psychological: Reports paranoid delusions,
personality change, social withdrawal, auditory
hallucinations, irritability, poor hygiene and
grooming, self-neglect, and h/o ADHD.
Mental status exam:
Orientation: Oriented to place, person, and
time
Appearance: Poorly groomed, self-neglect,
poor hygiene, starring at the wall
Behavior: Repetitive head-tilting movements,
staring spells, and scratching of the left ear.
Speech and language: Disorganized speech
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CASE STUDY 4
Attitude: Uncooperative
Affect: Flat affect
Thought processes: Illogical and unfocused
Thought content: Delusional thinking noted
Suicidal ideation: No suicidal/homicidal
ideation
Insight: Fair
Physical exam
Vital signs: BP: 118/82 mmHg
(Supine/sitting), 116/74 mmHg (Upon
standing) Temp: 98.6F (Oral) HR: 74 bpm
(Regular) RR: 16 Ht: 5’10’’ Wt: 180lbs BMI
(percentile): 25.8 SpO2: 100% on room air
General: Overweight male who is poorly
groomed and has poor hygiene with a strong
body odor
Skin: Warm, dry
HEENT: Normocephalic/atraumatic, starring
at the wall, head tilted to the left, scratching
behind the ear. Flat affect. no nasal discharge
Neck: No thyromegaly, JVD, or thyroid
masses
Lungs: CTA (Clear to auscultation) bilaterally
Cardiovascular: RRR (Regular, rate, and
rhythm), no murmur or gallops
Gastrointestinal: Soft and non-tender
Neurological: CN II-XII intact
Musculoskeletal: No dystonia or joint
tenderness
Psychological: A & O X 3, disorganized
speech, delusions noted
Lab results
Name Value Detection
time
Amphetamines None
detected
5 days
Benzodiazepines positive 6 weeks
Barbiturates None
detected
21 days
Cannabis (THC) Positive 4-6 weeks
Codeine None 5 days
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CASE STUDY 5
detected
Cocaine None
detected
7 days
Heroine None
detected
5 days
LSD None
detected
8 hours
MDMA (ecstasy) None
detected
24 hours
Methamphetamine
(Meth)
None
detected
3-5 days
Methaqualone
(Quaalude)
None
detected
2 weeks
Phencyclidine None
detected
5 days
Morphine/Opium None
detected
4-5 days
Assessment Differential diagnoses
1. Paranoid schizophrenia (ICD-10 code:
F20. 0)
2. Substance-induced psychotic disorder
(ICD-10 code: F19. 150)
3. Major depressive disorder (ICD-10
code: F33. 1)
4. Bipolar I disorder (ICD-10 code: F31.
1)
5. Obsessive-compulsive disorder (ICD10 code: F42. 9)
Primary diagnosis
1. Paranoid schizophrenia (ICD-10 code:
F20. 0)
Based on the physical examination findings,
objective data, and laboratory evidence, and
subjective data, paranoid schizophrenia
features as the primary diagnosis for this client.
This diagnosis is supported by the presence of
auditory hallucinations, paranoid delusions as
well as negative symptoms like lack of eye
contact, social withdrawal, self-neglect, and
poor hygiene (Chan, 2017).
The DSM-5 criteria for this diagnosis include;
the presence of paranoid delusions,
disorganized speech, hallucinations, negative
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CASE STUDY 6
symptoms, and catatonic behavior
(Biedermann & Fleischhacker, 2016). As such,
a patient ought to have at least two of the
aforementioned symptoms for at least one
month to be diagnosed with this disorder. The
subjective information indicates [Show Less]