NUR 664C- IHuman Week 13:
Justin Johnson,19 yrs Old Male
CC: Problems at school
Case Study
Johan Bello
IHuman week 13
Regis College
Class:
... [Show More] NU-664C-02-20PCFA FamilyPsychiatric Ment.Hlth I
CASE STUDY 2
Psychiatric SOAP Note Template
Criteria Clinical Notes
Subjective Patient name: Justin Johnson
Gender: Male
Age: 19 y/o
Chief 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
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 [Show Less]