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: Focused Soap Note For Anxiety Ptsd And OCD Focused Soap Note For Anxiety Ptsd And OCD Subjective: What details did the patient provide
Focused Soap Note For Anxiety Ptsd And OCD
Subjective:
CC (chief complaint): The patient (Sherman Tremaine) claims that individuals are watching him outside his window. According to him, he can hear them and see their shadows.
HPI: Sherman Tremaine was born on November 3, 1968. He complains primarily about being monitored outside his window. The patient claims to be able to hear and see the shadows of people outside his window. The patient’s mother passed away while she was still living with him. The patient said the government had sent the people to watch him. His taxes have increased as a result of this. According to the patient, he has been seeing these people for a while. The patient claims to have seen and heard an imaginary bird and heavy metal music while speaking with Dr. Moore. Additionally, loud sounds have been the source of the patient’s insomnia. Every day, Sherman smokes three packs. He admits to drinking alcohol. He claims that his sister purchases him a 12-pack weekly. Three years have passed since Sherman last smoked marijuana. He claims to never have used cocaine. Additionally, he has never experienced seizures, blackouts, or hallucinations induced by drugs. The patient wants to quit taking his prescriptions because he believes they are toxins. Risperidone, Seroquel, Haldol, and Thorazine are some of the drugs that the patient has been taking. Sherman’s family history shows that his mother experienced anxiety while his father had paranoid schizophrenia. The patient does not have suicide ideas, and his family has not reported any incidents either. The patient is using Metformin to manage diabetes mellitus. The patient claims that his father treated them harshly up to his death. Get in touch with us at eminencepapers.com. We offer assignment help with high professionalism.
Substance Current Use: Sherman smokes three packs daily. Furthermore, he drinks a 12-pack every week.
Medical History:
Current Medications: Metformin for diabetes mellitus. He reports having stopped taking Risperidone, Seroquel, Haldol, and Thorazine because he believes that they are poisons due to their adverse effects.
Allergies: No known drug and food allergies.
Reproductive Hx: No pertinent history
ROS:
GENERAL: No fever, chills, malaise, or weakness.
HEENT: Normocephalic, no blurred vision, no retinal edema, no diplopia, no conjunctivitis, no hearing impairment, no nasal congestion or rhinorrhea, no pharyngitis or exudate.
SKIN: no bruising, pruritus, or ulcers. Normal turgor without rashes.
CARDIOVASCULAR: No arrhythmia, hypertension, or heart gallops.
RESPIRATORY: No respiratory distress, shortness of breath, or dyspnea.
GASTROINTESTINAL: No nausea, vomiting, diarrhea, or constipation.
GENITOURINARY: No discharge, masses, dysuria, nocturnal enuresis, or polyuria.
NEUROLOGICAL: No headache, syncope, or ataxia. Normal proprioception.
MUSCULOSKELETAL: No arthritis, myositis, or myalgia. Normal range of motion.
HEMATOLOGIC: No anemia, leukocytosis, or leukopenia.
LYMPHATICS: normal lymphatic drainage and distribution.
ENDOCRINOLOGIC: insulin resistance due to diabetes mellitus, no hyperhidrosis.
Objective:
Diagnostic results: The patient is well-oriented to time and placed in time and space. He participates in the interview and answers the questions correctly. However, the patient demonstrates disorganized speech and auditory and visual hallucinations. In this scenario, laboratory tests are not necessary.
Assessment:
Mental Status Examination: The patient’s physical characteristics match his reported age. He answers all of the examiner’s questions cooperatively. He displays circumstantiality. Furthermore, the patient experiences auditory and visual hallucinations, as evidenced by his sighting and hearing of an imaginary bird and music. Additionally, the patient demonstrates disorganized speech.
Diagnostic Impression: Three potential diagnoses can be developed for this patient: schizophreniform disorder, paranoid schizophrenia, and schizoaffective disorder. In this context, the patient presents with disorganized speech and auditory and visual hallucinations. According to the DSM-5-TR, a patient with paranoid schizophrenia should present with at least two symptoms identified by the diagnostic criteria (Florida Medicaid Mental Health.org, 2019). The symptoms should be present for more than six