Please make a detailed case study of a patient with schizoaffective disorder, bipolar type.

SOAP Note

DEMOGRAPHIC INFORMATION

IDENTIFYING INFORMATION:

Patient:

DOS:

Informant:

SUBJECTIVE DATA

CC:

HISTORY OF PRESENT ILLNESS: (SUBJECTIVE).

PAST PSYCHIATRIC HISTORY:

PREVIOUS PSYCHIATRIC MEDICATIONS:

CURRENT MEDICATIONS:

SUBSTANCE USE/ ADDICTIVE BEHAVIORS:

FAMILY PSYCHIATRIC HISTORY:

MEDICAL HISTORY:

Allergies

PSYCHOSOCIAL:

OBJECTIVE DATA

MENTAL STATUS EXAM: (OBJECTIVE).

Mental Status Exam Elements-

A- Appearance

Height, build, hair color, style, facial hair, body modifications, facial features, scars, grooming, hygiene, odors, clothing, make-up, impression of general appearance and memorable aspects.

B- Behavior

Attitude

Motor activity

S- Speech

General quality

Fluency

Amount

Rate

Tone

Volume

Prosody

Spontaneity or Latency

A- Affect

Qualities of Affect

Stability

Appropriateness

Range

Intensity

Mood as defined by patient. Usually in quotation marks

T- Thought process

Flow and processing of thought. Examples:

Circumstantiality

Clang associations

Fight of ideas

Perseveration

Thought blocking

T- Thought content

Suicidal ideation (SI), Homicidal ideation (HI), Violent ideation (VI). If + comment on intent, plan, and preparation

Psychotic ideation or perceptual disturbances. Examples:

Delusions or hallucinations

Obsessional thoughts

Compulsions

Ideas of reference

Paranoia (suspiciousness)

Significant themes related to diagnosis

C- Cognitive exam - consider educational attainment when interpreting results.

Alertness

Orientation

Concentration

Memory (long and short term)

Calculation

Fund of knowledge

Abstract reasoning

Insight

Judgment

PHYSICAL EXAM: (VS, HT, WT, LABWORK AND OTHER DIAGNOSTICS)

DIFFERENTIAL DIAGNOSES:

DIAGNOSTIC IMPRESSION WITH FORMULATION:

RECOMMENDATIONS AND PLAN WITH GOALS AND RATIONALES WITH NEUROBIOLOGY:

Please include references.