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Running head: SOAP NOTES
Schizotypal Personality Disorder
Patient Name: Richard Simpson
Date Examined: 6/4/2021
Time Examined: 14:00
Examination Duration: 45 minutes
Subjective (S): The 19-year-old Caucasian male was accompanied to the hospital by his parents
after exhibiting odd behaviors. The parents described the patient as an odd teenager who
experiences challenges in socializing with friends and family members. According to the parents,
their son prefers locking himself in his bedroom and using the internet during the holidays. At
this point, the patient explained that he prefers researching paranormal events instead of
interacting with family members, neighbors, and classmates. The patient indicated that he is
attracted to films or narratives describing paranormal events. The patient explained that he
avoids cats, dogs, and friends at school since they may be possessed by evil spirits. The patient
believed that pets and friends would betray him.
Objective (O): Vital signs: BP: 120/75 mmHg, BMI: 23.5, Height: 5’7’’, T: 98.2 Degrees
Mental Status Exam (MSE):
Appearance: The patient appeared shaggy, detached, and shy. The patient wore a heavy
black coat despite the weather being hot. The patient also avoided eye contact and
laughed inappropriately during the interview.
Speech: The patient’s speech was vague and rambling.
Mood: The patient had social anxiety, avoidant, and flat emotions.
Thought process: The patient had non-suicidal or homicidal ideation but experienced
Memory: The patient had poor memory.
Intellectual function: The patient displayed poor intellectual function and judgment
Concentration: The patient was inattentive throughout the interview.
Assessment (A): The MSE and HPI indicate that the patient has schizotypal personality disorder
in accordance with the American DSM-5. Evident symptoms of schizotypal personality disorder
in the patient are odd speech, social anxiety, suspicious ideas, and unusual thinking.
Plan (P): The treatment plan for the patient will combine both psychotherapy and
pharmacotherapy. In this case, the patient will be offered psychotherapy at one session per month
for six months. The patient will be offered guanfacine (2 mg/day) to address his schizotypal
personality disorder symptoms.
Patient Name: Ms. Mary
Examination Date: 12/04/2021
Time: 12.00 p.m.
Duration: 2 Hours
Subjective (S): Ms. Mary, a 67-year-old Hispanic woman, came into the consultation room
complaining of memory loss and confusion, which started two weeks ago. Her daughter indicates
that her mother is getting forgetfulness, which has affected her daily activities. The daughter
fears that her mother may pull out her dialysis catheters due to her current mental conditions. Mr.
Mary has a medical of hypertension, restless syndrome, and diabetes mellitus. In the last three
months, she was hospitalized for pneumonia. In her childhood, she underwent a tonsillectomy.
She currently takes Metformin 250 mg for diabetes, Hydrochlorothiazide 25 mg for
hypertension, and Calcium acetate. Her children are all alive and giving her full support in
paying medical bills and eating healthy.
Objective (O): Vital Signs: Weight: 120lbs, BMI: 22.9 Temperature: 98.1F, BP 126/78, Height:
5’6” Pulse rate: 80 Resp: 17
General Appearance: Ms. Mary appears healthy but is distressed. She is quiet but well
informed about her age. She responds to questions averagely.
Skin: Free from rashes and lesions
Psychiatric: Appears depressed and withdrawn, able to concentrate, and maintains eye
Assessment (A): Memory loss and confusion are the main symptoms; thus, making them the
important diagnosis. The patient appears depressed, change of behavior, and inability to conduct
daily routines. Based on these symptoms, the main diagnosis of the patient is dementia.
Plan (P): The patient should continue taking Metformin 250 mg for diabetes and
Hydrochlorothiazide 25 mg for hypertension. Besides, the patient will start taking Aripiprazole
30 mg twice daily for two weeks to calm dementia. It is important to have someone taking care
of the patient to ensure that she adheres to the medication.
Attention Deficit Hyperactivity Disorder
Patient Name: Mr. Mickey
Examination Date: 10/04/2021
Time: 11.00 am
Duration: 2 Hours
Subjective (S): Mickey, 17-years old, comes with his mother to the consultation room. The
mother indicates, “My son has been making careless mistakes in his activities in school and at
home.” The mother indicates that Mickey enjoys playing with his age mates and friends. He can
also read and write well. The mother reports that the boy has lost focus and concentration in
school and at home. She indicates that Mickey has lost respect for the adults and is so
interruptive. The mother indicates that Mickey has never been diagnosed with any chronological
disorder. From the family history, the mother indicates that one of Mickey’s aunts was diagnosed
with ADHD when she was10 years old.
Objective (O): Vital signs: Weight: 46 BMI: 42.3 kg/m2 BP: 103/ 72 Temp: 98.6 Height: 4’ 10”
Pulse: 97 Resp: 22.
General appearance: The patient is looking healthy and well nourished. He loses
attention very fast when there is a little distraction and diverts quickly to other things.
Behavioral assessment: The patient seems not to listen when he is spoken to, cannot
concentrate for long on a single task, arrange his tasks in order, and cannot follow
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