Subjective
Informed consent given to patient psychiatric interview process and psychiatric/psychotherapy
treatment. Verbal and Written consent obtained. Patient has the ability/capacity to respond and
appears to understand the risk, benefits, and will review additional consent during treatment plan
discussion.
Name: J.S.
DOB: n/a (47-years-old)
Demographic: Caucasian
Gender Identifier Note: Male
CC: “I am so messed up I don’t even know where to start”
HPI: Patient presents for initial visit in person with complaints of impulsivity and anger issues.
When asked how he was doing patient responded, “if I was doing good, I would not be here.” He
reports that he has not had a healthy relationship in 30 years. Feels like he does not know what
it’s like to have a healthy conversation. Reports a major traumatic life event happened 4 years
ago when his daughter and his brother (not biological) died within 6 months of each other.
Patient owns a retail nutrition business. He reports being married three times, marriages 2 and 3
are to his current wife. He says they have known each other 12 years and have had a complicated
history, and she is the person he takes all his anger out on. He recalled one fight they had 7 days
after getting married in October 2021 where she told him she felt “gross” when he said he loved
her, so he cheated on her with his ex-girlfriend that night. He admits he looks to women for
validation, but his wife also knows exactly how to push his buttons. He reports using sex as a
way to temporarily relieve and put Band-Aids on problems. Told wife of his infidelity and it was
hardest thing he had to do besides see his daughter and brother die. He says he pushes her away
because of abandonment issues. On another occasion, patient reports he had a full night of being
with his wife intimately, then the next morning he was extremely upset and yelled at his wife for
no reason he can name. In December last year, she told him she was wanting to move back to
Arizona, and he got very angry and told her and her son to leave. After work the following day,
he came home to an empty house and all their stuff was gone. However, wife and son came back
because son got motion sickness and they had to turn around. This event prompted him to seek
help, so he got admitted to an intensive outpatient program, went for one week but stopped
because employees kept calling out sick and he had to cover shifts. He was diagnosed with
bipolar disorder and was prescribed lithium 300 mg once a day in morning. Has psychotherapist
every Thursday which has helped to talk things through. Reports he has cried more since
December til now more than he has in his life. Describes it as an emotional dump. He says wife
thinks he has dual personality disorder because he gets mad at only her and not others. On
Sunday had a good conversation with wife, but a day later wife told him she can’t do this
anymore, and he started getting anxiety and heart pain. Went to hospital and said they said he has
a heart arrhythmia due to stress. Patient reports being tired- of crying, of hurting, of being him,
and he wants to be even. Admits to hitting himself and punching to feel pain. Patient denies
taking any other medication. Patient reports anxiety issues. Insecurity and being alone makes
him anxious. First marriage he never lived with his wife, 2nd marriage never lived together
because neither would conceded to move to each other, then lived with a woman for 5 years for
This study source was downloaded by 100000838234991 from CourseHero.com on 08-17-2022 14:28:47 GMT -05:00
https://www.coursehero.com/file/151136592/NU-673-Unit-5-SOAP-notepdf/
, convenience- while he was still in love with current wife, but when remarried third wife they
lived together until she left last weekend. He wanted to show current wife that he could be true to
her, but it has been tumultuous with them with each one giving up on the other often. During
childhood mom was rough on dad, but dad stuck by her. One instance, she cheated on him and
he called her a “whore” and then she undressed and ran down the whole neighborhood street.
Denies physical abuse by dad, mom would try to hit dad, but he just held her and did not fight
back. Patient vowed to never let a woman speak to him the way that his mom spoke to his dad.
Says they were good parents to him, does not admit to being emotionally abused. Has been
feeling depressed/ sad for 4 years, since his daughter and brother’s (not biological) death.
Daughter died in car accident, his friend of a hereditary heart issue. Denies auditory/ visual
hallucination, delusions, SI. Reports sleep disturbances, gets up in middle of the night. Last time
he had good sleep was night before wife left (last Saturday). Patient reports feeling manic every
day, at work, feels he always must feel “on.” He used to be in military and said he felt this way
then but not as frequent. Reports ever since he got married last October a veil has been pulled
back on his anger and neediness issues. Patient reports lithium has not been working since he
does not feel calmer and he’s still making others mad around him. He states his infidelity and his
anger are not who he is. He is learning every day how to be better. Patient recalls being at the
hospital last night and sitting by an older gentleman, then the older man’s wife walked in and sat
in a chair further away since there were no chairs by husband. The older man got up and moved
to be next to her, patient says that was the most beautiful thing he has seen in a long time, and he
longs for connection like that. When wife left, she told him she cannot do this anymore, but she
does not want divorce, so he is hopeful. He reports his wife feeling like his drug, like she can
bring him so high and then get him so low immediately. No family psychiatric history that has
ever been diagnosed but he believes his mom had something. Patient reports finding IOP
program himself, going to hospital for heart issue, and seeing psychiatrist and psychotherapist
are against his genetic make-up as a Hispanic, military man. But wants to get better for himself,
not for anyone else, because if he knows he’s okay then he’s okay.
During assessment: Patient describes their mood as “not good”.
Patient self-esteem appears poor, reports feelings of guilt, does not report change in
concentration and memory, no reported anhedonia, does report sleep disturbance, does not report
change in appetite, does not report libido disturbances, does report change in energy
Patient reports excessive worries about marriage, wife, emotions.
Patient does not report hallucinations, delusions. Does report obsessions and compulsions in
impulsive behavior. Patient’s activity level, attention and concentration were observed to be not
within normal limits. Patient does not report symptoms of eating disorder behavior. There is no
recent weight loss or gain. Patient does not report symptoms of a characterological nature.
SI/ HI/ AV: Patient currently denies suicidal ideation, denies SIB, denies homicidal ideation,
denies violent behavior, denies inappropriate/illegal behaviors.
Allergies: NKDFA
(medication & food)
This study source was downloaded by 100000838234991 from CourseHero.com on 08-17-2022 14:28:47 GMT -05:00
https://www.coursehero.com/file/151136592/NU-673-Unit-5-SOAP-notepdf/
Informed consent given to patient psychiatric interview process and psychiatric/psychotherapy
treatment. Verbal and Written consent obtained. Patient has the ability/capacity to respond and
appears to understand the risk, benefits, and will review additional consent during treatment plan
discussion.
Name: J.S.
DOB: n/a (47-years-old)
Demographic: Caucasian
Gender Identifier Note: Male
CC: “I am so messed up I don’t even know where to start”
HPI: Patient presents for initial visit in person with complaints of impulsivity and anger issues.
When asked how he was doing patient responded, “if I was doing good, I would not be here.” He
reports that he has not had a healthy relationship in 30 years. Feels like he does not know what
it’s like to have a healthy conversation. Reports a major traumatic life event happened 4 years
ago when his daughter and his brother (not biological) died within 6 months of each other.
Patient owns a retail nutrition business. He reports being married three times, marriages 2 and 3
are to his current wife. He says they have known each other 12 years and have had a complicated
history, and she is the person he takes all his anger out on. He recalled one fight they had 7 days
after getting married in October 2021 where she told him she felt “gross” when he said he loved
her, so he cheated on her with his ex-girlfriend that night. He admits he looks to women for
validation, but his wife also knows exactly how to push his buttons. He reports using sex as a
way to temporarily relieve and put Band-Aids on problems. Told wife of his infidelity and it was
hardest thing he had to do besides see his daughter and brother die. He says he pushes her away
because of abandonment issues. On another occasion, patient reports he had a full night of being
with his wife intimately, then the next morning he was extremely upset and yelled at his wife for
no reason he can name. In December last year, she told him she was wanting to move back to
Arizona, and he got very angry and told her and her son to leave. After work the following day,
he came home to an empty house and all their stuff was gone. However, wife and son came back
because son got motion sickness and they had to turn around. This event prompted him to seek
help, so he got admitted to an intensive outpatient program, went for one week but stopped
because employees kept calling out sick and he had to cover shifts. He was diagnosed with
bipolar disorder and was prescribed lithium 300 mg once a day in morning. Has psychotherapist
every Thursday which has helped to talk things through. Reports he has cried more since
December til now more than he has in his life. Describes it as an emotional dump. He says wife
thinks he has dual personality disorder because he gets mad at only her and not others. On
Sunday had a good conversation with wife, but a day later wife told him she can’t do this
anymore, and he started getting anxiety and heart pain. Went to hospital and said they said he has
a heart arrhythmia due to stress. Patient reports being tired- of crying, of hurting, of being him,
and he wants to be even. Admits to hitting himself and punching to feel pain. Patient denies
taking any other medication. Patient reports anxiety issues. Insecurity and being alone makes
him anxious. First marriage he never lived with his wife, 2nd marriage never lived together
because neither would conceded to move to each other, then lived with a woman for 5 years for
This study source was downloaded by 100000838234991 from CourseHero.com on 08-17-2022 14:28:47 GMT -05:00
https://www.coursehero.com/file/151136592/NU-673-Unit-5-SOAP-notepdf/
, convenience- while he was still in love with current wife, but when remarried third wife they
lived together until she left last weekend. He wanted to show current wife that he could be true to
her, but it has been tumultuous with them with each one giving up on the other often. During
childhood mom was rough on dad, but dad stuck by her. One instance, she cheated on him and
he called her a “whore” and then she undressed and ran down the whole neighborhood street.
Denies physical abuse by dad, mom would try to hit dad, but he just held her and did not fight
back. Patient vowed to never let a woman speak to him the way that his mom spoke to his dad.
Says they were good parents to him, does not admit to being emotionally abused. Has been
feeling depressed/ sad for 4 years, since his daughter and brother’s (not biological) death.
Daughter died in car accident, his friend of a hereditary heart issue. Denies auditory/ visual
hallucination, delusions, SI. Reports sleep disturbances, gets up in middle of the night. Last time
he had good sleep was night before wife left (last Saturday). Patient reports feeling manic every
day, at work, feels he always must feel “on.” He used to be in military and said he felt this way
then but not as frequent. Reports ever since he got married last October a veil has been pulled
back on his anger and neediness issues. Patient reports lithium has not been working since he
does not feel calmer and he’s still making others mad around him. He states his infidelity and his
anger are not who he is. He is learning every day how to be better. Patient recalls being at the
hospital last night and sitting by an older gentleman, then the older man’s wife walked in and sat
in a chair further away since there were no chairs by husband. The older man got up and moved
to be next to her, patient says that was the most beautiful thing he has seen in a long time, and he
longs for connection like that. When wife left, she told him she cannot do this anymore, but she
does not want divorce, so he is hopeful. He reports his wife feeling like his drug, like she can
bring him so high and then get him so low immediately. No family psychiatric history that has
ever been diagnosed but he believes his mom had something. Patient reports finding IOP
program himself, going to hospital for heart issue, and seeing psychiatrist and psychotherapist
are against his genetic make-up as a Hispanic, military man. But wants to get better for himself,
not for anyone else, because if he knows he’s okay then he’s okay.
During assessment: Patient describes their mood as “not good”.
Patient self-esteem appears poor, reports feelings of guilt, does not report change in
concentration and memory, no reported anhedonia, does report sleep disturbance, does not report
change in appetite, does not report libido disturbances, does report change in energy
Patient reports excessive worries about marriage, wife, emotions.
Patient does not report hallucinations, delusions. Does report obsessions and compulsions in
impulsive behavior. Patient’s activity level, attention and concentration were observed to be not
within normal limits. Patient does not report symptoms of eating disorder behavior. There is no
recent weight loss or gain. Patient does not report symptoms of a characterological nature.
SI/ HI/ AV: Patient currently denies suicidal ideation, denies SIB, denies homicidal ideation,
denies violent behavior, denies inappropriate/illegal behaviors.
Allergies: NKDFA
(medication & food)
This study source was downloaded by 100000838234991 from CourseHero.com on 08-17-2022 14:28:47 GMT -05:00
https://www.coursehero.com/file/151136592/NU-673-Unit-5-SOAP-notepdf/
