Marcus Johnson is a 42-year-old male Army veteran WITh
evaluation of chronic sleep disturbance and persistent
irritability — WEEK 10 FOR WALDEN UNIVERSITY LOCATION
:OUTPATIENT CLINIC WITH X-RAY, ECG, AND LABORATORY
CAPABILITIES FULL CASE STUDY WITH A SOAP NOTE
Comprehensive Mental Health Case Study
Patient Profile
• Name: Marcus Johnson
• Age: 42 years
• Sex: Male
• Occupation: Army Veteran (recently separated)
• Setting: VA Mental Health Clinic (Outpatient)
• Chief Complaint (CC): “I can’t sleep and I’m always angry.”
,Patient Introduction
Marcus Johnson is a 42-year-old male Army veteran who presents to the
VA Mental Health Clinic for evaluation of chronic sleep disturbance and
persistent irritability. He appears concerned about how his mood and
sleep problems are affecting his relationships, daily functioning, and
overall quality of life. He is seeking help voluntarily and expresses a
desire to feel more in control of his emotions.
History of Present Illness (HPI)
Marcus reports that for the past 18 months, he has experienced:
• Difficulty falling asleep (often takes 1–2 hours)
• Frequent nighttime awakenings (3–4 times per night)
• Non-restorative sleep, waking feeling exhausted
• Persistent irritability and anger outbursts, especially toward family
members
• Feeling “on edge” most of the time
• Difficulty concentrating
• Increased startle response to sudden noises
• Avoidance of crowded places (e.g., malls, public transport)
He reports these symptoms worsened after returning from his last
deployment two years ago. He denies current substance intoxication
during the visit but admits to using alcohol in the evenings “to help calm
down and sleep.”
He denies current thoughts of harming himself or others and states he
wants to get better for his family.
, Past Psychiatric History
• No formal psychiatric diagnosis prior to military service
• No prior psychiatric hospitalizations
• Attended one counseling session through the VA six months ago
but did not continue
• No history of psychosis or mania reported
Past Medical History
• Chronic low back pain (service-related injury)
• Hypertension (controlled on medication)
• No history of traumatic brain injury reported
Medications
• Lisinopril 10 mg daily
• Ibuprofen as needed for back pain
• No current psychiatric medications
Allergies
• No known drug allergies (NKDA)
Family Psychiatric History
• Father: History of alcohol use disorder
evaluation of chronic sleep disturbance and persistent
irritability — WEEK 10 FOR WALDEN UNIVERSITY LOCATION
:OUTPATIENT CLINIC WITH X-RAY, ECG, AND LABORATORY
CAPABILITIES FULL CASE STUDY WITH A SOAP NOTE
Comprehensive Mental Health Case Study
Patient Profile
• Name: Marcus Johnson
• Age: 42 years
• Sex: Male
• Occupation: Army Veteran (recently separated)
• Setting: VA Mental Health Clinic (Outpatient)
• Chief Complaint (CC): “I can’t sleep and I’m always angry.”
,Patient Introduction
Marcus Johnson is a 42-year-old male Army veteran who presents to the
VA Mental Health Clinic for evaluation of chronic sleep disturbance and
persistent irritability. He appears concerned about how his mood and
sleep problems are affecting his relationships, daily functioning, and
overall quality of life. He is seeking help voluntarily and expresses a
desire to feel more in control of his emotions.
History of Present Illness (HPI)
Marcus reports that for the past 18 months, he has experienced:
• Difficulty falling asleep (often takes 1–2 hours)
• Frequent nighttime awakenings (3–4 times per night)
• Non-restorative sleep, waking feeling exhausted
• Persistent irritability and anger outbursts, especially toward family
members
• Feeling “on edge” most of the time
• Difficulty concentrating
• Increased startle response to sudden noises
• Avoidance of crowded places (e.g., malls, public transport)
He reports these symptoms worsened after returning from his last
deployment two years ago. He denies current substance intoxication
during the visit but admits to using alcohol in the evenings “to help calm
down and sleep.”
He denies current thoughts of harming himself or others and states he
wants to get better for his family.
, Past Psychiatric History
• No formal psychiatric diagnosis prior to military service
• No prior psychiatric hospitalizations
• Attended one counseling session through the VA six months ago
but did not continue
• No history of psychosis or mania reported
Past Medical History
• Chronic low back pain (service-related injury)
• Hypertension (controlled on medication)
• No history of traumatic brain injury reported
Medications
• Lisinopril 10 mg daily
• Ibuprofen as needed for back pain
• No current psychiatric medications
Allergies
• No known drug allergies (NKDA)
Family Psychiatric History
• Father: History of alcohol use disorder
