A/N: I've mentioned in my profile and in the author notes of one or two stories that I'm a medical student. We're currently doing our psychology section, and we had a lecture on schizophrenia today. As a fun break from studying, I wrote a doctor's note for Sam in 7x17. Now, just a brief explanation: a SOAP note is the standard note system. Subjective (what the patient tells you), Objective (what you find for yourself), Assessment (basically the diagnosis), Plan (what you are going to do/have already done for the patient). Chief complaint is "why the patient is here". I was going to list all the abbreviations I used, but it started getting extensive. Sorry! Message me if you're dying to know! I will say that "wnl" is "within normal limits" and is actually bad form to put down. Please keep in mind that I did not major in psych and I have not yet had my hospital psych rotations. If I am inaccurate with anything, I deeply apologize. Thanks for reading!
Chief Complaint: Insomnia and hallucinations
Subjective
Patient is a 29 y/o Caucasian M presenting with insomnia and hallucinations. Patient arrived at the ER after being struck by a car. Patient has explained that he did not realize the car was coming when he crossed the street, attributing his inattentiveness to sleep deprivation. Despite a fractured rib and multiple lacerations, patient rates pain as a 3 on a pain scale of 0 to 10. Patient reports having had hallucinations for several months. He states that pain in the form of self-mutilation helped him distinguish reality from hallucination, though that grounding force had been decreasing for some time before completely failing about a week ago. Patient states that exhaustion and stress makes the hallucinations more vivid. Patient also adds that he has been having difficulty sleeping for a few weeks, and as of now, he has not slept in 5 days despite trying several OTC drugs as well as illicit sleep aids. See mental status exam for further detail on hallucinations.
Allergies: no known allergies
Medications: Hospital-administered olanzapine for psychosis, diazepam for sedation
Patient has turned down analgesics
Past medical history: concussion with seizure at the start of hallucinations (though patient notes that the hallucinations came first)
Past hospitalization: broken arm, multiple concussions, various other broken bones over the past several years.
Past surgeries: no past surgeries
Social history:
Patient does not use tobacco products
Patient reports moderate alcohol use and claims to be very careful not to go overboard with alcohol
Patient reports heavy caffeine use, especially following onset of insomnia
Patient reports eating a well balanced diet
Patient reports a drug addiction (unstated drug), but adds that he quit 3 y/a
Family history:
Patient has 1 brother and has suggested his brother may be depressed. Patient reports that brother is alcoholic. Patient reports that brother has been the main caretaker during patient's illness.
Patient's mother died in a fire when he was an infant
Patient's father died of sudden cardiac arrest 5 y/a
No history of psychosis in family
Mental status exam:
Patient appears stated age of 29. He is well muscled, but appears to have lost some weight recently. Patient appears disheveled, though he is clean. Patient appears listless and slumps in bed and is guarded. He occasionally flinches without stimulus. Patient is drowsy. He is oriented to person, place, time, and details to situation. Eye contact is fleeting; patient attempts to make eye contact but seems to get distracted by hallucinations. His speech is slowed but coherent with slight pauses d/t apparent distraction. Thought processes appear to be direct as he has been able to participate in complex conversation about his situation. Memory is intact as patient has been able to describe his childhood as well as the road trip he and his brother have been on together. Mood is depressed with affect appropriate to the situation. Based on conversation, including vocabulary, knowledge, and speech pattern, patient appears to be of above average intelligence. Patient understands the current situation and is eager for any help the hospital can offer but also states that he believes his case hopeless. Patient does admit to some suicidal thoughts, but claims he "would not do that to [his] brother". He adds that even without suicide, he does not think he will last much longer. Hallucinations are varied from contamination of his food to loud noises to people being in the room with him. He adds that all the hallucinations stem from "Lucifer", the devil, being in the room and trying to torture him. Even without pharmacological intervention, patient is aware that his hallucinations are not real, but he is incapable of ignoring them.
Objective
HR: 66 bpm, BP: 110/78, T: 99.5 F, SaO2: 99%, RR: 12
HEENT: Eyes: PEaRLA, nose: wnl, ears: wnl, throat: wnl. Cranial nerves intact
Neck: wnl
Heart: rrr no murmurs
Lungs: ctax4
Chest: fractured right rib 8
Abdomen: soft, non-tender to palpation, bowel sounds are slightly decreased
Extremities: Upper: dtr 2+ x3 b/l, strength: right 4/5 d/t pain. Left arm 5/5, left hand 3/5. Sensations: left medial hand has paresthesias. There is a poorly healed scar where patient continued to self-mutilate in attempts to ground himself from hallucinations. Lower: dtr 2+ x2 b/l, strength 5/5 b/l, sensation intact
Assessment:
CC: Insomnia with hallucinations
Schizophrenia
Broken rib
Multiple lacerations
Plan:
Patient has been put on olanzapine to help control hallucinations.
CT has been ordered
Patient has been put on high dose diazepam for sleep aid, but so far it has not been helpful. It is hoped that olanzapine will control the hallucinations enough that the patient can sleep
Taping rib to limit movement and cold compress for swelling.