Week 3: Focused Soap Note And Patient Case Presentation

Assignment 2: Focused SOAP Note and Patient Case Presentation Client Information: 30 yr old male Chief Complaint: I have been exercising and my CK: was elevated over 2000 due to taking supplements to create larger muscles and not drinking even water. I have feelings of being lost History of Illness: Schizophrenia diagnosed 6 years ago. Past Psychiatric: Hospitalized a month ago. Initially for elevated CK: of >2000. The patient also stated that his first psychiatric hospitalization was a while ago but couldnt remember when. Substance Abuse: marijuana but stated its been 10 years ago; he rarely drinks a couple of beers and is not a cigarette smoker. During the assessment conversation the patient admitted to using PCP and has a medical care for the marijuana. Medical: prediabetes and hyperlipidemia. Hgt: 61. Weight: 260 lbs. Social: Patient state he goes out sometimes, but he doesnt go out much. He is on a waiting list for a job but is not currently working. He states that he supports himself with no help and uses his savings. No history of jail time nor prison. Family History: he as two brothers that he currently lives with. He also has a girlfriend but no children.