ASSIGNMENT: FOCUSED SOAP NOTE AND PATIENT CASE PRESENTATION, PART 1

AS 49 M
ADHD combined type, Encounter for screening for depression
Adderall XR 30mg, dextroamphetamine 10mg.
Patient stated to be good and denies having any issues to reported.
Patient indicated having construction in kitchen and can’t wait to get it done.
Patient denies having any depressive and anxiety moods.
Denies change with physical health.
Patient stated work to be good and will be off throughout the holidays which helps to finish remodeling his house.
Patient explained having skin issues that are bothering him.
Patient stated that medications prescribed to be working and explained being non-compliant with taking Adderall on the weekend.
He’s recently divorced.
Has 2 kids.
No self-harm behavior denies suicide attempts

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Current Mental Status
Orientation: X3, Oriented to person place and time
General Appearance: Appropriate
Dress: Appropriate
Motor Activity:
Interview Behaviour: Appropriate
Speech: Normal