Author: Dr. Prince

Week 5: Focused SOAP Note and Patient Case Presentation

College of Nursing-PMHNP, Walden University

NRNP 6675: PMHNP Care Across the Lifespan 2 Practicum

Introduction

Psychosis is a mental condition in which a person’s ideas and perceptions are disrupted, and the individual may have difficulty distinguishing between what is real and what is not.

A health condition, medications, or drug usage can all contribute to psychosis. Delusions, hallucinations, incomprehensible speech, and agitation are all possible signs; the patient has incorrect beliefs and sees or hears things that others do not see or hear. The person suffering from the disease is usually unaware of his or her actions. Medication, psychotherapy, peer support, family support and education, and talk therapy are all options for treatment.

More or less every mental intervention is backed by evidence accumulated during the patient’s initial interview; each patient’s therapy begins with a thorough medical and mental health evaluation, the incorporation of trust, and a discussion of past mental health history, substance misuse history, family mental health history, and so on. In this example, the patient’s evaluation was documented, and a diagnosis was made based on the information collected from the patient during the evaluation.

When the case was being developed, a therapeutic approach was designed. The patient is a 53-year-old Caucasian male who was scheduled for an initial screening for a psychotic disorder after his sister recommended a visit to the psychiatrist because patient’s behavior changed since the mother passed away.

Patient Initial: S.T Age: 53 Gender: Male

Subjective Data:

CC: “I was brought here by my sister because since my mother passed away, I was living on my own and not bothering anyone. Those people outside my window they are after me. They just want me dead”.

HPI: When patient was asked ” what people?”. Patient said ” the government sent them to get me because my taxes are high”. Suddenly patient asked the provider if she can see the birds or hear any loud noise. The provider responded by redirecting the patient that she does not hear any voice or see anything.

When the provider how long he is been hearing the voices or seeing things, patient said ” for weeks, weeks and weeks”. Patient also said the sister tapped her phone with the government. When asked about sleep, patient said ” I have not slept well because the voices keep me up for days. I try to watch the TV, they poison my food on TV, I locked everything down in the fridge”. Suddenly patient asked ” Can I smoke?”.

Provider said “no you can’t smoke here”. Patient admit that he smokes all day about 3 packs a day. Drinks alcohol which his sister purchased for him to last him for weeks. Patient denies use of drugs. Admit to history of marijuana use 3 years ago before the mother passed away. Denies blackout, seizures, collateral or legal issues or DUIs from use of drugs or alcohol. Patient admit that he hates Haldol and Thorazine which he used to take. Calls his medications poison and said he is not going to take it.

Substance Use History: Admits to use of alcohol, smokes 3 packs of cigarette per day. Admit history of marijuana 3 years ago Family Psychiatric/Mental/Substance Use History: Patient father paranoid and schizophrenia.

Patient’s mother: Anxiety. Sister: unknown Grandfather: unknown. Grandmother: unknown Psychosocial History: Patient lives alone. Mother is deceased. Father is undisclosed. Both parents are Caucasian. Patient is presently does not have friends. Educational Level: 10th grade.

Legal history: patient denies any history but said the police told him they would because patient calls 911 on people outside.

Psychiatric History: Mood disorder unspecified Medical History/Surgical History: Diabetes Birth and Developmental history: Vagina birth, denies any disclosed complication and all developmental millstones was met on time.

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However, in the state of Georgia, the regulations allow the APRN to only practice under

Current Medications: Haldol and Thorazine (all discontinued), Metformin

Allergies: NKDA or seasonal allergies

Reproductive Hx: Patient denies sexual history or abuse

APPEARANCE: Appeared disheveled

HEENT: No vision problem. Ears normal shape with no discharges. Nose normal shape; no

deviation or drainage. No sore throat or swelling around the neck.

CV: no cardiovascular abnormality

PULMO: Lungs sounds clear and no adventitious lung sounds

ABDOMEN: All bowel sounds on all four quadrant

GENITOURINARY: No disorder or problem with this system

EXTREM: All extremities is moveable; some tremors noted in upper extremities

NEURO: alert and oriented to person, place, time, and situation but very unrest

SKIN: Skin intact and appropriate; no rash or lesion noted

Physical exam:

Vital Signs: none at this time

Weight: 196 Ibs

Height: 5’9ft

Objective:

Diagnostic results: no diagnostic test ordered or required at this time

Assessment:

Mental Status Examination

On arrival and during the session, the patient appeared to be of the age reported, with no signs of discomfort. The patient appears to be well fed and groomed. Clean and well-dressed.

Patient was compliant, did not fidget, maintained good eye contact, and but could not stay still for long periods of time. The patient appears to be frightened and anxious. Affect was wide- ranging, a little constrained, and frequently depressing. There was no anomalous movement

observed. Maintain a steady gait and maintain an upright stance. Appeared anxious , the patient was coherent but not particularly logical. Although the patient did not have acute psychosis, he was actively delusional and responding to internal stimuli. Patient was delusions or paranoid behavior, suspicious thoughts and intrusive ideas plague the patient. Patient’s speech was normal rate, rhythm volume and clear. Patient does not feel like he will get better.

Patient was a good historian. Patient was attentive to the provider. Alert and oriented times 4. Memory both long

and short term was intact. Patient denies suicide ideation. Patient admits having intrusive thoughts of hurting. During assessment patient states “the government sent people to get me because my taxes are high”. Suddenly patient asked the provider if she can see the birds or hear any loud noise.

Differential Diagnoses

Schizophrenia: Schizophrenia is a “psychosis,” a sort of mental illness. A psychosis is a mental disease in which the sufferer is unable to distinguish between what is real and what is imagined.

People suffering from mental diseases can lose contact with reality at times (Sadock, 2014). The world may appear to be a tangle of perplexing ideas, images, and noises. One kind of schizophrenia is paranoid schizophrenia. In this case, the person’s incorrect beliefs are mostly concerned with being persecuted or punished by others. Someone’s voice may be heard, which

the individual believes is punishing them.

The individual may assume that he or she has been hand-picked to carry out a top-secret task. According to DSM-5, patient must meet certain to be diagnosed with schizophrenia; delusions, hallucinations, diagnosed speech or thought, negative symptoms, paranoid delusions, grossly disorganized or catatonic behavior for the duration of 6 months, symptoms not due to effects of substance or another medica condition (American Psychiatric Association2013). The above listed criteria are all evident in our patient.

Schizoaffective Disorder: In clinical practice, schizoaffective disorder is one of the most misdiagnosed psychiatric diseases. In fact, some academics have requested that the diagnostic criteria be revised, while others have suggested that the diagnosis be removed entirely from the DSM-5. Schizoaffective illness is easily confused with other mental disorders due to criteria that include both psychosis and mood symptoms.

Schizophrenia, Major Depressive Disease with Psychotic Features, and Bipolar Disorder are all disorders that must be ruled out during a schizoaffective disorder workup. According to DSM 5, to diagnose schizoaffective illness, there must be at least two weeks of exclusively psychotic symptoms (delusions and hallucinations) without any mood symptoms. However, throughout the majority of the illness’s existence, a major mood episode (depression or mania) is present.

When psychotic symptoms prevail for the bulk of the illness’s duration, the diagnosis is likely to be schizophrenia. Furthermore, schizophrenia requires 6 months of prodromal or residual symptoms, but schizoaffective disorder does not. Schizoaffective disorder is a psychotic disease similar to schizophrenia.

Delusion of Persecution: A delusion is a false belief that suggests a problem with the contents of the affected person’s thoughts. The person’s cultural or religious background, as well as his or her level of intelligence, have no bearing on the incorrect belief. The degree to which the person believes the belief is true is a significant component of a delusion (American Psychiatric Association2013).

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A person suffering from a delusion will cling to their belief despite evidence to the contrary. Delusion of Persecution occurs when a person believes that they (or someone close to them) is being mistreated, that someone is spying on them, or that someone is planning to harm them.

According DSM-5 patient must meet the following criteria before being one or more delusion for at least one month, fearing ordinary situations, feeling threatened without reason, frequently reporting to authorities, extreme distress, excess worry, constantly seeking safety and hallucinations associated with the delusions. The above listed criteria are evident in our patient

Reflection

Every mental intervention is determined by the information collected during the initial conversation with the client; every client’s therapy starts with a comprehensive medical and behavioral health examination, the creation of trust, and a discussion of previous mental health history, substance abuse history, family mental health history, and so on. Individuals with whom they had connections that comprised effective communication, cultural awareness, and the absence of compulsion were considered as trustworthy (Sadock et al., 2014).

As a PMHNP, one thing I might have done differently is to meet the patient first, develop a therapeutic relationship, inquire about the young patient’s relationship with his parents, and then ask questions irrelevant to the scheduled visit, which would assist to create a welcome atmosphere. Without appearing to be biased, ask open-ended questions about the patient’s personality, illness, or personality.

Inquire about the patient’s sexual orientation and communication preference. Cultural competency includes elements such as trust, respect for diversity, respect for religion, equity, fairness, and social justice, which must all be considered during any interview or encounter between a healthcare practitioner and a patient (Sadock et al., 2014). When I interview a patient about their mental illness symptoms, I look at how they look, speak, and act to determine if there are any clues that could explain their symptoms.

Case Formulation and Treatment Plan

The patient will begin individual supportive therapy then advance to family and peer group supportive therapy depending on level of improvement. The patient will receive an educational pamphlet, as well as assignments and a follow-up consultation, on themes that will aid in the healing and coping process.

Patient will be started on Perphenazine 32mg PO QHS, Benztropine 1mg PO BID for prevention of EPS. Education and side effects of medication was provided. Labs (CBC, CMP, A1C, lipid profile) will be ordered in the next visit.

Education on substance use and smoking cessation was provided for patient. Patient will be educated on importance of taking his vital signs daily, increase fluid intake, report change finger sticks of blood sugar check, In case of emergency, the provider provided patient with helpful phone numbers: 911 for emergencies and the Client’s Crisis Line. Reports from doctors and therapists were evaluated for mutual and collaborative understanding and for continuity of care.

Patient was educated and was advised to call their primary care physician or go to the nearest emergency department if they had any questions or concerns about the development of any undesirable or unexpected outcome or side effects.

Every 30 days, patient must return to appointments for continuity of care and for provider to monitor progress and outcome of treatment but patient will return a two week after starting the newly prescribed medications for adjustment of dosing and to monitor improvement.

References

American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental

Disorders, fifth edition DSM-5 American Psychiatric Association, 2013.

Bachem, R., & Casey, P. (2018). Schizoaffective Disorder: A diagnosis whose time has come.

Journal of Affective Disorders, 227, 243-253. https://doi.org/10.1016/j.jad.2017.10.034

Sadock, B.J., Sadock, V.A., & Ruiz, P. (2014). Kaplan and Sadock’s synopsis of psychiatry:

Behavioral sciences/clinical psychiatry (11 th ed.). Philadelphia, PA: Wolters Kluwer.

Thapar, A., Pine, D. S., Leckman, J. F., Scott, S., Snowling, M. J., & Taylor, E. A. (Eds.).

(2015). Rutter’s child and adolescent psychiatry (6th ed.). Wiley Blackwell.

Walden University. (2021). Case study: Sherman Tremaine. Walden University

https://doi.org/10.1016/j.jad.2017.10.034

Blackboard. https://class.waldenu.edu

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