PRAC 6665 Assignment 2 WEEK 7: Focused SOAP Note and Patient Case Presentation
PRAC 6665 Assignment 2 WEEK 7: Focused SOAP Note and Patient Case Presentation
Patient Information
Initials: P.L
Age: 54 years old
Gender: Female
Race: Caucasian
Subjective:
CC (chief complaint): “Psychiatric evaluation.”
HPI: P.L is a 54-year-old female patient who was accompanied by her sister to the psychiatric clinic as a result of strange behaviors. Her sister claims that the patient has been hearing sounds of people watching her across the window. She also reports that people on television are talking to her. She is very cautious, and if even afraid to eat as she believes that people on the television will pop out of the screen and poison her food. Additional symptoms include nightmares which affect her sleep. She denies suicidal ideation or potential harm to herself or others.
Past Psychiatric History:
PRAC 6665 Assignment 2 WEEK 7 Focused SOAP Note and Patient Case Presentation
- General Statement: Hospitalized at the age of 20 years due to psychiatric disorder. She has been on and off antipsychotics.
- Caregivers (if applicable): She stays with her mother and sister.
- Hospitalizations: Reports a history of hospitalization at the age of 20 years.
- Medication trials: The patient was previously on Thorazine and Haldol, which she disliked how they made her feel. Seroquel was then introduced, which was effective, but the patient was inconsistent with taking the drug.
- Psychotherapy or Previous Psychiatric Diagnosis: None specified.
Substance Current Use: Reports smoking tobacco, approximately 3 packs every day. She also confirms taking alcohol. Denies taking marijuana or any other drug of abuse.
Family Psychiatric/Substance Use History: Mother with a history of anxiety disorder, while the father with a history of paranoid schizophrenia, Father was diagnosed with paranoid schizophrenia.
Psychosocial History: The patient lies together with her sister and mother. She is unable to work as a result of her mental condition, which affected her highest level of education being the 10th grade.
Medical History: Currently managing diabetes. She also confirms having a fatty liver.
- Current Medications: Metformin 500mg twice daily.
- Allergies: No reported allergies
- Reproductive Hx: The patient denies ever being married. She confirms menopause at age of 45 years. No history of reproductive complications.
ROS:
- GENERAL: No fever, general body weakness, changes in body weight, fatigue, nausea, or vomiting.
PRAC 6665 Assignment 2 WEEK 7 Focused SOAP Note and Patient Case Presentation
- HEENT: Head: No headache or trauma. Eyes: No tearing, discharge, blurred vision, or redness. Ears: No discharge, tinnitus, or itchiness. Nose: No congestions or running nose. Throat: No sore throat, tonsillitis, or swallowing difficulties.
- SKIN: Intact with no rashes, hives, eczema, or itchiness.
- CARDIOVASCULAR: No palpitations, dyspnea, edema, cyanosis, or chest pressure.
- RESPIRATORY: No shortness of breath, wheezing, coughing, chest congestion, or sneezing.
- GASTROINTESTINAL: No changes in bowel movement, nausea, vomiting, diarrhea, constipation, abdominal tenderness, or hernia.
- GENITOURINARY: No dysuria, nocturia, discharge, urgency, or painful urination.
- NEUROLOGICAL: NO headache, loss of consciousness, or vision changes.
- MUSCULOSKELETAL: Full range of movement of joints with no pain, or inflammation.
- HEMATOLOGIC: No bleeding problems or prolonged healing of wounds.
- LYMPHATICS: No lymphedema
- ENDOCRINOLOGIC: No excessive thirst, polyuria, or polydipsia.
Objective:
Diagnostic results: For a general assessment of the patient’s health, routine blood works like WBC, RBC and CBC were ordered. A drug test of the urine and blood was also ordered to assess for substance use disorders. Organ function tests such as LFTs and RFTs were also ordered to assess the effects of the psychotropic agents on the patient’s liver and renal function. A CT scan of the head and X-Ray are also necessary to rule out physical trauma as the reason behind the patient’s condition. Additional diagnostic tests include Calgary Depression Scale for Schizophrenia, PANSS, Clinical Global Impression-Schizophrenia (CGI-SCH), SAPS test, Rorschach (inkblot) test, and SANS test (Lewine & Hart, 2020).
Assessment:
Mental Status Examination: The patient walks into the room, in age-appropriate and clean clothes. She seems quite confused and avoids eye contact. However, her orientation in person, time, and place are intact. She displays poor judgment and odd beliefs like her life is in danger. She is unable to maintain the same topic during the interview. Her short-term memory is quite shoddy, but her long-term memory is intact. She displays a flat affect. Her thought process is inconsistent, as she will give different answers to the same question. She displays signs of depression, anxiety, hallucination, and delirium. She denies suicidal ideation or potential harm to herself or others.
Diagnostic Impression:
- Schizophrenia Spectrum and Other Psychotic Disorders: Schizophrenic patients tend to display characteristics that suggest that they have lost contact with reality. Common symptoms include abnormal behaviors, visual or auditory hallucination, delusion, and disorganized thought processes. The DSM-V diagnostic criteria for this disorder requires the patient to display at least one symptom, from each of the two groups of symptoms (Addington et al., 2017). The first group of symptoms entails disorganized thought processes and speech, hallucination, and delirium, while the second group involves catatonic symptoms such as stupor, mutism, catalepsy, or negativism. The patient displayed both positive and negative symptoms which qualify for this diagnosis.
- Bipolar I Disorder with psychotic features: Patients with this disorder tend to have manic episodes, which are associated with psychotic features such as delusion and hallucination. The DSM-V diagnostic criteria require patients to present with at least 3 of the following manic symptoms such as inflated self-esteem, reduced sleep, easily distracted, racing thoughts, irritability, and increased psychomotor agitation (Tasic et al., 2019). The patient must also present with at least one psychotic feature such as hallucination, or delusion to qualify for this diagnosis. The patient displayed psychotic symptoms, with no manic episodes, which disqualifies this diagnosis.
- Delusional Disorder: In most cases, delusion is a symptom of other psychotic conditions. However, according to DSM-V, patients who display delusion only, and no other psychotic symptoms, for at least one month, qualifies for this diagnosis (Lewine, & Hart, 2020). However, the present patient displayed both delusion and hallucination among other symptoms. As such, she cannot qualify for this diagnosis.
Case Formulation and Treatment Plan:
Pharmacotherapy: Initiate 300mg of quetiapine (Rx) Extended-release on day one. Titrate the dose upwards by 25-50 mg per day to an optimal maintenance dose of between 400 to 800 mg once daily while observing patient outcome (Remington et al., 2017). This drug is effective in the management of schizoaffective symptoms and had already displayed great tolerance and adherence with the patient. The extended-release formulation will also help reduce the frequency of administration, hence promoting compliance.
Psychotherapy: Cognitive behavior therapy (CBT) is recommended among patients with schizophrenia to help promote appropriate behavior and positive thinking (Stijažiü et al., 2017).
Alternative therapy: The patient can also engage in Assertive community treatment (ACT), coordinated specialty care (CSC), self-help groups, or social skills training (Lewine, & Hart, 2020).
Health Promotion: Take part in physical exercise and consume a healthy diet to promote both physical and mental health (Stijažiü et al., 2017).
Patient Education: The patient must be educated on the importance of the consistency of taking medication as prescribed to promote treatment outcomes (Stijažiü et al., 2017).
Follow-up: The patient must report back to the clinic after 4 weeks for further evaluation of the treatment outcome so that necessary changes can be made to the treatment plan.
Reflections: The patient information provided is limited in making the required changes in the patient medication based on the severity of her condition. Both the subjective and objective portions of patient history suggest a diagnosis of schizophrenia. However, concerning her previous treatment approaches, some information is missing concerning the drug-specific side effects encountered, and the level of effectiveness of the psychotropic agents used. As such, it is necessary to talk to the patient informant more concerning her previous treatment to make sure that the current treatment plan does not display similar results. Consequently, the PMHNP must promote the health and well-being of the patient and prevent harm. As such, the next intervention will entail using both pharmacological agents which displayed great effectiveness with no harm to the patient, and psychotherapy, to promote patient’s compliance and treatment outcome (Remington et al., 2017).
References
Addington, D., Abidi, S., Garcia-Ortega, I., Honer, W. G., & Ismail, Z. (2017). Canadian guidelines for the assessment and diagnosis of patients with schizophrenia spectrum and other psychotic disorders. The Canadian Journal of Psychiatry, 62(9), 594-603. https://doi.org/10.1177/0706743717719899
Lewine, R., & Hart, M. (2020). Schizophrenia spectrum and other psychotic disorders. In Handbook of Clinical Neurology (Vol. 175, pp. 315-333). Elsevier. https://doi.org/10.1016/b978-0-444-64123-6.00022-9
Remington, G., Addington, D., Honer, W., Ismail, Z., Raedler, T., & Teehan, M. (2017). Guidelines for the pharmacotherapy of schizophrenia in adults. The Canadian Journal of Psychiatry, 62(9), 604-616. https://doi.org/10.1177/0706743717720448
Stijažiü, D., Jendrižko, T., & Biožina, S. M. (2017). Guidelines for individual and group psychodynamic psychotherapy for the treatment of persons diagnosed with psychosis and/or schizophrenia. Psychiatria Danubina, 29(3), 432-440. PMID: 28953804
Tasic, L., Larcerda, A. L., Pontes, J. G., da Costa, T. B., Nani, J. V., Martins, L. G., … & Hayashi, M. A. F. (2019). Peripheral biomarkers allow differential diagnosis between schizophrenia and bipolar disorder. Journal of psychiatric research, 119, 67-75. https://doi.org/10.1016/j.jpsychires.2019.09.009