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.

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). 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

Blackboard. https://class.waldenu.edu