NRNP/PRAC 6665 & 6675 Comprehensive Focused SOAP Psychiatric Evaluation Template

Week 9: Grand Rounds Discussion: Complex Case Study Presentation
Sherie Reed

College of Nursing-PMHNP, Walden University

NRNP 6675: PMHNP Care Across the Lifespan II

Dr. Nataliya Ishkova- Volovets

June 28, 2022

Subjective:

CC (chief complaint): “I’m starting to hear voices again.”

HPI

A.B. is a 37-year-old male with a history of Schizophrenia. The client is single with no children and resides with his parents in New Jersey. He lives in the finished basement of his parent’s home that they fixed up for him. His highest level of education is two years of community college. The patient is currently unemployed and on disability for his mental health issues. The client was going to a mental health professional that retired two years ago and hasn’t seen anyone since. He participates in therapy on and off with a therapist he has been visiting since he was 25. The patient was hospitalized when he was 24, and that is when he was diagnosed with Schizophrenia. His psychiatrist prescribed him Abilify, but he hasn’t taken it in the past year and a half due to his psychiatrist retiring. The patient has reported auditory and visual hallucinations since he stops taking Abilify. His parents helped him find this facility to start a treatment regimen.

Substance Current Use: The patient denies any substance use.

Medical History: The patient denies any medical or surgical history.

· Current Medications: The patient denies taking any medications.

· Allergies: No known drug or food allergies.

· Reproductive History: The client does not have any children.

ROS:

· GENERAL: Patient denies fevers, chills, sweats, or weight changes.

· HEENT: The patient denies any difficulty hearing and no symptoms of rhinitis or sore throat.

· SKIN: The patient denies any rashes or skin changes.

· CARDIOVASCULAR: The patient denies having chest pain or palpitations.

· RESPIRATORY: The patient denies dyspnea on exertion and no wheezing or cough.

· GASTROINTESTINAL: The patient denies nausea, vomiting, diarrhea, constipation, or stomach aches.

· GENITOURINARY: The patient denies any genitourinary issues.

· NEUROLOGICAL: The patient denies headaches, no seizures, no numbness, no tingling, and no weakness.

· MUSCULOSKELETAL: The patient denies myalgias or arthralgias.

· HEMATOLOGIC: The patient denies having any hematologic issues.

· LYMPHATICS: The patient denies having any lymphatic issues.

· ENDOCRINOLOGIC: The patient denies excessive urination or excessive thirst.

Objective:

Diagnostic Results:

The Moca Test

The Moca test is a cognitive test that can be useful for patients with Schizophrenia. It tests attention, concentration, executive functions, memory, language, visuoconstructional skills, conceptual thinking, calculations, and orientation. According to Yang, Abdul Rashid, Quek, Lam, See, Maniam, Dauwels, Tan, and Lee, the Moca test successfully detected mild and severe cognitive impairments in individuals with Schizophrenia (2018).

Laboratory Tests

An alcohol and drug screening should be completed. Also, a CBC, TFTs, glucose, Hemoglobin A1C, and a Liver function test should be done. An EKG should be done as a baseline before prescribing any antipsychotics. A Cat scan can be done to rule out any lesions.

Assessment

Mental Status Examination

The client is well groomed and appropriately dressed. His affect is flat, and his speech is every day. He reports experiencing auditory and visual hallucinations and seems preoccupied during the interview. The client’s insight and judgment are fair. The client denies having any anxiety or depressive symptoms. The client describes his voices as a command in nature and refers to the voices as demons. He reports that the voices tell him he is useless, but he explained that he understands that the voices are not authentic. He describes his visual hallucinations as men from the government watching him. He did say that he believes that the people are real but that he can no longer see them when he takes medication.

Diagnostic Impression

Schizophrenia

According to the DSM-5, to meet the criteria for Schizophrenia, the client must complete two criteria: Delusions, hallucinations, disorganized speech, grossly disorganized or catatonic behavior, and negative symptoms (2017). The client meets two criteria: a flat affect with little emotional response, delusion, and hallucinations.

Schizoaffective Disorder

In addition to meeting the criteria of Schizophrenia, the client must have had a depressive or manic episode according to the DSM-5 to meet the criteria for schizoaffective disorder (2017). This client does not meet the requirements due to denying any depressive or manic symptoms. According to Beckmann, Schnitzer, and Freudenreich, a diagnosis of the schizoaffective disorder requires the presence of a full mood episode that is there most of the time (2020).

Bipolar Disorder

A client must meet three or more of the following symptoms to be diagnosed with bipolar disorder according to the DSM-5; inflated self-esteem, decreased need for sleep, more talkative than usual, flight of ideas, distractibility, psychomotor agitation, and impulsive behaviors (2017). This client denies having any depressive or manic symptoms, so he does not meet the criteria for bipolar disorder. According to Mondragón-Maya, Flores-Medina, Silva-Pereyra, Ramos-Mastache, Yáñez-Téllez, Escamilla-Orozco and Saracco-Álvarez, bipolar disorder is diagnosed if the patient meets the criteria for a manic episode (2020).

Reflections

Looking back at this visit, the client has decompensated due to his psychiatrist retiring. A trusting relationship must be built for the client to feel safe. This can be done by offering a therapeutic environment where the patient can feel safe to be open. Speaking with the client’s parents can also provide insight into the client’s life.

Clinical Impression

The client will start Abilify 5mg PO daily to help to manage his symptoms. According to Schneider-Thoma, Chalkou, Dörries, Bighelli, Ceraso, Huhn, Siafis, Davis, Cipriani, Furukawa, Salanti, and Leucht, if a patient had no significant side effects in the acute phase of treatment, it might be wise for them to stay on the same drug (2022). This client has taken Abilify in the past with no adverse effects, so he is agreeable to starting the medication again. He will also begin cognitive behavioral therapy with the therapist he is seeing, and they will also have a family session. According to Boxell, O., & Marquis, combining antipsychotics and cognitive behavioral therapy will challenge the client’s insights about his delusions and hallucinations (2022). The client wants to start working when his symptoms improve so that he will participate in supported employment programs. He is also interested in art and music therapy. The client will follow up in two weeks to assess for any adverse effects, and his medication will be adjusted as needed.

Discussion Questions

1. Did you agree with the diagnosis?

2. What are some treatment options that you would add?

3. What is some other differential diagnosis that could have been ruled out?

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References

Beckmann, D., Schnitzer, K., & Freudenreich, O. (2020). Approach to the diagnosis of

schizoaffective disorder. Psychiatric Annals, 50(5), 195–199. https://doi.org/10.3928/00485713-20200408-01 pdf2.pdf

Boxell, O., & Marquis, A. (2022). An integral analysis of the etiology and treatment of

schizophrenia: Integrated pluralism in research and clinical practice. Journal of Psychotherapy Integration. https://doi.org/10.1037/int0000277 pdf5.pdf

CBS Publishers & Distributors, Pvt. Ltd. (2017). Diagnostic and statistical manual of mental

disorders: Dsm-5.

Mondragón-Maya, A., Flores-Medina, Y., Silva-Pereyra, J., Ramos-Mastache, D., Yáñez-Téllez,

G., Escamilla-Orozco, R., & Saracco-Álvarez, R. (2021). Neurocognition in bipolar and depressive schizoaffective disorder: A comparison with schizophrenia. Neuropsychobiology, 80(1), 45–51. https://doi.org/10.1159/000508188 pdf1.pdf

Schneider-Thoma, J., Chalkou, K., Dörries, C., Bighelli, I., Ceraso, A., Huhn, M., Siafis, S.,

Davis, J. M., Cipriani, A., Furukawa, T. A., Salanti, G., & Leucht, S. (2022). Comparative efficacy and tolerability of 32 oral and long-acting injectable antipsychotics for the maintenance treatment of adults with schizophrenia: A systematic review and network meta-analysis. The Lancet, 399(10327), 824–836. https://doi.org/10.1016/S0140-6736(21)01997-8 pdf4.pdf

Yang, Z., Abdul Rashid, N. A., Quek, Y. F., Lam, M., See, Y. M., Maniam, Y., Dauwels, J., Tan,

B. L., & Lee, J. (2018). Montreal Cognitive Assessment as a screening instrument for cognitive impairments in schizophrenia. Schizophrenia Research, 199, 58–63. https://doi.org/10.1016/j.schres.2018.03.008 pdf3.pdf

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