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

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

• Subjective: What details did the patient provide regarding  their chief complaint and symptomology to derive your differential  diagnosis? What is the duration and severity of their symptoms? How are  their symptoms impacting their functioning in life?

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• Objective: What observations did you make during the psychiatric assessment?
• Assessment: Discuss the patient’s mental status examination  results. What were your differential diagnoses? Provide a minimum of  three possible diagnoses with supporting evidence, and list them in  order from highest priority to lowest priority. Compare the DSM-5 diagnostic criteria for each differential diagnosis and explain what DSM-5 criteria  rules out the differential diagnosis to find an accurate diagnosis.  Explain the critical-thinking process that led you to the primary  diagnosis you selected. Include pertinent positives and pertinent  negatives for the specific patient case.
• Plan: What is your plan for psychotherapy? What is your plan  for treatment and management, including alternative therapies? Include  pharmacologic and nonpharmacologic treatments, alternative therapies,  and follow-up parameters, as well as a rationale for this treatment and  management plan. Also incorporate one health promotion activity and one  patient education strategy.
• Reflection notes: What would you do differently with this  patient if you could conduct the session again? Discuss what your next  intervention would be if you were able to follow up with this  patient. Also include in your reflection a discussion related to  legal/ethical considerations (demonstrate critical thinking beyond  confidentiality and consent for treatment!), health promotion, and  disease prevention, taking into consideration patient factors (such as  age, ethnic group, etc.), PMH, and other risk factors (e.g.,  socioeconomic, cultural background, etc.).
• Provide at least three evidence-based, peer-reviewed journal  articles or evidenced-based guidelines that relate to this case to  support your diagnostics and differential diagnoses. Be sure they are  current (no more than 5 years old).

Week ( #5): (schizophrenia)

Faculty Name

Assignment Due Date

Subjective:

CC (chief complaint): “ my sister made me come’

HPI: C. C. is a 52-year-old caucasian male who presented for psychiatric evaluation and medication management. The patient presented by his sister suggestion for auditory and visual hallucinations and has been off medication for an unknown period of time.

Past medical history– patient-reported Diabetes and fatty Liver (Hepatic staetosis).

Medication trials and current medications– Haldol, Thorazine, Seroquel, and Risperidone (dosage unknown). the patient reported gynecomastia with Risperidone. The patient takes metformin for diabetes.

Psychotherapy or previous psychiatric diagnosis- No history of previous psychotherapyon record. He had three hospitalizations when he was 20. During this visit, the patient was educated on a healthy living lifestyle

Pertinent substance use- The patient smokes 3 packs of cigarettes per day, drinks about 2 packs of beer for two weeks. Stopped smoking marijuana 3 years ago. Denies illicit use of other drugs drinks 2 to 3 bottles of beer socially. Currently smokes 3 to 5 ticks of cigarettes per day

Family psychiatric/substance use. The father was diagnosed with paranoid schizophrenia and the mother, Anxiety disorder. No history of sexual abuse. His dad takes Alcohol (?)

Social History- The patient lives alone now. He was raised by his mom and sister. The patient is a 10th grader, not working. The patient was never married and no children reported. Smokes and drinks for fun. No history of any form of exercise.

Allergies- No known allergies

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· Current Medications: Metformin (Dose unknown). Not on any psychotropic medication as at the moment

· Reproductive Hx: The patient was never married nor divorced and no Children noted. Its not if the patient is sexually active,

· ROS:

Vitals: BP 117/82, P- 87,T-97.8, R- 16, Spo2-98% in room air

· GENERAL: No fever, chills, weakness, or fatigue, and no weight loss. the patient has a history of diabetes and fatty liver,

· · HEENT: Head is Normocephalic and atraumatic, Eye- pupils are equal, no discharges, No double, blurred vision. Ear, Nose, and Throat -No hearing loss, No congestion, no sore throat, and no sneezing

· · SKIN: Skin is warm, No rash or itching

· · CARDIOVASCULAR: No chest pain, No chest pressure, and no edema, No palpitation

· · RESPIRATORY: No respiratory distress.

· · GASTROINTESTINAL: No distension noted, No anorexia and vomiting

· · GENITOURINARY: No burning on urination

· · NEUROLOGICAL: The patient is alert and oriented, no dizziness, numbness, or tingling sensation of the extremities

· · MUSCULOSKELETAL: No muscle pain, No back pain, nobody stiffness, no edema noted

· · HEMATOLOGIC: The patient is not frail and no bleeding

· · LYMPHATICS: No enlarged lymph nodes.

· · ENDOCRINOLOGIC: There is polydipsia. No sweating and heat intolerance.

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Objective:

Diagnostic results: Blood test, CT scan, and MRI to rule out physical illness as the cause of symptoms. Toxicology to rule any drug use.

Assessment

Mental Status Examination: He is a 52-year-old Caucasian male who looks his stated age. He is alert and orientated to place person, and partially to time and situations. He is independent of ADL and continent. He is neatly groomed and clean, dressed appropriately. The patient was calm and cooperative with the examiner. His speech was disorganized and loose because there is frequent derailment in his speech during the assessment. Patient-reported auditory hallucinations and has been having it for weeks and also reported visual hallucinations ( he sees people, shadows and also hears them. He was also seen actively hallucinating during the visit, Hearing high metal music. There is evidence of any abnormal motor activity based on his abnormal gazing with poor concentration. His thought process is tangential. patient seen to be paranoid and delusional, he believed his food is been poisoned and believed medications are poisoned and been watched through the television. Patient-reported that he has a problem falling asleep and staying asleep because of the voices in his head. flat affect noted with poor eye contact. Cognitively, His recent and remote memory is fair. His concentration is fair. His insight and judgment are poor. He denies suicidal and homicidal ideation.

Diagnostic Impression

Following the patient’s assessment and the information provided, he has been experiencing hallucinations, delusions, and paranoia for weeks. According to DSM-5, the signs presented could be due to schizophrenia, schizoaffective disorder, or mood disorders. As per my assessment of the client and diagnostic rules of DSM-5, the primary diagnosis for the patient’s condition is Schizophrenia (paranoid schizophrenia). The patient has experienced the aforementioned symptoms for weeks and has been diagnosed since he was in his 20s and has also caused a significant disturbance in major areas (Academics and work). Symptoms are not related to the psychological effects of drugs as the patient denies the use of illicit substances or medical disorders. According to Dina (2019), Paranoid schizophrenia is characterized by predominantly positive symptoms of schizophrenia, including delusions and hallucinations of life. Also, someone with active paranoid schizophrenia is consumed by their delusions or hallucinations. The vast majority of their energy and attention is focused on keeping to and protecting their falsely held beliefs or perceptual distortions (Center for Addiction and Mental Health, 2019) which is clearly noticeable in this patient. The negative symptom for this patient lack of mental function which is characterized by no social lifestyle, flat affect, and trouble with speech and sleep due to hallucinations.

Mood disorder could be another diagnosis possibility with this patient. Saddock and Kaplan (2015) stated that Major depressive and manic episodes may present with delusion and hallucinations. These symptoms come along with other predominant symptoms of depression or mania which are absent in this patient.

Personalty disorder could also be a possible diagnosis. Schizotypal, schizoid and borderline personality disorders may have the same features as schizophrenia. according to Shaddock and Kaplan (2015), symptoms are very mild, occur throughout a patient’s life, and also lack an identifiable date of onset, unlike schizophrenia. This patient was able to identify that his symptoms started weeks ago and the symptoms in this patient is severe

Case Formulation and Treatment Plan

Reflections

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References.

Center for Addiction and Mental Health, (2019). Schizophrenia Information Guide.

Availableat https://www.camh.ca/-/media/files/guides-and-publications/schizo phrenia-guide-en.

Cheng, B., Liu, Y., Tian, J., Gao, R., & Liu, Y. (2020). Complementary and alternative medicine for the treatment of insomnia: an overview of scientific evidence from 2008 to 2018. Current vascular pharmacology, 18(4), 307-321.

Seow, L. S. E., Verma, S. K., Mok, Y. M., Kumar, S., Chang, S., Satghare, P., … & Subramaniam, M. (2018). Evaluating DSM-5 insomnia disorder and the treatment of sleep problems in a psychiatric population. Journal of Clinical Sleep Medicine, 14(2), 237-244.