Week 5: Focused SOAP Note and Patient Case Presentation
\nCollege of Nursing-PMHNP, Walden University
\nNRNP 6675: PMHNP Care Across the Lifespan 2 Practicum
\nIntroduction
\nPsychosis is a mental condition in which a person’s ideas and perceptions are disrupted,
\nand the individual may have difficulty distinguishing between what is real and what is not.
\nA health condition, medications, or drug usage can all contribute to psychosis. Delusions,
\nhallucinations, incomprehensible speech, and agitation are all possible signs; the patient has
\nincorrect beliefs and sees or hears things that others do not see or hear. The person suffering from
\nthe disease is usually unaware of his or her actions. Medication, psychotherapy, peer support,
\nfamily support and education, and talk therapy are all options for treatment. More or less every
\nmental intervention is backed by evidence accumulated during the patient’s initial interview; each
\npatient’s therapy begins with a thorough medical and mental health evaluation, the incorporation
\nof trust, and a discussion of past mental health history, substance misuse history, family mental
\nhealth history, and so on. In this example, the patient’s evaluation was documented, and a
\ndiagnosis was made based on the information collected from the patient during the evaluation.
\nWhen the case was being developed, a therapeutic approach was designed. The patient is a 53-
\nyear-old Caucasian male who was scheduled for an initial screening for a psychotic disorder after
\nhis sister recommended a visit to the psychiatrist because patient’s behavior changed since the
\nmother passed away.
\nPatient Initial: S.T Age: 53 Gender: Male
\nSubjective Data:
\nCC: “I was brought here by my sister because since my mother passed away, I was living on my
\nown and not bothering anyone. Those people outside my window they are after me. They just
\nwant me dead”.
\nHPI: When patient was asked ” what people?”. Patient said ” the government sent them to get
\nme because my taxes are high”. Suddenly patient asked the provider if she can see the birds or
\nhear any loud noise. The provider responded by redirecting the patient that she does not hear any
\nvoice or see anything. When the provider how long he is been hearing the voices or seeing
\nthings, patient said ” for weeks, weeks and weeks”. Patient also said the sister tapped her phone
\nwith the government. When asked about sleep, patient said ” I have not slept well because the
\nvoices keep me up for days. I try to watch the TV, they poison my food on TV, I locked
\neverything down in the fridge”. Suddenly patient asked ” Can I smoke?”. Provider said “no you
\ncan’t smoke here”. Patient admit that he smokes all day about 3 packs a day. Drinks alcohol
\nwhich his sister purchased for him to last him for weeks. Patient denies use of drugs. Admit to
\nhistory of marijuana use 3 years ago before the mother passed away. Denies blackout, seizures,
\ncollateral or legal issues or DUIs from use of drugs or alcohol. Patient admit that he hates
\nHaldol and Thorazine which he used to take. Calls his medications poison and said he is not
\ngoing to take it.
\nSubstance Use History: Admits to use of alcohol, smokes 3 packs of cigarette per day. Admit
\nhistory of marijuana 3 years ago
\nFamily Psychiatric\/Mental\/Substance Use History: Patient father paranoid and schizophrenia.
\nPatient\u2019s mother: Anxiety. Sister: unknown Grandfather: unknown. Grandmother: unknown
\nPsychosocial History: Patient lives alone. Mother is deceased. Father is undisclosed. Both
\nparents are Caucasian. Patient is presently does not have friends. Educational Level: 10th grade.
\nLegal history: patient denies any history but said the police told him they would because patient
\ncalls 911 on people outside.
\nPsychiatric History: Mood disorder unspecified
\nMedical History\/Surgical History: Diabetes
\nBirth and Developmental history: Vagina birth, denies any disclosed complication and all
\ndevelopmental millstones was met on time.
\nCurrent Medications: Haldol and Thorazine (all discontinued), Metformin
\nAllergies: NKDA or seasonal allergies
\nReproductive Hx: Patient denies sexual history or abuse
\nAPPEARANCE: Appeared disheveled
\nHEENT: No vision problem. Ears normal shape with no discharges. Nose normal shape; no
\ndeviation or drainage. No sore throat or swelling around the neck.
\nCV: no cardiovascular abnormality
\nPULMO: Lungs sounds clear and no adventitious lung sounds
\nABDOMEN: All bowel sounds on all four quadrant
\nGENITOURINARY: No disorder or problem with this system
\nEXTREM: All extremities is moveable; some tremors noted in upper extremities
\nNEURO: alert and oriented to person, place, time, and situation but very unrest
\nSKIN: Skin intact and appropriate; no rash or lesion noted
\nPhysical exam:
\nVital Signs: none at this time
\nWeight: 196 Ibs
\nHeight: 5’9ft
\nObjective:
\nDiagnostic results: no diagnostic test ordered or required at this time
\nAssessment:
\nMental Status Examination
\nOn arrival and during the session, the patient appeared to be of the age reported, with no
\nsigns of discomfort. The patient appears to be well fed and groomed. Clean and well-dressed.
\nPatient was compliant, did not fidget, maintained good eye contact, and but could not stay still
\nfor long periods of time. The patient appears to be frightened and anxious. Affect was wideranging, a little constrained, and frequently depressing. There was no anomalous movement
\nobserved. Maintain a steady gait and maintain an upright stance. Appeared anxious , the patient
\nwas coherent but not particularly logical. Although the patient did not have acute psychosis, he
\nwas actively delusional and responding to internal stimuli. Patient was delusions or paranoid
\nbehavior, suspicious thoughts and intrusive ideas plague the patient. Patient\u2019s speech was normal
\nrate, rhythm volume and clear. Patient does not feel like he will get better. Patient was a good
\nhistorian. Patient was attentive to the provider. Alert and oriented times 4. Memory both long
\nand short term was intact. Patient denies suicide ideation. Patient admits having intrusive
\nthoughts of hurting. During assessment patient states “the government sent people to get me
\nbecause my taxes are high”. Suddenly patient asked the provider if she can see the birds or hear
\nany loud noise.
\nDifferential Diagnoses
\nSchizophrenia: Schizophrenia is a “psychosis,” a sort of mental illness. A psychosis is a mental
\ndisease in which the sufferer is unable to distinguish between what is real and what is imagined.
\nPeople suffering from mental diseases can lose contact with reality at times (Sadock, 2014). The
\nworld may appear to be a tangle of perplexing ideas, images, and noises. One kind of
\nschizophrenia is paranoid schizophrenia. In this case, the person’s incorrect beliefs are mostly
\nconcerned with being persecuted or punished by others. Someone’s voice may be heard, which
\nthe individual believes is punishing them. The individual may assume that he or she has been
\nhand-picked to carry out a top-secret task. According to DSM-5, patient must meet certain to be
\ndiagnosed with schizophrenia; delusions, hallucinations, diagnosed speech or thought, negative
\nsymptoms, paranoid delusions, grossly disorganized or catatonic behavior for the duration of 6
\nmonths, symptoms not due to effects of substance or another medica condition (American
\nPsychiatric Association2013). The above listed criteria are all evident in our patient.
\nSchizoaffective Disorder: In clinical practice, schizoaffective disorder is one of the most
\nmisdiagnosed psychiatric diseases. In fact, some academics have requested that the diagnostic
\ncriteria be revised, while others have suggested that the diagnosis be removed entirely from the
\nDSM-5. Schizoaffective illness is easily confused with other mental disorders due to criteria that
\ninclude both psychosis and mood symptoms. Schizophrenia, Major Depressive Disease with
\nPsychotic Features, and Bipolar Disorder are all disorders that must be ruled out during a
\nschizoaffective disorder workup. According to DSM 5, to diagnose schizoaffective illness, there
\nmust be at least two weeks of exclusively psychotic symptoms (delusions and hallucinations)
\nwithout any mood symptoms. However, throughout the majority of the illness’s existence, a
\nmajor mood episode (depression or mania) is present. When psychotic symptoms prevail for the
\nbulk of the illness’s duration, the diagnosis is likely to be schizophrenia. Furthermore,
\nschizophrenia requires 6 months of prodromal or residual symptoms, but schizoaffective disorder
\ndoes not. Schizoaffective disorder is a psychotic disease similar to schizophrenia.
\nDelusion of Persecution: A delusion is a false belief that suggests a problem with the contents
\nof the affected person’s thoughts. The person’s cultural or religious background, as well as his or
\nher level of intelligence, have no bearing on the incorrect belief. The degree to which the person
\nbelieves the belief is true is a significant component of a delusion (American Psychiatric
\nAssociation2013). A person suffering from a delusion will cling to their belief despite evidence
\nto the contrary. Delusion of Persecution occurs when a person believes that they (or someone
\nclose to them) is being mistreated, that someone is spying on them, or that someone is planning
\nto harm them. According DSM-5 patient must meet the following criteria before being one or
\nmore delusion for at least one month, fearing ordinary situations, feeling threatened without
\nreason, frequently reporting to authorities, extreme distress, excess worry, constantly seeking
\nsafety and hallucinations associated with the delusions. The above listed criteria are evident in
\nour patient
\nReflection
\nEvery mental intervention is determined by the information collected during the initial
\nconversation with the client; every client’s therapy starts with a comprehensive medical and
\nbehavioral health examination, the creation of trust, and a discussion of previous mental health
\nhistory, substance abuse history, family mental health history, and so on. Individuals with whom
\nthey had connections that comprised effective communication, cultural awareness, and the
\nabsence of compulsion were considered as trustworthy (Sadock et al., 2014).
\nAs a PMHNP, one thing I might have done differently is to meet the patient first, develop
\na therapeutic relationship, inquire about the young patient’s relationship with his parents, and
\nthen ask questions irrelevant to the scheduled visit, which would assist to create a welcome
\natmosphere. Without appearing to be biased, ask open-ended questions about the patient’s
\npersonality, illness, or personality. Inquire about the patient’s sexual orientation and
\ncommunication preference. Cultural competency includes elements such as trust, respect for
\ndiversity, respect for religion, equity, fairness, and social justice, which must all be considered
\nduring any interview or encounter between a healthcare practitioner and a patient (Sadock et al.,
\n2014). When I interview a patient about their mental illness symptoms, I look at how they look,
\nspeak, and act to determine if there are any clues that could explain their symptoms.
\nCase Formulation and Treatment Plan
\nThe patient will begin individual supportive therapy then advance to family and peer
\ngroup supportive therapy depending on level of improvement. The patient will receive an
\neducational pamphlet, as well as assignments and a follow-up consultation, on themes that will
\naid in the healing and coping process.
\nPatient will be started on Perphenazine 32mg PO QHS, Benztropine 1mg PO BID for
\nprevention of EPS. Education and side effects of medication was provided. Labs (CBC, CMP,
\nA1C, lipid profile) will be ordered in the next visit.
\nEducation on substance use and smoking cessation was provided for patient. Patient will
\nbe educated on importance of taking his vital signs daily, increase fluid intake, report change
\nfinger sticks of blood sugar check,
\nIn case of emergency, the provider provided patient with helpful phone numbers: 911 for
\nemergencies and the Client’s Crisis Line. Reports from doctors and therapists were evaluated for
\nmutual and collaborative understanding and for continuity of care.
\nPatient was educated and was advised to call their primary care physician or go to the
\nnearest emergency department if they had any questions or concerns about the development of
\nany undesirable or unexpected outcome or side effects.
\nEvery 30 days, patient must return to appointments for continuity of care and for provider
\nto monitor progress and outcome of treatment but patient will return a two week after starting the
\nnewly prescribed medications for adjustment of dosing and to monitor improvement.
\nReferences
\nAmerican Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental
\nDisorders, fifth edition DSM-5 American Psychiatric Association, 2013.
\nBachem, R., & Casey, P. (2018). Schizoaffective Disorder: A diagnosis whose time has come.
\nJournal of Affective Disorders, 227, 243-253. https:\/\/doi.org\/10.1016\/j.jad.2017.10.034
\nSadock, B.J., Sadock, V.A., & Ruiz, P. (2014). Kaplan and Sadock\u2019s synopsis of psychiatry:
\nBehavioral sciences\/clinical psychiatry (11 th ed.). Philadelphia, PA: Wolters Kluwer.
\nThapar, A., Pine, D. S., Leckman, J. F., Scott, S., Snowling, M. J., & Taylor, E. A. (Eds.).
\n(2015). Rutter\u2019s child and adolescent psychiatry (6th ed.). Wiley Blackwell.
\nWalden University. (2021). Case study: Sherman Tremaine. Walden University
\nBlackboard. https:\/\/class.waldenu.edu<\/p>\n","protected":false},"excerpt":{"rendered":"
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 […]<\/p>\n","protected":false},"author":4,"featured_media":0,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[1738,2474,2482,1563,2516,2499],"tags":[2501,2518,2477,2519,2520],"class_list":["post-9934","post","type-post","status-publish","format-standard","hentry","category-help-me-with-social-psychology-assignment","category-psyc-essays","category-psyc-paper-writing-service","category-psychology-case-study-examples","category-sociology-essays","category-write-my-psychology-papers","tag-psy-papers","tag-psych-research-paper-sample","tag-psychology-assignment","tag-psychology-dissertation-writing","tag-psychology-research-paper"],"_links":{"self":[{"href":"https:\/\/www.colapapers.com\/nursing\/wp-json\/wp\/v2\/posts\/9934","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/www.colapapers.com\/nursing\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/www.colapapers.com\/nursing\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/www.colapapers.com\/nursing\/wp-json\/wp\/v2\/users\/4"}],"replies":[{"embeddable":true,"href":"https:\/\/www.colapapers.com\/nursing\/wp-json\/wp\/v2\/comments?post=9934"}],"version-history":[{"count":0,"href":"https:\/\/www.colapapers.com\/nursing\/wp-json\/wp\/v2\/posts\/9934\/revisions"}],"wp:attachment":[{"href":"https:\/\/www.colapapers.com\/nursing\/wp-json\/wp\/v2\/media?parent=9934"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/www.colapapers.com\/nursing\/wp-json\/wp\/v2\/categories?post=9934"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/www.colapapers.com\/nursing\/wp-json\/wp\/v2\/tags?post=9934"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}