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Week 7 Discussion: Focused SOAP Note and Patient Case Presentation
Emilia Egwim
College of Nursing-PMHNP, Walden University
NRNP 6675: PMHNP Care Across the Lifespan 2 Practicum
- Nataliya Ishkova
January 15, 2023
Introduction
Mental health disorder has tremendous effect on individual life and can result to impairment in daily activities. Individual with mental health illness such as psychosis suffer a great deal of impairment, unaware of their action and have difficulties distinguishing between what is real and what is not. The patient in this case study have been diagnosed with Intellectual Disability, Major Depressive Disorder, and unspecified psychosis. The purpose of this assignment is to develop a focused soap note case presentation by obtaining patient pertinent information, developing differential diagnosis, selecting appropriate treatment as well as providing patient with education and health promotion activities. Care Across The Lifespan Il Paper
Subjective:
Patient Information
Name: J.W
Gender: Male
Age: 50 Years
Chief Complaint (CC): “I have been seeing my PCP with skin lesions and my PCP was unable to find the root of my problem and referred me to see a psychiatric for suspected psychosis.”
History of Presenting Illness: Patient is a 50-year-old Caucasian male seen at the clinic for initial psychiatry evaluation with a past psychiatric history of Intellectual Disability, Major Depressive Disorder, and unspecified psychosis. Patient presents stating he has been seeing his PCP with skin lesions, which his PCP was unable to find any medical bases and ruled it as psychosis. Patient reports that he has abscess on his nose with bruising on the outside, no doctors he has seen seems to believe him. He reports that his nose is sometimes discharging and comes out of the side of his cheek. He stated that when infections start to go away, he has black hard discharge coming out of his nose and then he sees it and it disappears. Patient reports increased anxiety due to stress. Patient reports have the same infection on his penis multiple different doctors have told him it’s all in his head. He states has Major problems with his ex-wife and lived with his mom. He reports feeling restless and have difficulty sleeping. Patient has been seeing his doctor for this infection for the past two years and doctors have told him to see a psychiatrist for evaluation. Patient reports seeing horizontal lines down his face, claims no one believes him, his girlfriend has reached out to his doctors to try to get him help. Patient states still grieving his father that passed away in 2007. He denies any thought of SI/HI/AVH or thoughts of harming himself nor others.
Past Psychiatric History: Patient has psychiatric history of Intellectual Disability, Major Depressive Disorder, and unspecified psychosis. Patient is currently not taking any psychiatric medication.
Family History: Patient denies any family history of psychiatric illnesses.
Substance Use: Patient denies any alcohol or substances used. Patient denies any family history of alcohol or substances used.
Medical History:
- Current Medications: Patient denies taken any psychiatric medications. After patient evaluation at the clinic, patient was started on venlafaxine ER 75 mg capsule, extended release 24 hour, 1 cap(s) orally once a day, OLANZapine 5 mg tablet, 1 tab(s) orally once a day and hydroxyzine pamoate 50 mg capsule, 1 tab(s) orally once a day.
- Allergies: Patient denies any known drug or food allergies.
- Reproductive History: Patient reports major problems with his ex-wife and stated that his girlfriend has been the one helping him. Patient did not mention having any children. Care Across The Lifespan Il Paper
Review of Systems:
- General: Denies any symptoms of fever, fatigue, chills, or weakness.
- HEENT: No head injury or headache. No blurred, double vision, diplopia, or loss of vision noted. No indication of hearing loss, sneezing, runny nose, congestion, or sore throats noted on ears, nose, or throat.
- SKIN: Skin intact, No bruising, itching, or rash.
- CARDIOVASCULAR: Denies any chest pain, palpitation, edema, or arrhythmia.
- RESPIRATORY: No shortness of breath, wheezing, cough, or respiratory discomfort.
- GASTROINTESTINAL: No diarrhea, distension, nausea, or vomiting.
- GENITOURINARY: Patient denies any enuresis.
- NEUROLOGICAL: No headache, seizure, syncope, paralysis, dizziness, or numbness.
- MUSCULOSKELETAL: No weakness or muscle noted.
- HEMATOLOGIC: No bleeding, bruising, or anemia.
- LYMPHATICS: No swellings in the lymph nodes.
- ENDOCRINOLOGIC: No polydipsia, sweating, heat, or cold intolerance.
Objective:
Diagnostic results: Although, there’s no specific lab test for psychiatric disorders, but some laboratory test and blood work can be conducted to rule out any medical issues that mimic psychiatric symptoms. The patient in this case study has no diagnostic test ordered or required at this time.
Assessment:
Mental Status Examination: During the zoom assessment interview, patient appeared to be of stated age. Patient is alert and oriented, well dressed and groomed. Patients maintain good eye contact throughout the zoom interview. Patient appeared anxious and look depressed. No abnormal movement observed and remained steady throughout the assessment interview. Although, patient has not yet confirmed psychotic diagnosis, but patient appeared paranoid and depressed. Patient had insight about his condition, was coherent and logical about his illness. Patient has clear speech, normal thought process and communicate appropriately. Patient was attentive to the provider, both long and short term was intact. Although, patient denies suicide ideation, homicidal ideation, or self-harm, but patient reports feeling restless and stated that he had a lot of stressors going on in his life that contributes to his anxiety. Care Across The Lifespan Il Paper
Differential Diagnoses
Schizophrenia Disorder: Is referred to as a psychiatric illness that is characterized by delusional and other psychotic symptom that impact how a person access and react to social stimuli/activities (Pinkham, Harvey, & Penn, 2016). Study indicated that multidisciplinary intervention is crucial when caring for individual with schizophrenia disorder and psychological interventions are considered a priority (Nuño et al, 2019). Individuals with schizophrenia endorses difficulty with realities. The symptoms of schizophrenia include delusional ideas, hallucination, disorganized speech, disorganized/catatonic behavior, and negative symptoms which are outline in the DSM-5 criteria. According to study by Ham et al, schizophrenia symptom is hard and difficult to distinguish symptoms due its similarity from those of medication-induced psychosis (2017). This patient endorses hallucination by stating that when infections start to go away, he has black hard discharge coming out of his nose and then he sees it and it disappears as well as delusional thinking stating he has abscess on his nose with bruising on the outside, no doctors he has seen seems to believe him including infection on his penis multiple different doctors have told him it’s all in his head. Based on patients presenting symptoms and assessment data collected during the interview which meet the criteria for schizophrenia as outlined by DSM-5 makes this disorder the appropriate diagnosis for this patient.
Somatic Delusional disorder: This is a mental health disorder that is commonly seen in various psychiatric illness such as schizophrenia, major depressive disorder, and bipolar disorder. Individual with somatic delusional disorder believes that something is wrong with a particular part of their body which may exist in array of mental health disorders. According to DSM-5 criteria, symptom of somatic delusional disorder includes distressing or disruptive of daily life for more than 6 months which includes one of these complains such as excessive and maladaptive thoughts, persistently high anxiety and excessive time and energy spent on those health concerns (D’Souza & Hooten, 2022). Study indicated that individual with this disorder often experience anxiety and nervousness and many of these individuals lack insight into their disorder and consequently refuse treatment. Patient in this case presentation reported skin infection on different part of his body which he had seen various providers and none of them seems to believe him, instead, he was referred to see a psychiatrist for psychosis. Patient endorses other symptoms not included in this disorder, making it the least possibly diagnosis.
Major depressive Disorder: Is a psychiatric illness that is associated with excessive change in patient mood resulting in functional impairment in daily activities. Individual with MDD is at increased risk for suicidal attempt, according to study, some individual eventually ended up committing suicide while other endorses suicidal thoughts (Tolentino & Schmidt, 2018). Based on DSM-5 criteria for MDD, the individual should experience symptoms such as loss of interest in previously pleasurable activities, depressed mood, lack of energy, suicidal thought, and lack of concentration or motivation. The patient in this case study reported feeling stressed, restless and have difficulty sleeping. Although, patient endorses some symptoms outline in the DSM-5 criteria for MDD, but not enough to make this disorder the actual diagnosis for this patient.
Reflections
The schizophrenia disorder is my priority diagnosis for this patient. Study has indicated that intervention for mental health illness is based on accurate collection of patient information both comprehensive mental health and medical health examination. I have learned that schizophrenia can be heritable and adequate assessment and collection of data is imperative to help reach the desirable goal. The other two differential diagnosis are also suitable in that some of patient’s symptoms aligned with the DSM-5 criteria. During the assessment interview, I could not obtain enough information pertaining to patient family history which is important and can assist in determining appropriate diagnosis as well as selecting intervention that will yield better patient’s outcome. What I would have done differently is to ensure to gather sufficient data pertaining to patient family history of psychiatric and substances used including patient. I would ensure to develop a working relationship with patient to help him feel comfortably relating information that can assist in the treatment plan. As an advanced practice nurse, it is imperative to apply therapeutic communication to enhance interaction with the patient. Care Across The Lifespan Il Paper
Case Formulation and Treatment Plan
There’s no specific test for diagnosis of mental health illness, but patient in this case study presentation will benefit for both pharmacological and non-pharmacological interventions. The pharmacological intervention that will be beneficial for this patient case is to start him on serotonin-norepinephrine reuptake inhibitors (SNRIs) such as venlafaxine ER 75 mg capsule, extended release 24 hour, 1 cap(s) orally once a day. Other medication such as Olanzapine 5 mg tablet, 1 tab(s) orally once a day and hydroxyzine pamoate 50 mg capsule, 1 tab(s) orally once a day was added to help manage patient’s symptom which have been approved by FDA and various evidenced based studies to manage anxiety, depression and psychosis. Psychotherapy in the other hand will be apply to assist with the treatment. According to study, pharmacological and psychotherapy when combine result in greater outcome. Patient recommended to start seeing therapy once a week to help develop coping mechanism. Patient was educated on the important taking medication as prescribed and report any undesirable side effects. In the case of emergency, patient was provided with Crisis Line phone number and encourage to call their primary care physician or go to the nearest emergency department if they had any questions or concerns regarding undesirable outcome. Will collaborate with multidisciplinary team for continuation of care. Patient will return in 4 weeks for follow up care.
Questions
Is the recommended medication appropriate for this patient condition?
Is there any other differential diagnosis for this patient?
What additional information is needed in the diagnosis of psychosis disorder?
What factors are important to consider when caring for a patient endorsing psychosis?
Is combination of pharmacological and non-pharmacological interventions beneficial for this patient?
Is patient family history important in assessing and developing treatment plan for this patient? Care Across The Lifespan Il Paper
References
D’Souza, R. S & Hooten, W. M. (2022). Somatic Syndrome Disorders. Treasure Island (FL):
StatPearls Publishing; https://www.ncbi.nlm.nih.gov/books/NBK532253/
Ham, S., Kim, T. K., Chung, S., & Im, H. I. (2017). Drug Abuse and Psychosis: New Insights
into Drug-induced Psychosis. Experimental neurobiology, 26(1), 11–24. https://doi.org/10.5607/en.2017.26.1.11
Nuño, L., Guilera, G., Coenen, M., Rojo, E., Gómez-Benito, J & Barrios, M. (2019). Functioning
in schizophrenia from the perspective of psychologists: A worldwide study. PLoS ONE 14(6): e0217936. https://doi.org/10.1371/journal.pone.0217936
Pinkham, A. E., Harvey, P. D., & Penn, D. L. (2016). Paranoid Individuals with Schizophrenia
Show Greater Social Cognitive Bias and Worse Social Functioning than non-paranoid individuals with schizophrenia. Schizophrenia research. Cognition, 3, 33–38. https://doi.org/10.1016/j.scog.2015.11.002
Tolentino, J. C., & Schmidt, S. L. (2018). DSM-5 Criteria and Depression Severity: Implications
for Clinical Practice. Frontiers in Psychiatry, 9(OCT), 450.
https://doi.org/10.3389/fpsyt.2018.00450
