NRNP/PRAC 6665 & 6675 Focused SOAP Psychiatric Evaluation Exemplar EXEMPLAR BEGINS HERE Subjective: CC (chief complaint): The patient presents with c/o visual and auditory hallucinations with delusions “the government sent people to watch me”, “the people outside my window won’t leave me alone”, “I can hear them and see their shadows,” and “they watch me through my TV.” History obtained from the patient: S.T. HPI: S.T. is a 52-year-old, African American, male, unemployed, presents to the office for a psychiatric evaluation with complaints of psychosis with a history of Schizophrenia, Diabetes Mellitus Type 2, and Hepatic Steatosis (Fatty Liver). He is currently prescribed Seroquel, Risperdal, Thorazine, and Haldol for Schizophrenia. The patient also takes Metformin for treatment of Diabetes. The patient admits he is currently non-compliant with his medication regimen. He states, “It is all poison and I’m not going to take it.” He was hospitalized 3 times before in his 20’s. He has a family history of mental illness. His father had a hx of Schizophrenia and his mother had a hx of Anxiety. The patient explains he was living with his mother until she passed away 3 years ago. He now lives alone and was encouraged to obtain a psychiatric evaluation by his sister. The patient has been having visual and auditory hallucinations: The patient states, “people were sent by the government” and “they are outside my window watching me.” He states, “they will not leave me alone” and that “I can hear them” and “I can see their shadows.” The patient has been having persecutory delusions. He states, “the government tapped my phone” and “they are watching me through my T.V.” The patient states the onset of his symptoms began “weeks, weeks, weeks, weeks ago”. He reports increased difficulty in sleeping. Extended insomnia is reported. He describes the voices as “loud” and reports “they keep me awake for days and days.” He states he is unable to grocery shop for himself because the heavy metal music inside the store is “too loud” and “people follow me there.” His sister grocery shops for him weekly. He explains he likes to heavily smoke cigarettes and drink alcohol for fun. He has paranoid thoughts. He believes his sister is plotting with the government to make changes so that he can no longer live alone. He states he locks his food in the refrigerator so other people cannot poison his food. He reported visually seeing a bird in the office, stating “Do you see that bird?” He also reported hearing heavy metal music during the assessment. The patient admits he constantly calls 911 regarding the auditory and visual hallucinations. He admits he has been warned by the police that he will be arrested if the calls continue. He denies suicidal ideations and attempts. He denies homicidal ideations and impulses. Substance Use History: The patient admits smoking cigarettes. He smokes 3 packs of cigarettes per day, last known use was today. He admits to consumption of alcoholic © 2021 Walden University Page 1 of 12 NRNP/PRAC 6665 & 6675 Focused SOAP Psychiatric Evaluation Exemplar beverages, last known use was today and he drinks a 12 pack per week. The patient admits a history of smoking marijuana, last known use 3 was years ago. He denies use of cocaine or any other illicit substances. He denies any history of any withdrawal complications. Past Medical Hx: Schizophrenia, Diabetes Mellitus Type 2, Hepatic Steatosis (Fatty Liver Disease). Hospitalizations: The patient admits to past hospitalizations x3 at the age of 20 years old. Past Surgical History: Denies any past surgeries. Current Medication Hx: Seroquel 75mg per day orally for managing Schizophrenia, Risperidone 5 mg per day taken orally for Schizophrenia, Thorazine 350 mg per day taken orally for Schizophrenia, Haldol 2mg twice per day taken orally for managing Schizophrenia, Metformin 500mg daily taken orally for managing type 2 Diabetes. Allergies: No known allergies. No known drug allergies. Reproductive Hx: The patient is a 52-year-old male that denies any sexual concerns or reproductive issues. Family Hx: Father: Father has a history of Paranoid Schizophrenia and alcohol abuse issues. Father was hospitalized in Old State Hospital. Denies father had a history of suicidal ideations or attempts. Father is deceased. Mother: Mother has history of Anxiety. Denies mother had a history of suicidal ideations or attempts. Mother is deceased, died 3 years ago Social Hx: The patient is single, never married, no children. He is unemployed and lives alone. He was raised by his mother and sister. He used to live with his mother until she passed away 3 years ago. He smokes 3 packs of cigarettes per day, last use today 3/18/20. Drinks 12 cans of alcohol per week, last use yesterday 3/17/2020. Admits he likes to drink and smoke for fun. Admits past use of Marijuana, last use 3 years ago. Denies use of cocaine or any other illicit drugs. Denies history of sexual abuse. When asked if there was a history of physical abuse the patient admits his father was physically “hard on them” until he died. His social support system includes his sister.10th grade his highest level of education. Never arrested, No DUI’s. . ROS: © 2021 Walden University Page 2 of 12 NRNP/PRAC 6665 & 6675 Focused SOAP Psychiatric Evaluation Exemplar GENERAL: Denies fever, chills, weight loss or weakness HEENT: Eyes: Denies vision loss, blurred vision, double vision, or yellow sclerae. Denies use of contacts or reports of cataracts or glaucoma. Last eye exam not reported. EARS: Denies hearing loss, ringing in ears, dizziness, discharge, or pain, NOSE: Denies sneezing, congestion, runny nose, sinus pain, nose bleeds or allergies. THROAT: Denies sore throat, hoarseness, voice changes, mouth sores or dentures. Last dental visit not reported. SKIN: Denies rashes, bumps or itching. Denies jaundice or cyanosis. Denies any hair or nail changes, changing or new moles. CARDIOVASCULAR: Denies chest pain, chest pressure, or chest discomfort. Denies palpitations or edema. RESPIRATORY: Denies shortness of breath, wheezing, cough, or sputum. GASTROINTESTINAL: Denies anorexia, nausea, vomiting, heartburn, indigestion, constipation, or diarrhea. Denies abdominal pain or rectal bleeding. LBM not reported. GENITOURINARY: Denies burning on urination, decreased force of stream, increased frequency, urgency, hesitancy, incontinence, odor, odd color, hematuria, penile discharge, or any sexual dysfunction. NEUROLOGICAL: Denies headache, dizziness, confusion, syncope, paralysis, ataxia, numbness, or tingling in the extremities. Denies any changes in bowel or bladder control. Denies loss of consciousness or seizures. MUSCULOSKELETAL: Denies muscle, back pain, joint pain, or stiffness. HEMATOLOGIC: Denies anemia, bleeding, or bruising. LYMPHATICS: No enlarged nodes. No history of splenectomy. ENDOCRINOLOGIC: Denies reports of sweating, cold, or heat intolerance. Denies polyuria or polydipsia. Denies hypoglycemia or hyperglycemia. Objective: Diagnostic results: © 2021 Walden University Page 3 of 12 NRNP/PRAC 6665 & 6675 Focused SOAP Psychiatric Evaluation Exemplar Vital signs: BP: 120/79, Temp. (Oral): 98.6, RR: 19, Height: 5’6”, Weigh: 159 lbs., BMI:24 Physical Exam Alanine Transaminase (ALT) Aspartate Transaminase (AST): Blood Alcohol Level CBC with Differential and Platelets Comprehensive Metabolic Panel Fasting Plasma Glucose Gamma Glutamyl Transferase (GGT) Hemoglobin A1 Lipid Panel Thyroid Function Tests (T3, T4, and TSH) Toxicology Screening. Urinalysis EKG CT Scan Assessment: Mental Status Examination: S.T. is a 52-year-old, African American, male, who looks his stated age. He is clean, well-groomed, and dressed appropriately for today’s weather: face is clean shaven, with a low fade haircut, dressed in a brown blazer, a black under shirt and light blue jeans. Mental status included: correct time, place and person, normal recent and remote memory. The patient presented with monotonous speech that was clear, normal in rate, volume, and articulation. He speaks using random clang associations at times. He has minimal eye contact and often gazes around the room. Emotionally the patient appears © 2021 Walden University Page 4 of 12 NRNP/PRAC 6665 & 6675 Focused SOAP Psychiatric Evaluation Exemplar guarded, and his posture is closed. He keeps his hands close to his body, crosses his arms and legs when speaking. His mood appears calm. His affect appears to fluctuate between euthymic and blunted. His affect appears appropriate to his mood. He is cooperative with the examiner but easily distracted. The patient demonstrates evidence of perceptual abnormalities, suspicions, and paranoid thoughts. His content of thought includes delusions of persecution. The patient believes the government sent people to watch him outside his window and they will not leave him alone. He believes his phone is tapped and that his food is being poisoned. He has difficulty with concentration. He tries to watch television, but he believes he is being watched through his T.V. His visual and auditory hallucinations include visually seeing a bird and hearing heavy metal music during the interview. There is evidence of a disturbed sleep pattern and extended insomnia. He admits he is unable get any sleep because the loud voices keep him awake for days. His unemployment status and the death of his mother appears to have a negative effect on the patient. He admits to smoking heavily and drinking alcohol for fun and because he is not working. There are no signs of alcohol withdrawal present. He appears to need assistance with some ADL’s. He believes people follow him to the grocery store and the heavy metal music is too loud there. He is unable to grocery shop for himself. His depends on his sister to grocery shop for him once a week. His level of insight and judgment regarding his illness appears to be poor. The patient is currently non-compliant with his medication regimen. He believes that all medication is poison, and he refuses to take it. The patient’s judgment is unrealistic with an abnormal insight into the severity of his present condition. He denies suicidal ideations and attempts. He denies homicidal ideations and impulses. The denial is convincing. Diagnostic Impression: The diagnosis I chose for the presenting condition is Schizophrenia. The rationale for choosing Schizophrenia was according to ( ) the patient must show two of the following symptoms for 1 month and some mental disturbance for over 6 months: • • • • • Hallucinations Delusions Disorganized speech and behavior Catatonic or coma like daze Bizarre or hyperactive behaviour The patient in this case showed evidence of experiencing active visual and auditory hallucinations, along with delusions for more than one month and mental confusion for more than 6 months. The patient stated the onset of the hallucinations and delusions started “weeks, weeks, weeks, weeks ago.” He also stated that he is currently © 2021 Walden University Page 5 of 12 NRNP/PRAC 6665 & 6675 Focused SOAP Psychiatric Evaluation Exemplar prescribed medication for schizophrenia which indicates a current diagnosis. His father had a history of Schizophrenia, and the patient had a history of 3 hospitalizations in his 20’s. The patient appears to be experiencing a psychotic break caused by the death of his mother 3 years ago, discontinuing his prescribed medication and/or his alcohol abuse. I ruled out schizophreniform because the hallucination and delusional symptoms were active for more than 6 months. Next, I ruled out Brief Psychotic disorder because the positive symptoms were active for more than one month. Lastly, I ruled out schizoaffective disorder, Bipolar Type because the patient did not appear to display symptoms of mania. Initial Diagnosis: Schizophrenia 295.90 (F20.9) Pertinent positives: visual and auditory hallucinations, persecutory delusions, blunted affect, abnormal thoughts, disorganized speech, clang associations, disorganized thinking, paranoia, and lack of sleep, 2 symptoms constantly active over 1 month, episode for more than 6 months. Pertinent negatives: abnormal motor behavior, catatonic behavior, coma like daze. Differential Diagnoses: Schizophreniform 295.40 (F20.81) Pertinent positives: visual and auditory hallucinations, persecutory delusions, blunted affect, abnormal thoughts, disorganized speech, clang associations, disorganized thinking, paranoia, and lack of sleep. Pertinent negative: abnormal motor behavior, catatonic behavior, coma like daze, episode at least 1 month but less than 6 months. Brief Psychotic Disorder 298.8 (F23) Pertinent positives: visual and auditory hallucinations, persecutory delusions, blunted affect, abnormal thoughts, disorganized speech, clang associations, disorganized thinking, paranoia, and lack of sleep. Pertinent negative: abnormal motor behavior, catatonic behavior, coma like daze, episode less than 1 month. Schizoaffective Disorder, Bipolar Type 295.70 (F25.0) © 2021 Walden University Page 6 of 12 NRNP/PRAC 6665 & 6675 Focused SOAP Psychiatric Evaluation Exemplar Pertinent positives: visual and auditory hallucinations, persecutory delusions, blunted affect, abnormal thoughts, disorganized speech, clang associations, disorganized thinking, paranoia, and lack of sleep. Pertinent negative: abnormal motor behavior, catatonic behavior, coma like daze, mania, symptoms more than 1 months but less than 6 months. Reflection: I am only enrolled in the didactic portion of the class, so I do not have a preceptor to answer the first question. What I learned from this case is the time of onset and duration of symptoms is especially important when having to diagnosis a patient with a mental illness. I also learned that the symptoms of Brief Psychotic Disorder, Schizophreniform and Schizophrenia all have the same symptoms but what differentiates them is the amount of time the patient has been experiencing the symptoms. What I would do differently is include involving the sister in the assessment to attain appropriate informed consent and medical history since the patient is delusional and experiences hallucinations. I would interview the sister using scales or questionnaires to assist with Schizophrenia diagnosis and to help with discovering other problems that may exist with the patient. Legal and ethical considerations would be to ensure that the patient has a legal guardian already established to assist with medical decisions by acting in the patient’s best interest when the patient is experiencing illness that affects his decision making. Health Promotions for this client would include creating a supportive environment, implementing employment opportunities, establishing a healthy sleep routine, eating a healthy diet, following medication regimen, smoking cessation and committing to abstaining from alcohol consumption. Case Formulation and Treatment Plan Medications: Abilify (aripiprazole) administer 400mg IM q monthly in the deltoid or gluteal muscle. (Give oral aripiprazole 2mg for 14 consecutive days after first injection). Abilify (aripiprazole) extended-release injectable suspension, one 400mg IM injection is given once every 4 weeks in the deltoid or gluteal muscle, along with one 2mg dose of oral Abilify (aripiprazole) daily for 2 weeks. It requires a 2-week oral overlap, which means the muscular injection is given together with an oral dose of aripiprazole for 14 days and afterwards does not require any future overlap. Aripiprazole is an atypical antipsychotic (2nd generation) FDA approved for treatment of agitation in Schizophrenia. © 2021 Walden University Page 7 of 12 NRNP/PRAC 6665 & 6675 Focused SOAP Psychiatric Evaluation Exemplar I made this decision because the patient is noncompliant with taking his medications. This patient needs a medication that that is long acting and does not need to be taken daily. The most appropriate medication route is IM intramuscular to improve adherence to the medication regimen. When taking aripiprazole hallucinations, delusions and disorganized thing may improve in the first 1-2 weeks. A visiting nurse or a family member may be needed for the first month to ensure the patient will be compliant for the 2 week oral medication regimen. After the first month the patient will only need to get an injection once per month. Psychotherapeutic Interventions: • • • • • • • • Cognitive behavioral therapy. Provides treatment to help patients manage psychotic symptoms and improve medication compliance. Individual psychotherapy. Assists with normalizing thoughts, learning coping strategies, helps to recognize signs of relapse so patients can better manage their illness. Social skills training. Assists with improving communicating and social interactions to increase the ability to participate in social activities. Family therapy. Provides education and support for family of patients with schizophrenia. Vocational rehabilitation and supported employment. Provides help for patients with Schizophrenia to prepare, search for and maintain employment. Detox and withdrawal treatment for alcohol. Patients with Schizophrenia should avoid alcohol. The patient may benefit from a program of detoxification that is medically managed. Smoking Cessation Program. This program assists the patient with cessation of tobacco use and dependence. Dialectical behavior therapy. Combines cognitive and behavioral theories to improve interpersonal skills. Referrals: Psychiatrist or PMHNP. The patient needs a physician or psychiatric mental health nurse practitioner to assess, diagnose and plan treatment. Prescribe psychotropic medications and meet with the patient weekly or monthly on a regular basis. This patient has already had the psychiatric evaluation and MSE today. Therapist. The patient needs a social worker, psychologist or licensed counselor that assists with stressors or uses more structured coping strategies such as cognitive behavioral therapy. Social Worker/Case manager. The patient may benefit from a program that assists with housing, transportation, employment, and other resources. © 2021 Walden University Page 8 of 12 NRNP/PRAC 6665 & 6675 Focused SOAP Psychiatric Evaluation Exemplar Registered Dietician. The patient with a diagnosis of diabetes needs a registered dietician to assist with choosing healthy food to manage and maintain a healthy blood sugar. Individuals with mental health disorders such as schizophrenia can also benefit from healthy eating. Endocrinology. A referral to an endocrinologist is needed because the patient admits having a diagnosis of Diabetes Mellitus which needs to be treated and managed properly. Hepatology. A referral to a hepatologist is needed because the patient was unclear about having a diagnosis of fatty liver. A patient with a diagnosis of fatty liver needs to be treated and effectively managed. Liver function is important for a patient that is prescribed medications for Schizophrenia to prevent toxicity. A referral to a hepatologist is needed especially if the patient has blood test results that indicate liver disease. Cardiology. The patient has been prescribed antipsychotics an EKG periodically to be monitored for QT prolongation. Home Care Aide. To assist with aiding with activities of daily living. The patient with Schizophrenia may need assistance with grocery shopping, cooking, laundry, etc. Visiting Nurse. To assist patients with complex medication regimen or medical needs such as (Insulin injections, antipsychotic injections, medication administration etc.) Detox Treatment Program. This patient may benefit from entering a detox treatment program. The patient needs to avoid alcohol due to his diagnosis of schizophrenia, fatty liver, and diabetes. Smoking Cessation Program. This patient may benefit from a smoking cessation program. Labs/Diagnostics Ordered: with rationale Physical Exam: obtain baseline and rule out or identify any physical abnormalities. Alanine Transaminase (ALT): To assess liver function, the patient consumes alcohol, he is prescribed antipsychotics and he states has fatty liver. Aspartate Transaminase (AST): To assess liver function, the patient consumes alcohol, he is prescribed antipsychotics and he states he has fatty liver. Blood Alcohol Level: To assess for alcohol use and levels. CBC with Differential and Platelets: To rule out disease or any other health issues. © 2021 Walden University Page 9 of 12 NRNP/PRAC 6665 & 6675 Focused SOAP Psychiatric Evaluation Exemplar Comprehensive Metabolic Panel: Obtain baseline and assess electrolytes, BUN, creatinine, glucose, calcium etc. Fasting Plasma Glucose: The patient has a diagnosis of Diabetes. Gamma Glutamyl Transferase (GGT): To assess liver function, the patient consumes alcohol, and he states he has fatty liver. Hemoglobin A1: The patient has a diagnosis of Diabetes, and he is prescribed an antipsychotic that may increase the blood sugar and is at risk for developing metabolic syndrome. Lipid Panel: The patient is prescribed an antipsychotic that can cause increased cholesterol and metabolic syndrome. Cholesterol levels need to be monitored. Thyroid Function Tests (T3, T4, and TSH): To rule out abnormal thyroid levels which can cause mental health issues. Toxicology Screening: To rule out substance abuse, to rule out psychotropic toxicity. Urinalysis: To rule out disease or any other health issues. EKG: to obtain baseline for antipsychotic medication, to assess QT prolongation and to monitor QT and to monitor for an irregular heartbeat. CT Scan: to rule out brain tumor or any other abnormalities that may cause a new onset of psychosis. Education/ Recommendations/ Follow-up Patient/Family provided psychoeducation. Patient/Family recommended individual and family therapy. Patient/Family recommended to participate in 30 minutes of physical activity daily. Patient/Family recommended to attend detox and withdrawal treatment program for alcohol use. Patient/Family recommended to participate in smoking cessation program. Patient/Family educated on the 5 A’s model for treating tobacco use and dependence. © 2021 Walden University Page 10 of 12 NRNP/PRAC 6665 & 6675 Focused SOAP Psychiatric Evaluation Exemplar Patient/Family given resource for the Free Tobacco Quit line instructed to call 1-800Quit-Now for assistance with smoking cessation support. Patients/Family educated on the importance of being monitored for QT prolongation and for obesity related metabolic syndrome. Educated on importance of monitoring weight, cholesterol, and BMI while on psychotropic medication. Patient/Family educated on the risks and symptoms of neuroleptic malignant syndrome: a life threating reaction cased by anti-psychotic drugs characterized by fever, muscle rigidity, decreased level of consciousness, and autonomic dysfunction. Patient/Family educated on importance of adherence to medication regimen. Medication instructions provided to patient and sister since she is the primary contact person. Discussed danger of mixing medication with OTC drugs, herbal, alcohol/illegal drugs. Instructed patient to avoid this practice. Encouraged abstinence from drugs and alcohol. Discussed how drugs, alcohol effect mental health, physical health, and sleep hygiene. Discussed danger and benefits of medication are discussed including non-treatment, potential side effects of medications discussed. Discussed side effects of Abilify (aripiprazole) extended release include headache, drowsiness, restlessness, extrapyramidal symptoms, sedation, agitation, insomnia, anxiety, weight gain, increased glucose, increased cholesterol, nausea, vomiting, constipation, rash at the injection site and tremors. Written and verbal education provided on medication and adverse side effects. Education on the importance of compliance for efficacy with antipsychotics as well as safe medication management. If you miss a dose of aripiprazole, take it as soon as you remember, unless it is closer time to your next dose. If you miss an aripiprazole injection, call your doctor, practitioner, or pharmacist right away. Avoid drinking alcohol or using illegal drugs when prescribed aripiprazole. It may lessen the benefits or raise the adverse effects. If you overdose on your medication, call 911. You may need emergency care. You may contact the poison control center at 1-800-222-1222. Informed patient not to stop medication abruptly without consulting providers. Instructed to call and report any adverse reactions. © 2021 Walden University Page 11 of 12 NRNP/PRAC 6665 & 6675 Focused SOAP Psychiatric Evaluation Exemplar Patient was referred to case management for closer monitoring and avoiding possible harm to the patient. The patient was offered an opportunity to ask questions and to express their needs about treatment. Provided supportive listening. The patient’s legal guardian (sister) verbalizes understanding to this plan and agrees to follow treatment regimen as discussed. The patient follow up will be carried out remotely with the sister at weekly intervals and the patient is required to return to the clinic in 3 weeks. Sister instructed to follow up with clinic in 1 week. Patient instructed to return to clinic in 3 weeks for follow up. Patient instructed to follow up with PCP as needed. Patient given resource for Substance Abuse and Mental Health services Administration (SAMHSA) 24-hour mental health crisis hotline that provides support, education and contacts for treatment 1-800-662-4357. Instructed patient and sister to call 911 or go to the nearest emergency room for suicidal or homicidal ideations and worsening auditory or visual hallucinations. References (move to begin on next page) You are required to include at least three evidence-based, peer-reviewed journal articles or evidenced-based guidelines which relate to this case to support your diagnostics and differentials diagnoses. Be sure to use correct APA 7th edition formatting. © 2021 Walden University Page 12 of 12 Week (enter week #): (Enter assignment title) Student Name College of Nursing-PMHNP, Walden University NRNP 6675: PMHNP Care Across the Lifespan II Faculty Name Assignment Due Date NRNP/PRAC 6665 & 6675 Comprehensive Focused SOAP Psychiatric Evaluation Template Subjective: CC (chief complaint): HPI: Substance Current Use: Medical History: • • • Current Medications: Allergies: Reproductive Hx: ROS: • • • • • • • • • • • • GENERAL: HEENT: SKIN: CARDIOVASCULAR: RESPIRATORY: GASTROINTESTINAL: GENITOURINARY: NEUROLOGICAL: MUSCULOSKELETAL: HEMATOLOGIC: LYMPHATICS: ENDOCRINOLOGIC: Objective: Diagnostic results: Assessment: Mental Status Examination: Diagnostic Impression: Reflections: Case Formulation and Treatment Plan: © 2021 Walden University Page 2 of 3 NRNP/PRAC 6665 & 6675 Comprehensive Focused SOAP Psychiatric Evaluation Template References © 2021 Walden University Page 3 of 3
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