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 condition, medications, or drug usage can all contribute to psychosis. Delusions,
hallucinations, incomprehensible speech, and agitation are all possible signs; the patient has
incorrect beliefs and sees or hears things that others do not see or hear. The person suffering from
the disease is usually unaware of his or her actions. Medication, psychotherapy, peer support,
family support and education, and talk therapy are all options for treatment. More or less every
mental intervention is backed by evidence accumulated during the patient’s initial interview; each
patient’s therapy begins with a thorough medical and mental health evaluation, the incorporation
of trust, and a discussion of past mental health history, substance misuse history, family mental
health history, and so on. In this example, the patient’s evaluation was documented, and a
diagnosis was made based on the information collected from the patient during the evaluation.
When the case was being developed, a therapeutic approach was designed. The patient is a 53-
year-old Caucasian male who was scheduled for an initial screening for a psychotic disorder after
his sister recommended a visit to the psychiatrist because patient’s behavior changed since the
mother passed away.
Patient Initial: S.T Age: 53 Gender: Male
Subjective Data:
CC: “I was brought here by my sister because since my mother passed away, I was living on my
own and not bothering anyone. Those people outside my window they are after me. They just
want me dead”.
HPI: When patient was asked ” what people?”. Patient said ” the government sent them to get
me because my taxes are high”. Suddenly patient asked the provider if she can see the birds or
hear any loud noise. The provider responded by redirecting the patient that she does not hear any
voice or see anything. When the provider how long he is been hearing the voices or seeing
things, patient said ” for weeks, weeks and weeks”. Patient also said the sister tapped her phone
with the government. When asked about sleep, patient said ” I have not slept well because the
voices keep me up for days. I try to watch the TV, they poison my food on TV, I locked
everything down in the fridge”. Suddenly patient asked ” Can I smoke?”. Provider said “no you
can’t smoke here”. Patient admit that he smokes all day about 3 packs a day. Drinks alcohol
which his sister purchased for him to last him for weeks. Patient denies use of drugs. Admit to
history of marijuana use 3 years ago before the mother passed away. Denies blackout, seizures,
collateral or legal issues or DUIs from use of drugs or alcohol. Patient admit that he hates
Haldol and Thorazine which he used to take. Calls his medications poison and said he is not
going to take it.
Substance Use History: Admits to use of alcohol, smokes 3 packs of cigarette per day. Admit
history of marijuana 3 years ago
Family Psychiatric/Mental/Substance Use History: Patient father paranoid and schizophrenia.
Patient’s mother: Anxiety. Sister: unknown Grandfather: unknown. Grandmother: unknown
Psychosocial History: Patient lives alone. Mother is deceased. Father is undisclosed. Both
parents are Caucasian. Patient is presently does not have friends. Educational Level: 10th grade.
Legal history: patient denies any history but said the police told him they would because patient
calls 911 on people outside.
Psychiatric History: Mood disorder unspecified
Medical History/Surgical History: Diabetes
Birth and Developmental history: Vagina birth, denies any disclosed complication and all
developmental millstones was met on time.
Current Medications: Haldol and Thorazine (all discontinued), Metformin
Allergies: NKDA or seasonal allergies
Reproductive Hx: Patient denies sexual history or abuse
APPEARANCE: Appeared disheveled
HEENT: No vision problem. Ears normal shape with no discharges. Nose normal shape; no
deviation or drainage. No sore throat or swelling around the neck.
CV: no cardiovascular abnormality
PULMO: Lungs sounds clear and no adventitious lung sounds
ABDOMEN: All bowel sounds on all four quadrant
GENITOURINARY: No disorder or problem with this system
EXTREM: All extremities is moveable; some tremors noted in upper extremities
NEURO: alert and oriented to person, place, time, and situation but very unrest
SKIN: Skin intact and appropriate; no rash or lesion noted
Physical exam:
Vital Signs: none at this time
Weight: 196 Ibs
Height: 5’9ft
Objective:
Diagnostic results: no diagnostic test ordered or required at this time
Assessment:
Mental Status Examination
On arrival and during the session, the patient appeared to be of the age reported, with no
signs of discomfort. The patient appears to be well fed and groomed. Clean and well-dressed.
Patient was compliant, did not fidget, maintained good eye contact, and but could not stay still
for 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
observed. Maintain a steady gait and maintain an upright stance. Appeared anxious , the patient
was coherent but not particularly logical. Although the patient did not have acute psychosis, he
was actively delusional and responding to internal stimuli. Patient was delusions or paranoid
behavior, suspicious thoughts and intrusive ideas plague the patient. Patient’s speech was normal
rate, rhythm volume and clear. Patient does not feel like he will get better. Patient was a good
historian. Patient was attentive to the provider. Alert and oriented times 4. Memory both long
and short term was intact. Patient denies suicide ideation. Patient admits having intrusive
thoughts of hurting. During assessment patient states “the government sent people to get me
because my taxes are high”. Suddenly patient asked the provider if she can see the birds or hear
any loud noise.
Differential Diagnoses
Schizophrenia: Schizophrenia is a “psychosis,” a sort of mental illness. A psychosis is a mental
disease in which the sufferer is unable to distinguish between what is real and what is imagined.
People suffering from mental diseases can lose contact with reality at times (Sadock, 2014). The
world may appear to be a tangle of perplexing ideas, images, and noises. One kind of
schizophrenia is paranoid schizophrenia. In this case, the person’s incorrect beliefs are mostly
concerned with being persecuted or punished by others. Someone’s voice may be heard, which
the individual believes is punishing them. The individual may assume that he or she has been
hand-picked to carry out a top-secret task. According to DSM-5, patient must meet certain to be
diagnosed with schizophrenia; delusions, hallucinations, diagnosed speech or thought, negative
symptoms, paranoid delusions, grossly disorganized or catatonic behavior for the duration of 6
months, symptoms not due to effects of substance or another medica condition (American
Psychiatric Association2013). The above listed criteria are all evident in our patient.
Schizoaffective Disorder: In clinical practice, schizoaffective disorder is one of the most
misdiagnosed psychiatric diseases. In fact, some academics have requested that the diagnostic
criteria be revised, while others have suggested that the diagnosis be removed entirely from the
DSM-5. Schizoaffective illness is easily confused with other mental disorders due to criteria that
include both psychosis and mood symptoms. Schizophrenia, Major Depressive Disease with
Psychotic Features, and Bipolar Disorder are all disorders that must be ruled out during a
schizoaffective disorder workup. According to DSM 5, to diagnose schizoaffective illness, there
must be at least two weeks of exclusively psychotic symptoms (delusions and hallucinations)
without any mood symptoms. However, throughout the majority of the illness’s existence, a
major mood episode (depression or mania) is present. When psychotic symptoms prevail for the
bulk of the illness’s duration, the diagnosis is likely to be schizophrenia. Furthermore,
schizophrenia requires 6 months of prodromal or residual symptoms, but schizoaffective disorder
does not. Schizoaffective disorder is a psychotic disease similar to schizophrenia.
Delusion of Persecution: A delusion is a false belief that suggests a problem with the contents
of the affected person’s thoughts. The person’s cultural or religious background, as well as his or
her level of intelligence, have no bearing on the incorrect belief. The degree to which the person
believes the belief is true is a significant component of a delusion (American Psychiatric
Association2013). A person suffering from a delusion will cling to their belief despite evidence
to the contrary. Delusion of Persecution occurs when a person believes that they (or someone
close to them) is being mistreated, that someone is spying on them, or that someone is planning
to harm them. According DSM-5 patient must meet the following criteria before being one or
more delusion for at least one month, fearing ordinary situations, feeling threatened without
reason, frequently reporting to authorities, extreme distress, excess worry, constantly seeking
safety and hallucinations associated with the delusions. The above listed criteria are evident in
our patient
Reflection
Every mental intervention is determined by the information collected during the initial
conversation with the client; every client’s therapy starts with a comprehensive medical and
behavioral health examination, the creation of trust, and a discussion of previous mental health
history, substance abuse history, family mental health history, and so on. Individuals with whom
they had connections that comprised effective communication, cultural awareness, and the
absence of compulsion were considered as trustworthy (Sadock et al., 2014).
As a PMHNP, one thing I might have done differently is to meet the patient first, develop
a therapeutic relationship, inquire about the young patient’s relationship with his parents, and
then ask questions irrelevant to the scheduled visit, which would assist to create a welcome
atmosphere. Without appearing to be biased, ask open-ended questions about the patient’s
personality, illness, or personality. Inquire about the patient’s sexual orientation and
communication preference. Cultural competency includes elements such as trust, respect for
diversity, respect for religion, equity, fairness, and social justice, which must all be considered
during any interview or encounter between a healthcare practitioner and a patient (Sadock et al.,
2014). When I interview a patient about their mental illness symptoms, I look at how they look,
speak, and act to determine if there are any clues that could explain their symptoms.
Case Formulation and Treatment Plan
The patient will begin individual supportive therapy then advance to family and peer
group supportive therapy depending on level of improvement. The patient will receive an
educational pamphlet, as well as assignments and a follow-up consultation, on themes that will
aid in the healing and coping process.
Patient will be started on Perphenazine 32mg PO QHS, Benztropine 1mg PO BID for
prevention of EPS. Education and side effects of medication was provided. Labs (CBC, CMP,
A1C, lipid profile) will be ordered in the next visit.
Education on substance use and smoking cessation was provided for patient. Patient will
be educated on importance of taking his vital signs daily, increase fluid intake, report change
finger sticks of blood sugar check,
In case of emergency, the provider provided patient with helpful phone numbers: 911 for
emergencies and the Client’s Crisis Line. Reports from doctors and therapists were evaluated for
mutual and collaborative understanding and for continuity of care.
Patient was educated and was advised to call their primary care physician or go to the
nearest emergency department if they had any questions or concerns about the development of
any undesirable or unexpected outcome or side effects.
Every 30 days, patient must return to appointments for continuity of care and for provider
to monitor progress and outcome of treatment but patient will return a two week after starting the
newly prescribed medications for adjustment of dosing and to monitor improvement.
References
American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental
Disorders, fifth edition DSM-5 American Psychiatric Association, 2013.
Bachem, R., & Casey, P. (2018). Schizoaffective Disorder: A diagnosis whose time has come.
Journal of Affective Disorders, 227, 243-253. https://doi.org/10.1016/j.jad.2017.10.034
Sadock, B.J., Sadock, V.A., & Ruiz, P. (2014). Kaplan and Sadock’s synopsis of psychiatry:
Behavioral sciences/clinical psychiatry (11 th ed.). Philadelphia, PA: Wolters Kluwer.
Thapar, A., Pine, D. S., Leckman, J. F., Scott, S., Snowling, M. J., & Taylor, E. A. (Eds.).
(2015). Rutter’s child and adolescent psychiatry (6th ed.). Wiley Blackwell.
Walden University. (2021). Case study: Sherman Tremaine. Walden University
Blackboard. https://class.waldenu.edu
