FOCUSED SOAP NOTE RESPONSE
NRNP/PRAC 6665 & 6675 Comprehensive Focused SOAP Psychiatric Evaluation Template
Amarachi Okafo
Subjective:
CC (chief complaint): “I do not feel safe.”
HPI:
79-year-old widowed Caucasian female who presents accompanied by daughter to establish care and for psychiatric evaluation. Her daughter reports she has had an increase in irritability, aggression, paranoia, delusion, and hallucinations since August 2022. Daughter notes prior to August 2022, patient had moments of delusional content but never persistent or consistently and had clear thought process with no major concerns. Daughter explains delusions and hallucinations have been happening throughout the day and at night both auditory and visual. She notes the patient believes there is a ”wire transmitter” in ear and individuals are attempting to break into her home and exploit her and harm her. She explains she has visual hallucinations seeing “animals and circus people.” She notes that her recent and remote memory is intact but the delusional content remains. Her daughter notes that she does not sleep 3-4 nights a week and when she does she gets about 1 hour of sleep a night. She also notes a decrease in appetite due to often times believing individuals have poisoned her food. Daughter explains yesterday patient was endorsing SI. She notes frequent crying spells and episodes of aggression most recently punching daughter in the face unprovoked. She notes that the patient has been smelling pine trees and wood burning causing her eyes to water and burn.
She notes she recently had MRI in December that showed shrinkage in the brain, benign tumor, and stroke. She denies any history of temporal lobe epilepsy and recent UTI.
Patient has had no previous psychiatric diagnosis or hospitalization. She notes she has taken Effexor in the past for depressed mood after her husband passed away in 2005 but no longer takes that medication. She is currently on mirtazapine 15mg for sleep but notes it does not help.
Patient endorses auditory and visual hallucinations. Patient notes that there is a “wire transmitter in ear that Ray speaks with her.” Pt states she hears individuals in the attic cooking “that stuff and murdering people.” She notes that she does not feel safe at home and feels safe in the bathroom only. She notes that she slept on the floor of the bathroom last night with her feet propped against the door to ensure her safety. She notes she does not sleep but still feels like she has a lot of energy at times.
Substance Current Use: denies substance use.
Medical History:
·
Current Medications: Tylenol 325mg, Vitamin B-12 500mg, aspirin 81mg, multivitamin, vitamin D3 2000 unit, famotidine 20mg, amlodipine 10mg, propranolol HCL 80mg daily, and Mirtazapine 15mg for sleep.
·
Allergies:
NKA
·
Reproductive Hx:
Gravida 3
, post-menaposal
·
Psychiatric Hx: n/a.
ROS:
· GENERAL: Denies weight loss, No fever, chills, fatigue, or weakness. Decrease sleep.
· HEENT: No visualize blurred vision, double vision, or yellow sclera. No hearing loss, sneezing, coughing, congestion, runny nose or sore throat. Wears glasses.
· SKIN: no rash or itching.
· CARDIOVASCULAR: : No chest pain, chest pressure, or chest discomfort. No palpitations or edema.
· RESPIRATORY: no shortness of breath cough or sputum.
· GASTROINTESTINAL: No anorexia, nausea, vomiting or diarrhea. Denies abdominal pain.
· GENITOURINARY: no burning or urination urgency hesitancy odor or color.
· NEUROLOGICAL: Denies headache. Nor does he know syncope paralysis or ataxia, numbness or tingling in the extremities. Denies bladder control.
· MUSCULOSKELETAL: No muscle pain. Back pain. Joint pain or stiffness.
· HEMATOLOGIC: No anemia, bleeding or bruising.
· LYMPHATICS: No enlarged nodes, no history of splenectomy.
· ENDOCRINOLOGIC: No sweating, cold, or heated tolerance. No polyurea polydipsia.
· PSYCHIATRIC: Positive auditory and visual hallucinations, paranoia, somatic, grandiose, paranoid delusions, irritability, insomnia, aggressive behavior. No mania, hypomania, panic attacks or eating disorder.
Objective:
Diagnostic results:
Since this patient is presenting new a full bloodwork panel is needed to ensure there are no underlying medical conditions causing presenting symptoms. The patient also received a previous MRI which showed shrinkage in the brain, benign tumor, and CVA. Previous urince culture done to assess UTI was also negative. The reason assessing for UTI’s is important because it can cause delirum in elderly patients (Dutta et al., 2022).
Assessment:
Mental Status Examination:
This is a well groomed, pleasant appearing elderly woman dressed in casual clothing who presented herself engaged in interview. She made fair eye contact with a euphoric mood. Affect was incongruent with mood. Her speech was pressured with paranoid, somatic, and grandeur delusions noted. Her thought process poor with auditory and visual hallucinations with excessive ruminations of individuals attempting to come in her home and attack her. Judgement and insight are limited. She is Alert and oriented to self and location. She denies SI/HI. There is no evidence of abnormal motor activity.
Diagnostic Impression: One of the differential diagnoses I have given to this patient includes delusional disorder persecutory type with bizzare content. I have given this patient this diagnosis due to the delusional content that was expressed during the interview. This patient has expressed paranoia towards individuals spying on her, attempting to harm her, and exploit her which fall under the criteria for persecutory delusions (American Psychiatric Association Publishing, 2022). The content can also be specified to bizzare because the patient believes a neurotransmitter was implanted in her brain where she is able to hear other individuals.This patient has never met the criteria for schizophrenia and these delusions have been occurring for greater than one month (American Psychiatric Association Publishing, 2022).
Another differential diagnosis I would give this patient is minor neurocognitive disorder due to Alzheimer’s disease due to the patient’s past family history of Alzheimer’s disease (American Psychiatric Association Publishing, 2022). Also, there has been a steady progressive decline in cognition and no evidence of mixed etiology which makes this disorder a possible cause of symptoms (American Psychiatric Association Publishing, 2022).
Reflections:
After discussing the case with my preceptor we came to the same conclusion for differential diagnoses for this patient due to the symtoms the patient was presenting with and the information gathered from collateral. I learned that when patients are unable to contract for safety in the outpatient setting you should send them straight to the emergency department for further evaluation if significant distress is presented despite denying suicidal and homicidal ideations. If I was able to redo the case I would have asked more questions regarding the patient’s behavior over the last 6 months compared to previous times.
Legally because this patient is her own guardian and not under IVC we cannot for ce her to go to the emergency department. The family could have an option to IVC the patient if they felt the need but at this time assessing if the patient would be voluntarily willing to go to the hospital for monitoring is best. By forcing the patient to go to the hospital we take away autonomy which is the patient’s right to refuse treatment (Haddad et al., 2022). On the other hand this patient does pose an imminent risk to herself and others due to her impulsive and paranoid behaviors so could be emergently committed into the hospital.
Case Formulation and Treatment Plan:
Plan is to trial patient on Namenda 5mg daily for severe confusion related to possible dementia or alzheimers. Risks and benefits discussed of Namenda including symptoms like dizziness, headache, and constipation (Stahls et al., 2021). Will also start Seroquel 50mg for sleep and psychosis symptoms. Risk and benefits discussed of Seroquel including symptoms like dizziness, sedation, and may increase risk for diabetes (Stahls et al., 2021). Discussed taking these medicaitons at bedtime. If medication does not improve sxs and patient is unable to contract for safety, patient should be sent to the emergency department.
Time allowed for questions and answers provided. Patient and daughter agreeable to treatment plan.
References
American Psychiatric Association Publishing. (2022). Delusional Disorder.
Diagnostic and statistical manual of mental disorders, fifth edition text revision: Dsm-5-Tr.
American Psychiatric Association Publishing. (2022). Minor neurocognitive disorder due to Alzehimer’s disease.
Diagnostic and statistical manual of mental disorders, fifth edition text revision: Dsm-5-Tr.
Dutta, C., Pasha, K., Paul, S., Abbas, M., Nassar, S., Tasha, T., Desai, A., Bajgain, A., Ali, A., & Mohammed, L. (2022). Urinary tract infection induced delirium in elderly patients: A systemic review.
Cureus, 14(12), e32321. doi: 10.7759/cureus.32321
Haddad, L., & Geiger, R. (2022). Nursing ethical considerations.
StatPearls, Retrieved January 25th, 2023 from
https://www.ncbi.nlm.nih.gov/books/NBK526054/
Stahls, S. M., & Grady, M. M. (2021).
Stahl’s essential psychopharmacology: The Prescriber’s Guide. Cambridge University Press.
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