NRNP/PRAC 6665 & 6675 Comprehensive Focused SOAP Psychiatric Evaluation

Subjective:

CC (chief complaint): “I was living with my mom, and she died. I was living, not bothering anyone, and those people-those people just won’t leave me alone. They watch me. I can hear them, and I see their shadows. They think I don’t see them, but I do. The government sent them to watch me, so my taxes are high, so high in the sky. They keep me up for days and days. I try to watch TV, but they watch me through the screen, and they come in and poison my food. I tricked them, though. I tricked them. I locked everything up in the fridge. They aren’t getting in there. I smoke all day. Three packs a day.”

HPI: S.Tis is a 54-year-old male brought forward by his sister for psychiatric evaluation. Currently, he is given metformin for diabetes. Besides, he mentions Risperidone, Haloperidol (Haldol), and Thorazine, which he hates and likes only Seroquel. These medications are commonly prescribed to patients who have schizophrenia. The patient appears to have hallucinations that make him see people watching over him and hear what they say, which is not real. Also, he has delusional thinking, whereby he firmly believes that the people who keep watching him through the windows and television are sent by the government, making him pay higher tax rates. His speech is disorganized and gives less accurate responses to the questions.

Substance Current Use: The patient has been smoking and drinking alcohol. Before the death of his mother 3 years ago, he got himself smoking marijuana.

Medical History:

• Current Medications: Currently, he uses metformin for diabetes. Also, he was once treated with Risperidone, Haldol, Thorazine, and Seroquel.
• Allergies: No allergies were mentioned
• Reproductive Hx: No records regarding sexual concerns.

ROS:

• GENERAL: The patient showed no signs or records of weight loss. Also, he had no fatigue or weaknesses, including chills and fever.
• HEENT: He has no issues with eye vision (i.e., no double or blurred vision). Also, he has no hearing loss or complaints about sore throat, runny nose, or frequent sneezing.
• SKIN: The patient did not have itching skin and no rashes.
• CARDIOVASCULAR: The patient did not complain about chest discomfort, pain, or pressure. And there are no signs of edema or palpitations.
• RESPIRATORY: The client did not show signs of coughing, sputum, or breathing difficulties.
• GASTROINTESTINAL: The patient did not experience diarrhea, nausea, vomiting, or anorexia.
• GENITOURINARY:
• NEUROLOGICAL: The patient did not have an odor, color, or burning sensation when urinating. Also, he did not experience any urgency when urinating.
• MUSCULOSKELETAL: No complaints about joint pain, muscle stiffness, or back pain.
• HEMATOLOGIC: The patient did not have anemia, including bruising or bleeding.
• LYMPHATICS: There is no medical history of splenectomy. No swollen nodes.
• ENDOCRINOLOGIC: No records about cold, sweating, and heat intolerance. No signs of polydipsia.

Objective:

Diagnostic results: The patient was once diagnosed with schizophrenia. Therefore, there is a need to use the Brief Psychiatric Rating Scale (BPRS) to check the severity of schizophrenia. BPRS focuses on at least 16 symptoms associated with schizophrenia, including disorientation, hostility, anxiety, hallucinations, depression, and psychosis. It has a scale that ranks the severity of symptoms from mild to extreme. Another important scale that fits appropriately for this patient is the use of Clinical Global Impression-Schizophrenia (CGI-SCH). CGI-SCH is used for diagnosing psychiatric illnesses. It is commonly applied to check the severity of symptoms and how they have changed over time. CGI-SCH relies on designed questions to interview the patient to find out the patient’s symptoms in the last seven days.

Assessment:

Mental Status Examination: He is a 54-year-old male who appears overweight and more like his age. He was cooperative with the psychiatrist and was willing to answer questions. He did not have any physical disabilities. His speech was distorted, less clear, and less coherent to the questions asked. The tone of his speech varied from high to low, depending on the questions asked. His way of thinking appeared to lack logic. Moreover, his expression was accompanied by hallucinations and delusional thinking. Throughout the interview, he smiled in a few instances. He denies not to have any homicidal or suicidal ideation. His concentration doesn’t seem good, and cognitively, he is less oriented and alert. 

Diagnostic Impression:

Substance-induced psychotic disorder

Drug-induced psychosis is closely linked with alcohol and substance abuse. Common drugs known to cause substance-induced psychosis are marijuana, alcohol, and cocaine. Also, prolonged use of hallucinogenic drugs such as catecholamines, serotonin, and acetylcholine can alter the brain’s neurotransmitters, which distorts a person’s view of reality. In this regard, it increases the risk of schizophrenia (Alderson et al., 2017). Symptoms of substance-induced psychotic disorder include hallucinations, delusions, or both. An individual develops these symptoms when withdrawn from taking or using them. The symptoms only last for one month once a person uses the drugs or withdraws from them.

Schizophrenia

Schizophrenia is a severe mental illness that affects how an individual perceives reality, expresses emotions, and thinks. Patients with schizophrenia tend to lose their sense of reality. In other words, despite lacking evidence, they have persistent delusions that make them unshakable beliefs about something (Upthegrove, Marwaha & Birchwood, 2017). Also, they have persistent hallucinations, whereby they smell, hear, touch, feel, or see things that do not exist in reality. Persons with schizophrenia have disorganized thinking that is often irrelevant or disorganized speech. Also, they have persistent difficulties in their cognitive abilities, such as problem-solving, attention, and memory. Other symptoms of schizophrenia are losing track of memories and quickly becoming upset and being suspicious, anxious, and angry with persons around them (Upthegrove, Marwaha & Birchwood, 2017).

Delusional disorder

Delusional disorder is another mental disorder that makes a person have difficulties distinguishing between what is imagined and reality. An individual may have more than one delusion, an unshakable belief about something false (Peralta & Cuesta, 2016). The prevalent type of delusions among patients with delusion disorder are non-bizarre delusions. Non-bizarre delusions are highly likely to occur in real-life settings, such as being loved or deceived by a person or being followed by people. In reality, none of these situations is taking place. Individuals with delusional disorders can function and socialize well apart from instances that lead them to be delusional (Peralta & Cuesta, 2016). Different types of delusional disorders include somatic, persecutory, jealous, erotomaniac, and grandiose.

Reflections:

Although schizophrenia and delusional disorder have similar symptoms, they are distinguishable. For instance, schizophrenia consists of a broad range of conditions, which incorporate psychotic symptoms such as disorganized behavior or speech. Also, negative symptoms such as decreased motivation and facial expression are symptoms of schizophrenia. On the other hand, delusional disorder focuses on delusions and does not involve the criteria of psychotic symptoms. Moreover, individuals with schizophrenia have impaired daily functioning compared to individuals with delusional disorder. Therefore, based on the differential analysis, the patient exhibits symptoms of schizophrenia grounded on the fact that he has hallucinations and delusions. Other noted signs and symptoms include distorted speech, difficulty concentrating, suspicion of people watching over him, and poisoning his food, an exaggerated aspect lacking reality.

Case Formulation and Treatment Plan:

S.T. is a 54-year-old male previously diagnosed with schizophrenia. He is currently prescribed metformin for diabetes. He thinks people are bothering him and always watching over him and cannot leave him alone, which is not reality. Before his mother’s death three years ago, he was involved in taking marijuana. Also, he smokes and takes alcohol. The patient shows signs and symptoms of schizophrenia, such as distorted speech, delusions, and hallucinations. Also, he was once treated with Risperidone, Haloperidol (Haldol), Thorazine, and Seroquel, which are drugs for treating schizophrenia. In this regard, the patient has not healed from schizophrenia and needs to undergo phase two of his treatment.

The treatment for the patient shall involve using risperidone and Olanzapine, which are efficacious and FDA-approved drugs for treating patients with non-resistant schizophrenia. Essentially, risperidone should be applied as the first-line treatment for the patient, considering that he falls in the category of aging persons. The adverse effects of risperidone include seizures, dizziness, feeling sleepy, and increased heart rate. Nonpharmacological interventions for reducing symptoms associated with schizophrenia use cognitive remediation. Cognitive remediation is done through strategic acquisition or repeatedly doing a task to improve cognitive functions.

References

Alderson, H., Semple, D., Blayney, C., Queirazza, F., Chekuri, V., & Lawrie, S. (2017). Risk of transition to schizophrenia following the first admission with substance-induced psychotic disorder: A population-based longitudinal cohort study. Psychological Medicine, 47(14), 2548-2555. doi:10.1017/S0033291717001118

Dazzi, F., Shafer, A., & Lauriola, M. (2016). Meta-analysis of the Brief Psychiatric Rating Scale–Expanded (BPRS-E) structure and arguments for a new version. Journal of Psychiatric Research, 81, 140-151. Retrieved from https://doi.org/10.1016/j.jpsychires.2016.07.001

Peralta, V., & Cuesta, M. (2016). Delusional disorder and schizophrenia: A comparative study across multiple domains. Psychological Medicine, 46(13), 2829-2839. doi:10.1017/S0033291716001501

Upthegrove, R., Marwaha, S., & Birchwood, M. (2017). Depression and schizophrenia: cause, consequence, or trans-diagnostic issue? Schizophrenia Bulletin, 43(2), 240-244. Retrieved from https://doi.org/10.1093/schbul/sbw097