Clinical Follow-Up SOAP Note for a Psychiatric Patient Comprehensive Nursing Essay Example

Clinical Follow-Up SOAP Note for a Psychiatric Patient Comprehensive Nursing Essay Example

Patient Initials: A.Z, Age: 57 years, Gender: Male, Race: Hispanic White of Cuban Origin

Subjective

CC: Follow-up: ‘I feel better today

HPI: Mr. AZ is a 57-year-old Hispanic White male with a history of Major Depressive Disorder comorbid with paranoid schizophrenia who presents to the clinic for follow up. He reports current prescription medications as Fluoxetine Hydrochloride 20mg- 20mg PO q day, Abilify 15mg-15mg PO q day, Klonopin 1mg-1 mg PO qhs and 0.5mg PO on a pro re nata (PRN) basis for heightened anxiety. The patient is currently faring well and has exhibited significant improvement over the last couple of weeks. He can still participate in a conversation without hallucinations or psychotic delusions popping up. His chief delusion previously was believing he is a secret service agent who was privy to a plot to assassinate his immediate senior and is the only one to eliminate the assassins. His delusions motif makes him believe young men and teenagers are these assassins who want to eliminate him first since they know he is the only one who could foil their plans. During this interview, AZ did not bring up these topics in any way unless he was explicitly asked to. Asked about auditory hallucinations, he claims there are times when stealthy young men in the neighborhood creep into his doorstep. He appears to understand that neither of these events is real and lets them go after one mention only. A persistent delusion is a thought that one of the teenagers in his rented apartment is the mastermind and knows AZ is out to stop him. He rationalizes that this may not be real as the teenager is only in his elementary grades and that AZ cannot think about the assassination plot all the time. His concentration has significantly improved, as has his relationship with two of his sons, who discourage him from speaking about the ‘assassination plot’. He admits they generally offer him a sound, reliable support system. He also complains of gaining some unwanted extra weight due to increased appetite after being on Abilify medication. He manages the weight gain by exercising in the morning, taking a jog after work and keeping a healthy diet. His depression was 4/10 during the last visit and continues to improve. He denies suicidal or homicidal ideation. (Clinical Follow-Up SOAP Note for a Psychiatric Patient Comprehensive Nursing Essay Example)

Past Psychiatric History: His 30-year-old son reports the father has had paranoid symptoms where he believed his estranged wife wanted to kill him by poisoning his food or hiring some hitmen for the last 18 years. AZ has had persistent hallucinations and delusions for close to twenty years, but the psychotic symptoms have worsened after he separated with his wife in 2012, who was granted custody of their last-born child, a girl aged 10 years today. He sought psychiatric help in2013 and was treated for depression. In 2017, he faced significant life stressors like being fired from his workplace. Past psychotropic medications are Seroquel for psychosis, Klonopin for anxiety, and Lexapro for depression. (Clinical Follow-Up SOAP Note for a Psychiatric Patient Comprehensive Nursing Essay Example)

Past Medical History: AZ has been diagnosed with T2DM adult-onset, back pain, hypertension, and constipation. Medication interventions include Lisinopril – HCTZ 20 mg – 20mg PO qday, Metformin hydrochloride 500mg- 500 mg PO bid, Omeprazole  20 mg- 20mg 1 PO q day, and aspirin 325 mg – 325 mg PO q day. (Clinical Follow-Up SOAP Note for a Psychiatric Patient Comprehensive Nursing Essay Example)

Health maintenance history:  PSA, physical exam and urinalysis all on 02/ 01/ 2021

Social History: Mr. AZ lives in Chicago, Illinois, in a rented apartment by himself. He has a limited social life and has painting as his hobby. He is currently working full-time as a civil engineer in the Department of Housing, and this has been his workstation ever since he was hired in 2019. He is a 12^th-grade graduate and has an associate degree from a technical college. He had a normal life, meeting all developmental milestones when growing up.  He has married once but divorced his wife in 2017, after 23 years of a tumultuous marriage. He has three children, 2 boys (30 years and 24 years), both married and a15 year daughter currently under the custody of his divorced wife. He admits being a smoker, is an occasional drinker and denies any current or past use of hard drugs. He enjoys caffeine taking 4 cups of coffee daily. He reports a troubled sexual history where his uncle sexually abused him at preschool age. (Clinical Follow-Up SOAP Note for a Psychiatric Patient Comprehensive Nursing Essay Example)

Spiritual history: He identifies himself with the Baptist Convention and regularly attends church.

Family Psychiatric History:  His mother had a history of paranoid behavior, while a paternal uncle had depression and ended his life through a prescribed medication overdose. One of his sons- the elder one- has been treated for anxiety. No other family history is significant, and no member has ever been put in a mental asylum. (Clinical Follow-Up SOAP Note for a Psychiatric Patient Comprehensive Nursing Essay Example)

Family medical history: HAs a pedigree for T2DM with uncles on both sides diagnosed.

Review of symptoms

General:  Patient reports some weight gain after using Abilify medication, indicating some pants and shirts no longer fit him, admits having difficulties sleeping, and persistent back pain.

HEENT Negative for head trauma or injury, no headache, negative for past eye disorders, vision changes, blurred images or double vision, negative for changes in hearing acuity, no earache or discharge, no nasal discharge or postnasal drip, no voice charges, no difficulties swallowing food. (Clinical Follow-Up SOAP Note for a Psychiatric Patient Comprehensive Nursing Essay Example)

Skin and Hair: Negative for skin eruptions/ rashes, no lesions, no itching, no skin growth, no hair loss and no fungal infection.

Pulmonary:  No chronic or past pulmonary disorders, Negative for chest pain, no, no wheezing, no coughing, no hemoptysis (Clinical Follow-Up SOAP Note for a Psychiatric Patient Comprehensive Nursing Essay Example)

Cardiovascular (C/V) Denied chest pain or pressure, no shortness of breath while at rest or with exertion, no orthopnea, no lower extremity edema. Denies wounds and ulcers that are slow to heal.

Gastrointestinal: Negative for abdominal pain, no difficulties swallowing, no nausea or vomiting, no diarrhea, but reports constipation. (Clinical Follow-Up SOAP Note for a Psychiatric Patient Comprehensive Nursing Essay Example)

Genito-Urinary:  No chronic or past disorders, denied burning in passing urine, no bloody urine, no incontinence, no urgency to urinate and increased frequency, especially at night,

Hematology/Oncology: Denied fevers, chills, sweats

Ob/Gyn/Breast: N/A

Infectious Diseases: Reports no known disease, negative for fevers, chills, and sweats.

Musculoskeletal: Reports chronic back pain

Neurological: No sudden loss of neurological function

Endocrine: Reports polyuria and increased weight gain

Objective

Mental Status Exam:

Orientation: Oriented to person, place, time, and situation

Appearance: Appropriately dressed, appeared the stated age and maintained good eye contact

Behavior: calm, concerned

Attitude: co-operative, composed

Rapport:  Easily established

Speech and Language: candid, clear, normal in rate, rhythm, and volume

Mood: moderately depressed (Clinical Follow-Up SOAP Note for a Psychiatric Patient Comprehensive Nursing Essay Example)

 Affect: mood-congruent

Thought Process/ Associations: goal-focused, and logical,

Thought content: Presence of delusional thinking, has auditory hallucinations and other issues as per HPI

Suicidal/ Homicidal ideation: Negative for suicidal or homicidal ideation

Cognitive: Determined to be within limits though not tested.

Concentration: Within limits

Abstraction:  Fair

Serial Sevens:  Errors absent

Memory: Within normal standards

MMSE: 28/30

Insight: good

Judgement: Fair

Physical Exam

VS: BP 120/89, P 83, R 17, Weight 95 kg

Labs:

Past CT neuroimaging indicates moderate cerebral atrophy, recent abnormal results on 12/31/2020

CK-Total/Creatine Kinase,Total,Serum 367 U/L 24-173 H   02/ 14/ 2020 Vitamin D, 25-Hydroxy/Vitamin D, 25-Hydr 22.7 ng/mL 32.0-100.0 L (Clinical Follow-Up SOAP Note for a Psychiatric Patient Comprehensive Nursing Essay Example)

Assessment:

Differential diagnosis

Psychiatric

1. Major depressive episode:  The patient seems to have met six out of the nine symptoms in his course (Thomas & Seedat, 2018).
2. Schizophrenia, paranoid type: AZ has a history of hallucinations and delusions lasting more than six months. To confirm the paranoid type, he exhibits paranoid delusions to some extent with specific auditory hallucinations on initial assessment, while his affect is not prominently flat (Wright, 2020). (Clinical Follow-Up SOAP Note for a Psychiatric Patient Comprehensive Nursing Essay Example)

Medical causes to the symptoms suggesting the two conditions like hyperglycemia, hypoglycemia, nutritional deficiencies, paraneoplastic syndrome, and hypothyroidism appear to have been ruled out by evaluation and labs. (Clinical Follow-Up SOAP Note for a Psychiatric Patient Comprehensive Nursing Essay Example)

Plan:

1. Major Depressive Episode: Continue taking Prozac 20 mg q day. Prozac is an SSRI possessing antidepressant properties. He may need to be on this medication for not less than 12months to stabilize his mood and keep the depression at bay. According to Lam et al. (2016), It may also be necessary to keep him on Prozac across the lifespan for the said purpose, and he is taught how to manage or alleviate the side effects.  The side effects include but are not limited to sleeplessness, sedation, nausea, sexual dysfunction, and restlessness. (Clinical Follow-Up SOAP Note for a Psychiatric Patient Comprehensive Nursing Essay Example)
2. Klonopin 1 mg qhs is to also continue for sleep and decrease anxiety with depression. This is because benzodiazepine MOA revolves around agonist activity at the central nervous system GABA receptors. Basit and Khawaja, 2020) note that some side effects he may have to grapple with are grogginess or sedation. (Clinical Follow-Up SOAP Note for a Psychiatric Patient Comprehensive Nursing Essay Example)
3.  Schizophrenia, paranoid type: Continue with Abilify 15 mg q day. As an atypical antipsychotic, this medication has benefits in treating hallucinations and delusions besides acting as a mood stabilizer. At 15 mg, this is only 50% of the maximum dose, with doses above 15 mg being effective in schizophrenia hardly. Abilify’s exact disease-modifying MOA is unknown. Be that as it may, providers know that this atypical antipsychotic is a partial agonist at the D2 dopamine receptor and the 5HT1A serotonin receptor (De Bartolomeis et al., 2015). The same Abilify is known to be an antagonist at the 5HT2A serotonin receptor. (Clinical Follow-Up SOAP Note for a Psychiatric Patient Comprehensive Nursing Essay Example)
4. Counselling: Refer his sons to family therapy to improve their relationship with the father and supplement the support system that AZ receives (Gelenberg et al., 2010). The counselling also can give all three enhanced insights into AZ’s illness and, therefore, help enhance understanding amongst the father and children, leading to the latter helping him more. (Clinical Follow-Up SOAP Note for a Psychiatric Patient Comprehensive Nursing Essay Example)

Referral: AZ is to be referred for individual psychotherapy as it may help alleviate the symptoms of depression. The patient is encouraged to participate in social activities and establish meaningful interpersonal relationships.

Monitoring & the other comorbidities effectively managed by the prescribed medications indicate a need to monitor the blood pressure and blood sugar levels (Steffens et al., 2020).

Follow up: The patient’s progress will be reviewed in the subsequent follow up the clinic after four weeks. The next f/u clinic is slated for October 14^th 2021.

References

Basit, H., & Kahwaji, C. I. (2020). Clonazepam.

De Bartolomeis, A., Tomasetti, C., & Iasevoli, F. (2015). Update on the mechanism of action of aripiprazole: translational insights into antipsychotic strategies beyond dopamine receptor antagonism. CNS drugs, 29(9), 773-799. (Clinical Follow-Up SOAP Note for a Psychiatric Patient Comprehensive Nursing Essay Example)

Gelenberg, A. J., Freeman, M. P., Markowitz, J. C., Rosenbaum, J. F., Thase, M. E., Trivedi, M. H., … & Silbersweig, D. A. (2010). Practice guideline for the treatment of patients with major depressive disorder third edition. The American journal of psychiatry, 167(10), 1. (Clinical Follow-Up SOAP Note for a Psychiatric Patient Comprehensive Nursing Essay Example)

Lam, R. W., Levitt, A. J., Levitan, R. D., Michalak, E. E., Cheung, A. H., Morehouse, R., … & Tam, E. M. (2016). A randomized clinical trial is the efficacy of bright light treatment, fluoxetine, and the combination in patients with nonseasonal major depressive disorder. JAMA Psychiatry, 73(1), 56-63.

Thomas, E., & Seedat, S. (2018). The diagnosis and management of depression in the era of the DSM-5. South African Family Practice, 60(1), 22-28. (Clinical Follow-Up SOAP Note for a Psychiatric Patient Comprehensive Nursing Essay Example)

Wright, M. (2020). Schizophrenia and schizophrenia spectrum disorders. Journal of the American Academy of PAs, 33(6), 46-47. (Clinical Follow-Up SOAP Note for a Psychiatric Patient Comprehensive Nursing Essay Example)

National Center for Biotechnology Information (nih.gov)