Clinical Soap Note on Psychiatric Progress Note Comprehensive Nursing Paper Example

Clinical Soap Note on Psychiatric Progress Note Comprehensive Nursing Paper Example

The client provides verbal and written consent for the psychiatric interview and the treatment plan. The client can respond to the psychiatric questions and understands the psychiatric assessment, risks, and benefits.

Patient Initials: ZA Age: 39 years Gender: Female Race: African American

Subjective

Chief Complaint: ‘I have a right to call my attorney.’

HPI : ZA is a 39 yo female brought to this hospital by the state police for admission as her first time. The patient had caused a commotion a local boutique, prompting the proprietor to seek police intervention. She was brought to the facility under protective custody. ZA clinical manifestations include delusions where she believes aliens from Mars force their way into her apartment at night, rape her, and eventually insert pins in her stomach before they leave. She also asserts that an Al Qaida sympathizer pretends to be her, decapitated her feet , then reattached after they were sent to Pakistan, and that her ova harvested. She claims unnamed terrorists have placed electrodes in her head and use her as cyber organism transmitter. These are accompanied by grandiose ideations of having been a princess to an unnamed African King, and is heiress to gold mine, high end fashion modeling house. She rambles in her speech. (Clinical Soap Note on Psychiatric Progress Note Comprehensive Nursing Paper Example)

Allergies: Penicillin rash.

Past Psychiatric History: Denies previous hospitalizations

Past Medical history: Had appendicitis 90 days ago. No documentation to prove rape, broken hip.

Family Psychiatric History: Claims that she is an adopted child with her foster family having no psychiatric issues. (Clinical Soap Note on Psychiatric Progress Note Comprehensive Nursing Paper Example)

Social History: She separated and eventually divorced with her Non-Hispanic White husband, has no children, confirms smoking 1 packet of cigarette daily, and denies taking alcohol. She is currently unemployed after she was fired for her Supermarket attendant job, and lives alone in her apartment. (Clinical Soap Note on Psychiatric Progress Note Comprehensive Nursing Paper Example)

Review of Systems (ROS)

Constitution: Patient complains unsteady gait, general weakness, and failure to thrive.

HEENTM: Denies experiencing any symptoms.

Respiratory: Denies experiencing any symptoms.

Cardiovascular: Denies experiencing any symptoms.

GI/Abdominal: Complains of occasional GI upsets due to the nails in her stomach.

GU: Negative for GU infections. (Clinical Soap Note on Psychiatric Progress Note Comprehensive Nursing Paper Example)

Musculoskeletal: Complains of general weakness.

Skin: Denies experiencing any symptoms no skin infection signs are visible

Psychiatric/Neurologic: Denies experiencing any symptoms.

Endocrine: Denies experiencing any symptoms.

Hematological /Lymphatic: Denies experiencing any symptoms.

All other systems: Reviewed and determined to be non- contributory.

Current Medications

Unknown as she denies.

Objective

Vitals

Temp. 98.3, Pulse 76, Resp 19, BP (MAP) 107/ 70, Pulse oxi 95 , O2 delivery Room air

Ht/Wt/BMI

Ht. 69.5 Inches, Wt 121. 9 lbs, BMI. 18.7

Mental Status Exam

Evaluation type by complexity

Appearance: Female of AA ethnicity, morbidly overweight, poorly groomed with unkempt hair.

Speech: Unclear sometimes, constant, pressured with rambling and flight of ideas. (Clinical Soap Note on Psychiatric Progress Note Comprehensive Nursing Paper Example)

Mood: Marked grandiosity

Affect- Mood congruent

Thought Process: Delusional , grandiose and illogical

Thought content: Negative for auditory hallucinations, visual hallucinations present,

Suicidal ideation: Patient denies current suicidal ideation, is negative for active plans or intent but has been exhibiting passive suicidal ideations going his dramatic statement provoking the healthcare to ‘kill me’ (Clinical Soap Note on Psychiatric Progress Note Comprehensive Nursing Paper Example)

Homicide ideation: Negative.

Memory: immediate, recent, and remote are moderate

Concentration: moderate

Intellectual function: moderate

Judgement: Significantly impaired

Insight significantly impaired

Diagnoses, Assessment, and Plan

Problems

1. F20.0 Schizophrenia, paranoid Type

ZA presents with at least three of the five characteristic symptoms required to confirm a diagnosis of Schizophrenia namely delusions, jumbled speech, and disorganized behavior (Patel et al, 2014). The patient’s prominent symptoms of delusions persecutory and grandiose makes the diagnosis be of paranoid type. Antipsychotic treatment is recommended specifically of second generation type. (Clinical Soap Note on Psychiatric Progress Note Comprehensive Nursing Paper Example)

Anxiety Likewise, the patient exhibited other symptoms suggestive of existing comorbidity. The patient does not present with excessive anxiety and worry accompanied by multiple themes that exceeded more than six months. The individual has no challenges controlling excessive worry, even in minor matters. Giacobe and Flint (2018) posit that the individual must exhibit somatic symptoms consistent with hyperarousal like irritability and insomnia, all are absent in the patient, thus refuting a generalized anxiety disorder.  (Clinical Soap Note on Psychiatric Progress Note Comprehensive Nursing Paper Example)

Bipolar Disorder (Refuted)

Renard et al (2017) note that schizophrenia has symptoms that are similar to those of bipolar disorder like mood disturbances and impaired thinking. However, Bipolar disorder was refuted because BPD patients present with shifts in mood, energy levels, and thinking whereas ZA appears to have lost touch with the reality. The patient does not present with mania and depression often separated by durations of relative stability. (Clinical Soap Note on Psychiatric Progress Note Comprehensive Nursing Paper Example)

Plan 

The goals of therapeutic intervention target the resolution of the symptoms and eventual remission while simultaneously minimizing the side effects of the prescribed medicines. Likewise nonpharmacological interventions should be included through patient education on stress management and adherence to medication (Koutsouleris et al, 2015). (Clinical Soap Note on Psychiatric Progress Note Comprehensive Nursing Paper Example)

Medications: 

Aripiprazole 10mg qAM to be titrated upwards daily by 1-2mg each day The maintained drug dosage per PUI is 20 mg / day ( Di Sciascio & Riva,2015). The provider needs to review the onset of the medications’ effect as efficacy is not observable for several weeks meaning the patient should be encouraged  to continue taking the medication despites its seeming ineffectiveness as this is expected to be temporarily. It is important to note that low initial doses and slow titration helps to minimize the risk of developing akathisia. (Clinical Soap Note on Psychiatric Progress Note Comprehensive Nursing Paper Example)

Risk Assessment

Risk for harm to others is deemed low, the risk for suicide in the current setting low, as do risk for self-harm or self-mutilation. The medications included in the treatment plan were duly discussed, and informed consent was given. The patient may require hospitalization for ongoing psychiatric evaluation and medication adjustment. The other reasons for her admission to a hospital at the hospital are the unstable clinical manifestation of not eating, being too weak to walk and psychotic delusions. (Clinical Soap Note on Psychiatric Progress Note Comprehensive Nursing Paper Example)

References

Patel, K. R., Cherian, J., Gohil, K., & Atkinson, D. (2014). Schizophrenia: overview and treatment options. Pharmacy and Therapeutics, 39(9), 638. (Clinical Soap Note on Psychiatric Progress Note Comprehensive Nursing Paper Example)

Koutsouleris, N., Meisenzahl, E. M., Borgwardt, S., Riecher-Rössler, A., Frodl, T., Kambeitz, J., … & Davatzikos, C. (2015). Individualized differential diagnosis of schizophrenia and mood disorders using neuroanatomical biomarkers. Brain, 138(7), 2059-2073. (Clinical Soap Note on Psychiatric Progress Note Comprehensive Nursing Paper Example)

Renard, S. B., Huntjens, R. J., Lysaker, P. H., Moskowitz, A., Aleman, A., & Pijnenborg, G. H. (2017). Unique and overlapping symptoms in schizophrenia spectrum and dissociative disorders in relation to models of psychopathology: a systematic review. Schizophrenia bulletin, 43(1), 108-121. (Clinical Soap Note on Psychiatric Progress Note Comprehensive Nursing Paper Example)

Di Sciascio, G., & Riva, M. A. (2015). Aripiprazole: from pharmacological profile to clinical use. Neuropsychiatric disease and treatment, 11, 2635. (Clinical Soap Note on Psychiatric Progress Note Comprehensive Nursing Paper Example)

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