Mental Health Clinical SOAP Note Comprehensive Nursing Paper Example

Mental Health Clinical SOAP Note Comprehensive Nursing Paper Example

Informed Consent The mental health care provider obtained informed consent on the psychiatric interview process and the psychiatric and or psychotherapy treatment to follow. The patient gave both oral and written consent since she demonstrated capacity as well as ability to respond and understand the risks, benefits, and promise s to review any additional consent during the treatment plant discussions. (Mental Health Clinical SOAP Note Comprehensive Nursing Paper Example)

Subjective CC: “I am surprised that everybody here takes the side of this arrogant lady who gawks at customers”. HPI: BC is a 37-year-old female brought to the hospital by the police and her husband for her first admission. She created a scene at a local store after she attacked the supervisor without any provocation. The store’s management sought police help, and therefore she was brought to this facility on an order of protective custody. The patient manifests several delusions including believing that people are trying to steal from her. (Mental Health Clinical SOAP Note Comprehensive Nursing Paper Example) She believes she is the latest winner of a one-million-dollar jackpot. She further exhibits grandiose ideas like believing she was 2021 Miss America First Runners Up Winner. In her rumblings she reports having the power to read other people’s mind’ especially her enemies who wants to disfigure her face with acid. She displays blunted emotional expressions.(Mental Health Clinical SOAP Note Comprehensive Nursing Paper Example) As per the husband she has never exhibited this strange behavior but was diagnosed with toxoplasmosis 9 months that was treated with Pyrimethamine 100mg PO once daily. Despite her recovery BC appeared to be not her usual self sometimes and the symptoms were increased in intensity after the couple moved from their country home residence to renting a flat after they migrated to town. She also reports a family history of a paternal uncle who was diagnosed with delusional disorders and died believing was the unheralded savior of the US to deliver it from the jaws of communism. Past Medical Hx: Medical history: Patient reports enjoying relatively good health except a toxoplasmosis 9 months ago that was successfully treated with medication as per HPI. Surgical history: an appendectomy 11 months ago. Past Psychiatric Hx: Denies past inpatient management or outpatient care for psychiatric conditions. Previous psychiatric diagnoses: Past diagnosis of anxiety/ panic disorder and feels the course of her anxiety seems to be getting worse. Current Medications: Xanax 0.5 mg q8hr (Contraceptives): None Supplements: B-Vitamin supplementation and Iron supplementation. (Mental Health Clinical SOAP Note Comprehensive Nursing Paper Example)

HPI

Previous medication trials: Unknown. Allergies: Penicillin + rashes Therapy History: Anxiety: BC reports to having been diagnosed with GAD at the age of 19 and uses Xanax 1mg PO once daily to alleviate anxiety. Patient confirms that taking extended-release Xanax helps her remain calmer amidst stressful situations, reduce panic attacks, and calm her body over activity (George & Tripp, 2020). Mental health treatment history discussed: History of outpatient treatment: 90-day CBT course for GAD, psychoeducation on psychophysiology of anxiety reactions, exercise like active walking or jogging, and psychosocial support. Previous psychiatric hospitalizations: None Prior substance abuse treatment: occasionally takes alcohol on social events Trauma history: Client Negative for physical or emotional or psychological trauma. No history of sexual abuse. Substance Use: Occasionally takes alcohol on social events like parties commemorating major milestones her life or that of friends. Past Psych Med Trials: unknown at this time Family Medical Hx: Grandmothers on both sides had a history of CVD and obesity both died aged 72 and 71 years. Maternal uncle succumbed to MI at age 67 years. Family Psychiatric Hx: Paternal uncle while believing he was America’s Messiah from communism bondage. Birth and Development History: Deemed noncontributory as all childhood development milestones were achieved with no significant challenges. ROS: Constitutional: In general, fair condition , AA female, alert, and in moderate acute distress Eyes: No eye pain, no discharge, and no changes in vision. ENT: No hearing alternations no tinnitus, no earache, .no running nose, bleeding, no swollen thyroid gland, no changes in voice ,no difficulties in swallowing food. Cardiac: Negative for chest pain, lower extremities swelling or orthopnea. (Mental Health Clinical SOAP Note Comprehensive Nursing Paper Example)

Respiratory: Negative for dyspnea, cough or wheezing. GI: No abdominal pain abdomen is soft, non- tender. Normoactive bowel sounds. GU: Denies excessive thirst and frequent urination. Musculoskeletal: Negative for joint pain or swelling. Skin: Normal skin tone, no discoloration, rash, lesion, abrasions. Neurologic: Negative for seizures, blackout, numbness or focal weakness. Endocrine: No polyuria and polydipsia. Hematologic: Negative for blood clots or easy bleeding or splenectomy Allergy: Penicillin + rashes. Reproductive: LMP 7 weeks ago Cycle length and frequency 5/28 heavy bleeding IMB –Absent PCB-Absent Age of Menarche/Menopause- 11 years and not yet respectively Miscarriages G 2 P 0 A 0 L 2 (Mental Health Clinical SOAP Note Comprehensive Nursing Paper Example)

Objective Vital Signs: BP 143/87, HR 81, Temp 37.4, RR 18, O2 97% Ht 5’3” Wt 97kg BMI 37.9 Obesity Class II) Lab tests results Neutrophils -67% Lymphocytes 25%, monocytes 9% GGT 39Total cholesterol 209 Phosphate 5.2 the rest were WNL. Urine pregnancy test positive Physical Exam: Noncontributory. MSE: Appearance: Appears the stated ethnicity of non- Hispanic White, morbidly obese, modestly dressed but in disarray, hair messed up. Speech: Clear and constant but pressured, rambling sometimes, with flight of ideas (Mental Health Clinical SOAP Note Comprehensive Nursing Paper Example)

Mood: Euphoria present, significant grandiosity Affect: Mood congruent Thought process: Grandiose, delusional, and not logical Thought Content: no suicidal or homicidal ideation, negative for a/v hallucinations, signification delusions with prominent paranoia Memory: fair at all levels immediate, moderate, or remote Concentration: Sufficient Intellectual function: moderate Judgment: significantly impaired Insight: significantly impaired Relevant Screening Tools Scale for the Assessment of Positive Symptoms (SAP) – 4 (moderate) Positive and Negative Symptom Scale (PANSS) with a score of 5 ( moderate severe) GAD-7 Screener with score of 4 indicating moderate anxiety (Mental Health Clinical SOAP Note Comprehensive Nursing Paper Example)

Assessment DSM5 Diagnosis: with ICD-10 codes Diagnosis 1. F20.9 Schizophrenia Unspecified 2. F25.2Schizoaffective Disorder 3. F41.9Anxiety Disorders Unspecified 4. F22 Delusional disorders Differential Diagnoses: 1. F20.9 Schizophrenia Unspecified -Confirmed For a mental healthcare provider to confirm a diagnosis of schizophrenia, the client has to present two or more primary symptoms one of which must be hallucinations, delusions or disorganized speech for a minimum of one month. According to the husband, BC has exhibited some unusual symptoms like being deluded that she is the most beautiful woman in their county but judges would not acknowledge her because is married grandiosity . She is also overly excited sometimes. Schizophrenia was further confirmed because BC had two of the symptoms in the mnemonic HalDol disorganizes Speech and behavior in cat negatively that had lasted more than six months (Kadivala, 2020). (Mental Health Clinical SOAP Note Comprehensive Nursing Paper Example) Similarly, when PANSS and SAPs screening tools were administered the scores were suggestive of schizophrenia (Kumari et al, 2017). 2. F41.9 Generalized Anxiety Disorders Unspecified-Confirmed The patient also has a history of anxiety and panic disorders which effectively manages using Xanax medication and nonpharmacological interventions like exercises, and CBT. It was also confirmed because the patient has exhibited excessive anxiety and worry on various events and activities in her life like money being remotely fished out of her wallet. 3. F25.2Schizoaffective Disorder- Refuted Individuals with F25.2 schizoaffective disorder exhibit similar symptoms to those of schizophrenia. In both cases delusions and hallucinations may be present. These include loss of touch with the reality and the inability to tell what is real from fantasy or imagined. (Mental Health Clinical SOAP Note Comprehensive Nursing Paper Example) However, patients with schizoaffective disorder also have episodes of depression and moments when they are extremely happy and therefore it was refuted. 4. F31.9 Bipolar Disorder –Refuted Bipolar disorder patients can sometimes present with symptoms that mimic those of schizophrenia. It was ruled out using the PANSS scoring and the assessment also indicated that BC’s symptoms lacked strong shifts in energy, mood and activity levels as manifested in BPD patients. BPD also occurs in late teens and the twenties compared to schizophrenia whose onset is usually in the thirties. Treatment Goals: F20.9 Schizophrenia Unspecified The long-term goal of treating schizophrenia is to retain and sustain the gains made during acute treatment, prevent worsening of symptoms, enhance the client’s psychosocial functioning, and improve the quality of life. Other goals include but are not limited to decrease the psychotic symptoms, minimize the likelihood of relapse and prevent complication psychosocial complications like legal incidents and the like. F41.1 Generalized Anxiety Disorder – a. Minimize the somatic and psychic symptoms of GAD b. Improve the patient’s function in her daily activities and better quality of life c. Effectively treat and manage co existing disorders whether medical or psychological d. Correct irrational thinking by identifying specific areas of distorted cognition. e. Improve coping strategies of dealing with anxiety and anxiety symptoms. Informed Consent Ability: In my considered opinion the client has the ability and capacity to respond to psychiatric pharmacological and psychotherapy interventions and appears to (Mental Health Clinical SOAP Note Comprehensive Nursing Paper Example)

Informed Consent Ability understand the need for medications/psychotherapy. She also expresses her readiness and willingness to adhere to the recommended treatment and care plan. (Mental Health Clinical SOAP Note Comprehensive Nursing Paper Example)

Plan

Pharmacological Interventions According to Ganjuly et al. (2018), antipsychotic medications like Clozapine 25mg PO once daily is prescribed as the starting dose. If well tolerated it will be increased to achieve a target dose of 300 mg per day in divided doses within the first 14 days. Clozapine is an antipsychotic whose MOA works by reducing the positive symptoms of schizophrenia by blocking dopamine receptors. The side effects are severe neutropenia and orthostatic hypotension, Bracydia and syncope. The medication is contraindicated in patients with a history of serious hypersensitivity to clozapine. Similarly, the patient will still continue to use Xanax at the dose she was taking as per HPI to manage the GAD Nonpharmacological interventions A multimodal approach is to be incorporated in the treatment plan. The non-medication interventions include ü Psychoeducation on how to recognize and deal with anxiety and its symptoms ü Supportive therapy on how to cope with life stressing situations ü Social skills training on how to relate well with other people ü Use of art as a form of therapy by encouraging the patient to develop and practice a new hobby like drawing and painting. Referral ·(Mental Health Clinical SOAP Note Comprehensive Nursing Paper Example) The patient is to be referred to a Psychotherapist for CBT. · The patient is to be referred to a non- psychiatric professional dietitian to help her deal with the excess weight. (Mental Health Clinical SOAP Note Comprehensive Nursing Paper Example)

Follow up Return for follow up a month’s time but earlier if the psychotic symptoms worsen to a level where the patient cannot life harmoniously with others. (Mental Health Clinical SOAP Note Comprehensive Nursing Paper Example)

References

Ganguly, P., Soliman, A., & Moustafa, A. A. (2018). Holistic management of schizophrenia symptoms using pharmacological and non-pharmacological treatment. Frontiers in public health, 6, 166. (Mental Health Clinical SOAP Note Comprehensive Nursing Paper Example)

George, T. T., & Tripp, J. (2020). Alprazolam. StatPearls [Internet]. (Mental Health Clinical SOAP Note Comprehensive Nursing Paper Example)

Kadiyala, P. K. (2020). Mnemonics for diagnostic criteria of DSM V mental disorders: a scoping review. General psychiatry, 33(3). (Mental Health Clinical SOAP Note Comprehensive Nursing Paper Example)

Kumari, S., Malik, M., Florival, C., Manalai, P., & Sonje, S. (2017). An assessment of five (PANSS, SAPS, SANS, NSA-16, CGI-SCH) commonly used symptoms rating scales in schizophrenia and comparison to newer scales (CAINS, BNSS). Journal of addiction research & therapy, 8(3). (Mental Health Clinical SOAP Note Comprehensive Nursing Paper Example)

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