Week 7- PRAC-6665 Focused Soap Note and Patient Case Presentation-nursing Paper Examples

Subjective: (Patient Case Presentation-nursing Paper Examples)

CC (chief complaint): I’m here for a psychiatric assessment to determine the need for psychotropic medication management.”

HPI: DD, a 66-year-old Caucasian male, presented for a psychiatric assessment to determine the need for psychotropic medication management. The patient complains of easy distraction, often elated, but can quickly get angry and has social anxiety, which makes it challenging to engage in social interactions, forcing him to take alcohol. He is also disturbed by illogical thinking, such as the non-existence of God. He previously used Vyvanse, which no longer helps with his psychotropic problem. The patient currently uses Zoloft 150 mg daily.

Substance Current Use: The patient is an alcoholic, a substance he uses to increase his confidence (Patient Case Presentation-nursing Paper Examples).

Medical History:

• Current Medications: Zoloft 150 mg daily.
• Allergies:The patient reports no food or environment-related allergy.
• Reproductive Hx:The patient reports no sexual activity.

ROS:

GENERAL: The patient reports no weight loss, fatigue, or weakness. He feels energized most of the time.

HEENT: Eyes: the patient reports no visual loss or blurred vision. Ear: no hearing loss, nasal congestion, or sore throat reported.

SKIN: The patient reports no skin rashes or itching.

CARDIOVASCULAR: no chest pain or discomfort.

RESPIRATORY: The patient reports no shortness of breath or coughing.

GASTROINTESTINAL: The patient reports no nausea, vomiting, diarrhea, or abdominal pain.

GENITOURINARY: reports no urination urgency, hesitancy, or burning sensation. Reports odor urine.

NEUROLOGICAL: reports no headaches, dizziness, or paralysis.

MUSCULOSKELETAL: reports no pain in the back, joints, or stiffness.

HEMATOLOGIC: reports no anemia or bleeding.

LYMPHATICS: No enlarged nodes are visible. Denies splenectomy in the past.

ENDOCRINOLOGIC: Denies heat intolerance, polyuria, or polydipsia (Patient Case Presentation-nursing Paper Examples).

Objective:

Diagnostic results: No labs or x-rays were conducted (Patient Case Presentation-nursing Paper Examples).

Assessment: (Patient Case Presentation-nursing Paper Examples)

The patient is a 66-year-old Caucasian male referred for a psychiatric assessment by a primary care provider. He appears energetic, well-groomed, and presentable. He was cooperative throughout the assessment process. However, when asked normal questions, he exhibited anxious distress, panic, and restlessness. He also exhibited normal speech but experienced challenges concentrating. He has good insight and judgment since he recognizes his mental health issues. He is non-delusional and cognitively oriented due to his ability to construct correct sentences and make meaningful but complex arguments, such as questioning the non-existence of God (Patient Case Presentation-nursing Paper Examples).

Diagnostic Impression:

Bipolar disorder I (ICD 11 code: 6A60): Painter et al. (2019) explain that bipolar disorder is associated with symptoms like feelings of self-importance, energy, irritation, distraction, hyperactivity, and substance use (Grunze et al., 2021). The patient was hyperactive, consumed alcohol, was restless, and easily irritated during the interview (Patient Case Presentation-nursing Paper Examples).

Social anxiety (ICD 11 code: 6B04): Individuals with social anxiety exhibit fear of embarrassment, low confidence, anxiety, and intense fear when interacting with large groups of people. Schuster et al. (2021) explain that the patients also have negative expectations about social interactions and fear of speaking in public. They also exhibit physical symptoms like sweating, muscle tension, nausea, and increased heart rate. In this case, the patient was fearful of social interactions and often consumed alcohol to gain confidence to interact with other people. Henceforth, the patient could be suffering from a social anxiety disorde (Patient Case Presentation-nursing Paper Examples)r. 

Generalized anxiety disorder (GAD) (ICD 11 code: 6B00): DeMartini et al. (2019) observe that individuals with GAD experience persistent anxiety, lack of concentration, fear of making wrong decisions, nervousness, and irritability. They also experience challenges with substance use and perceive every event as life-threatening. The patient in the case study has problems controlling alcohol consumption, experiences irritability, nervousness fears shame resulting from wrong decisions, and is often distracted. These symptoms indicate the presence of GAD (Patient Case Presentation-nursing Paper Examples).

Therefore, the primary diagnosis is bipolar disorder I since the patient exhibited symptoms described in the DSM-5 criteria for the psychiatric condition. For instance, Grunze et al. (2021) illustrate that a person must exhibit at least one maniac episode, which should not be associated with other mental problems like schizophrenia or other psychotic disorders. The patient must have also exhibited hyperactivity for at least a week.

The patient must also exhibit at least 3 of the following symptoms during episodes of mood disturbance; hyperactivity, distraction, inflated self-esteem, sleep disturbance, and talkative and goal-oriented activity (Grunze et al., 2021). In this case, the patient’s maniac symptoms are not caused by schizophrenia; he is hyperactive, distracted, and exhibits goal-oriented thinking patterns (Patient Case Presentation-nursing Paper Examples).

Treatment plan

Pharmacological treatment of the patient should involve the administration of mood stabilizers like lithium to control the mania symptoms. Fountoulakis et al. (2022) illustrate that lithium alters the production of chemicals like dopamine and serotonin in the brain, enabling individuals to control emotions and mood swings. Additionally, antipsychotic medications like Loxapine can be administered to manage maniac episodes. Faden and Citrome (2019) observe that Loxapine balances natural substances in the brain, reducing agitation and hyperactivity (Patient Case Presentation-nursing Paper Examples).

Besides, the patient should be enrolled in cognitive behavioral therapy (CBT) interventions. CBT helps in bipolar I management by helping with the identification of unhealthy feelings and thought processes that increase the risk of maniac episodes and distraction (Özdel et al., 2021). It focuses on the patient’s current psychosocial problems, making it easy to replace negative feelings and thoughts with positive ones.

Finally, the follow-up plan for bipolar disorder will involve routine exercise activities and monitoring of the patient’s psychosis and mood swings based on the prescribed treatment plan. Referring the patient to an experienced behavioral psychologist to provide CBT is also essential (Patient Case Presentation-nursing Paper Examples). 

Access to quality healthcare is a critical social determinant of health that satisfies Healthy People 2030 objectives (Santana et al., 2021). Patients with psychiatric health conditions like bipolar I disorder should receive quality and accessible mental care to improve their mental conditions. In addition, a suitable health promotion activity for psychiatric care should involve access to good nutrition and exercise (Firth et al., 2020). Good nutrition consisting of plenty of vegetables and fruits reduces the risk of depression and enhances cognitive functioning (Patient Case Presentation-nursing Paper Examples).

Consequently, exercise is integral in boosting mood, concentration, and alertness (Fossati et al., 2021). Moreover, patient education should involve creating awareness about mental health conditions, their causes, and treatment interventions (Fossati et al., 2021). This could help reduce stigmatization and the adoption of easily accessible interventions like exercise to manage the symptoms. These measures could help reduce inequalities within psychiatric care, improving health outcomes among patients with mental health problems (Patient Case Presentation-nursing Paper Examples)

Reflections

I was not able to follow up on the patient’s progress. However, if given another chance with the patient again, I will do a follow-up to determine how the patient’s condition improves with the medication-assisted therapy. I would conduct diagnostic tests like blood tests, thyroid function, and urinalysis to determine if other factors may contribute to the patient’s condition. The diagnosis was inconclusive since other underlying conditions could contribute to the bipolar I disorder symptoms (Patient Case Presentation-nursing Paper Examples). 

Case Formulation and Treatment Plan: 

PRECEPTOR VERIFICATION: (Patient Case Presentation-nursing Paper Examples)

I confirm the patient used for this assignment is a patient who was seen and managed by the student at their Meditrek-approved clinical site during this quarter’s course of learning.

Preceptor signature: ________________________________________________________

Date: ________________________

References

DeMartini, J., Patel, G., & Fancher, T. L. (2019). Generalized anxiety disorder. Annals of Internal Medicine, 170(7), ITC49-ITC64. https://doi.org/10.7326/AITC201904020

Faden, J., & Citrome, L. (2019). Examining the safety, efficacy, and patient acceptability of inhaled Loxapine for the acute treatment of agitation associated with schizophrenia or bipolar I disorder in adults. Neuropsychiatric Disease and Treatment, 2273-2283. https://doi.org/10.2147/NDT.S173567

Firth, J., Gangwisch, J. E., Borsini, A., Wootton, R. E., & Mayer, E. A. (2020). Food and mood: How do diet and nutrition affect mental well-being? Bmj, 369. https://doi.org/10.1136/bmj.m2382

Fossati, C., Torre, G., Vasta, S., Giombini, A., Quaranta, F., Papalia, R., & Pigozzi, F. (2021). Physical exercise and mental health: The routes of a reciprocal relation. International Journal of Environmental Research and Public Health, 18(23), 12364. https://doi.org/10.3390/ijerph182312364

Fountoulakis, K. N., Tohen, M., & Zarate Jr, C. A. (2022). Lithium treatment of Bipolar disorder in adults: A systematic review of randomized trials and meta-analyses. European Neuropsychopharmacology, 54, 100-115. https://doi.org/10.1016/j.euroneuro.2021.10.003

Grunze, A., Born, C., Fredskild, M. U., & Grunze, H. (2021). How Does Adding the DSM-5 Criterion Increased Energy/Activity for Mania Change the Bipolar Landscape? Frontiers in Psychiatry, 12, 638440. https://doi.org/10.3389/fpsyt.2021.638440

Özdel, K., Ayşegül, K. A. R. T., & Türkçapar, M. H. (2021). Cognitive behavioral therapy in treatment of bipolar disorder. Archives of Neuropsychiatry, 58(Suppl 1), S66. https://doi.org/10.29399%2Fnpa.27419

Painter, J. M., Mote, J., Peckham, A. D., Lee, E. H., Campellone, T. R., Pearlstein, J. G., … & Moskowitz, J. T. (2019). A positive emotion regulation intervention for bipolar I disorder: Treatment development and initial outcomes. General Hospital Psychiatry, 61, 96-103. https://doi.org/10.1016/j.genhosppsych.2019.07.013

Santana, S., Brach, C., Harris, L., Ochiai, E., Blakey, C., Bevington, F., … & Pronk, N. (2021). Practice full report: Updating health literacy for healthy people 2030: Defining its importance for a new decade in public health. Journal of Public Health Management and Practice, 27(6), S258. https://doi.org/10.1097%2FPHH.0000000000001324

Schuster, P., Beutel, M. E., Hoyer, J., Leibing, E., Nolting, B., Salzer, S., … & Leichsenring, F. (2021). The role of shame and guilt in social anxiety disorder. Journal of Affective Disorders Reports, 6, 100208. https://doi.org/10.1016/j.jadr.2021.100208