Comprehensive Focused SOAP Psychiatric Evaluation-Differential diagnoses-Nursing Examples-1

SUBJECTIVE (Psychiatric Evaluation-Nursing)

CC: “My anxiety is getting bad. I have anxiety and ADHD. Is there anything they can give me to help with my anxiety?” (Psychiatric Evaluation-Nursing).

Subjective data:

HPI: Mr. BD is a 27-year-old male with a history of anxiety and ADHD. According to the patient, he has had ADHD since he was a child. His mom reckoned that as a child, he was “all over the place, jumping off the wall,” although the condition was not diagnosed until 2021, but was diagnosed with anxiety “a long time ago.”

Moreover, Patient stated that he came to the facility for his “sobriety”, and he’s “trying to figure it out” on his own and would like to take a medication to help him focus. Patient is a resident of a treatment center for substance use, and according to him he’s going through rehabilitation as a requirement to get back to his mother’s house (Psychiatric Evaluation-Nursing).

Social Hx: Dominic is a 27-year-old single white male who was born in the US. His parents remained unmarried, he lived with his mom during his child and adolescent years. His highest level of education completed is high school. However, patient stated he would like to get a college degree. He enjoys fishing, reading, and talking to people and is currently a substance abuse treatment center resident (Psychiatric Evaluation-Nursing).

Legal Hx: Patient reported breaking into his friend’s house to steal his mom’s marijuana at the age of 14. He stood arrested though not jailed.

Medical Hx: Denied

Surgical Hx: Appendectomy in 2018

Psychiatric Hx: Patient has history of Anxiety and ADHD. Denied family history of mental illness.

Psychiatric medication use: Adderall 30 mg daily, Xanax 1 mg daily, Clonidine 0.1 mg daily (at night).

Substance Abuse history: Patient reported using multiple recreational drugs, for example

Marijuana, last used 2 weeks ago.

Cocaine, last used 3 weeks ago

Heroine, last used 5 years ago

Xanax, last used 5 days ago (Xanax was not prescribed for patient, patient reported getting it from a friend).

MSE: Mr Dominic remained preferred for Psychiatric evaluation. Patient was dressed appropriately for the occasion and time of year. He was seated throughout the interview, he was compliant, though hyper verbal, but did not appear to be in any obvious distress. Consequently, Patient denied insomnia, loss of appetite, auditory/visual hallucinations, suicidal/homicidal ideations, and paranoid thoughts (Psychiatric Evaluation-Nursing).

ROS:

General: Denies weight loss, fever, chills, weakness, or fatigue.

Heent: Eyes: denies visual loss, blurred vision, double vision, or yellow sclerae. Ears, Nose, Throat: No hearing loss, sneezing, congestion, runny nose, or sore throat (Psychiatric Evaluation-Nursing).

Skin: No rash or itching.

Cardiovascular: Denies chest pain, chest pressure, or chest discomfort. No palpitations or edema.

Respiratory: Denies wheezes, shortness of breath, consistent coughs, and breathing difficulties while resting.

Gastrointestinal: No anorexia, nausea, vomiting, or diarrhea. No abdominal pain or blood.

Genitourinary: Denies burning on urination, urgency, hesitancy, odor, odd color

Neurological: Denies headache, dizziness, syncope, paralysis, ataxia, numbness, or tingling in the extremities. No change in bowel or bladder control. Reports difficulties concentrating and paying attention.

Musculoskeletal: Denies muscle, back pain, joint pain, or stiffness.

Hematologic: Denies anemia, bleeding, or bruising.

Lymphatics: Denies enlarged nodes. No history of splenectomy.

Endocrinologic: Sweating, No reports of cold or heat intolerance. No polyuria or polydipsia.

OBJECTIVE DATA:

General appearance: the patient appears healthy-looking and well-nourished. He interacts and usually converses with the medical care team but loses attention or diverges discussions very fast to topics he is interested in.

Cardiovascular: heart rates and rhythm are regular and murmurs and extra sounds can be heard from the patient’s chest. Moreover, patient pulse rate is normal throughout and capillaries refill in 2 seconds.   

Respiratory: no wheezes and respirations are easy and regular.

Neurological: balance is stable, gait is normal, posture is erect, tone is good, and speech is clear.

Psychiatric: inattentiveness is displayed as the patient diverts from one conversation or topic to another quickly. Patient is easily distracted and sometimes seems to listen to the care provider.

In house lab tests: 

Neuropsychological testing: patient struggles and has deficit executing functions where he is required to prioritize, plan, inhibit behavior, and attend to processing speed (Psychiatric Evaluation-Nursing).

ASSESSMENT:

Mental status examination: Patient is worrisome and does not pay attention to detail, has difficulty sustaining attention to activities, and does not seem to listen continuously when spoken to directly. Consequently, patient fails to follow through on instructions, struggles to organize tasks and activities, and is reluctant to engage in activities that need sustained mental effort.

Furthermore, Patient is easily distracted by extraneous stimuli, is forgetful, fidgets with feet, talks too much, has difficulty waiting, and interrupts conversations. In addition, the patient does not display delusional thinking and denies suicidal or homicidal ideation. Moreover, patient is alert and oriented; his short-term memory is intact and insight is good. Patient struggles with concentration(Psychiatric Evaluation-Nursing).

Differential diagnoses

F90.9. Attention-Deficit Hyperactivity Disorder (Confirmed):

the patient reported with feelings of anxiety and wanted medication to help him focus. DSM-5 diagnostic criteria for ADHD in adults include five or more symptoms of inattention, several symptoms present before the age of 12 years, several symptoms present in 2 settings, evidence that symptoms interfere with or lower the quality of social, academic, or occupational functioning, and symptoms do no occur exclusively during the course of another psychotic disorder (Magnus et al., 2017). The patient displays lack of attention for an extended period, lack of focus, and was diagnosed with ADHD when young. Based on the assessment, ADHD is the primary diagnosis (Psychiatric Evaluation-Nursing).

F41.9. Generalized Anxiety Disorder (Refuted):

generalized anxiety disorder (GAD) is characterized by excessive, exaggerated anxiety and worry about normal life events for no particular reason (Munir et al., 2021). It affects over 6.8 million adults or 3.1% of the country’s population. It appears gradually and can begin at any stage across the lifespan, but the risk is highest between childhood and middle age. The exact cause of GAD is no certain, but contributing factors include biological factors, family background, life experiences, and other stressors (Toussaint et al., 2020).

A criterion for diagnosing general anxiety disorder includes symptoms like excessive, ongoing worry and tension, unrealistic view of problems, restlessness or a feeling of being “edgy,” trouble concentrating, tiring easily or being fatigued, increased crankiness or irritability, trouble sleeping, and muscle tension. Moreover, people with GAD often anticipate disaster and are overly concerned with normal day events like work. GAD is diagnosed when an individual cannot control worrying (Psychiatric Evaluation-Nursing).

F90.9. Attention-Deficit Hyperactivity Disorder, Unspecified Type (Refuted):

Attention-deficit/hyperactivity disorder (ADHD) is a chronic mental health condition that impacts millions of children and mostly progresses into adulthood. In Addition,ADHD is a combination of persistent issues, including difficulty sustaining attention, impulsive behavior, and hyperactivity. People with ADHD, especially children, often struggle with low self-esteem, troubled relationships, and poor engagement (Magnus et al., 2017).

Symptoms of ADHD in adults include, impulsiveness, disorganization and problems prioritizing, poor time management skills, problems focusing on a task, trouble multitasking, excessive activity and restlessness, poor planning, low frustration tolerance (Psychiatric Evaluation-Nursing).

DSM-5 diagnostic criteria for ADHD in adults include five or more symptoms of inattention, several symptoms present before the age of 12 years, several symptoms present in 2 settings, evidence that symptoms interfere with or lower the quality of social, academic, or occupational functioning, and symptoms do no occur exclusively during the course of another psychotic disorder (Psychiatric Evaluation-Nursing).

F19. 20. Psychotic Substance Dependence (Refuted):

Substance dependence describes a disorder involving altered brain function brought on by using psychotic substances that affect normal perceptual, emotional, and motivational brain processes (de Matos et al., 2018). Furthermore, substance dependencies include alcohol, opioid, sedative or anxiolytic, cocaine, cannabis, and amphetamine dependencies (Psychiatric Evaluation-Nursing).

Diagnostic criteria for psychotic substance dependence include at least three of: substance often taken in large quantities of an elongated period; persistent desire or one or more unsuccessful efforts to quit or control use; extended time spent to get the substance, take or recover from effects; frequent intoxication or withdrawal symptoms; giving up or reduced vital social, occupational; or recreational activities to use substances; continued use despite knowledge of harm; and marked tolerance. The patient can develop dependence syndrome after long periods of use (Psychiatric Evaluation-Nursing).

Case Formulation and Treatment Plan:

Pharmacology:

Start Buspar 10 mg 1 tab PO BID.

Venlafaxine 18.75-75 mg/day; may increase to 150 mg/day after 4 weeks

Bupropion Initial: 150 mg/day PO

Imipramine 75 PO qDay initially; may increase to 150 mg/day gradually

Metadate CD: Initial, 20 mg PO qAM before breakfast

Atomoxetine 40 mg PO once daily initially; increase after ≥3 days to 80 mg PO once daily or divided q12hr

Psychotherapy

Behavioral psychotherapy: behavioral therapy coupled with appropriate medication will go a long way to improve ADHD symptoms, enhance executive function, and help minimize feelings of anxiety (Psychiatric Evaluation-Nursing).

Psychosocial interventions: psychosocial interventions such as social skills training, applied relaxation interpersonal psychotherapy, mindfulness training, and short-term psychodynamic psychotherapy are effective in minimizing ADHD and anxiety symptoms.

Cognitive therapy: cognitive-behavioral therapy can help enhance focus and time management and counter anxiety and restless symptoms that appear during task performance (Lopez et al., 2018) (Psychiatric Evaluation-Nursing).

Patient education

• Discuss with patient risks and benefits of medication, including non-treatment, probable side effects.
• Discuss with patient when to stop medication, how to identify and when to report adverse events.
• Discuss with patient risk of mixing medications with herbal, illegal, and OTC drugs.
• Educate patient to develop structured daily routines, daily schedule, and minimize changes.
• Engage patient in skills training.
• Encourage patient to make time for exercise every day.
• Teach patient to accept himself and his limitations and to interact with people that accept him.
• Teach patient to create a system for prioritizing the day and create deadlines for activities.

Patient should follow-up after one week.

Reflection:

Given another chance or session with the patient, I would ask more about the impact of feelings of anxiety and ADHD on his daily life, particularly social interactions. My assessment would be more comprehensive and try to investigate the interventions taken earlier to control anxiety and ADHD symptoms (Psychiatric Evaluation-Nursing).

The interventions I adopted, including pharmacological and non-pharmacological, were effective in addressing the patient’s anxiety and inattentiveness. Moreover, the development of structured daily routines and daily schedule and setting aside time to exercise helped the patient improve his focus. Consequently, my next intervention would be to help the patient get to college to get his degree as he desires. Also, I would share resources like college referrals and scholarships appropriate to him (Psychiatric Evaluation-Nursing). 

References

de Matos, M. B., de Mola, C. L., Trettim, J. P., Jansen, K., da Silva, R. A., Souza, L., Ores, L., Molina, M. L., Coelho, F. T., Pinheiro, R. T., & Quevedo, L. A. (2018). Psychoactive substance abuse and dependence and its association with anxiety disorders: a population-based study of young adults in Brazil. Revista brasileira de psiquiatria (Sao Paulo, Brazil : 1999), 40(4), 349–353. https://doi.org/10.1590/1516-4446-2017-2258

Lopez, P. L., Torrente, F. M., Ciapponi, A., Lischinsky, A. G., Cetkovich-Bakmas, M., Rojas, J. I., Romano, M., & Manes, F. F. (2018). Cognitive-behavioural interventions for attention deficit hyperactivity disorder (ADHD) in adults. The Cochrane database of systematic reviews, 3(3), CD010840. https://doi.org/10.1002/14651858.CD010840.pub2

Magnus, W., Nazir, S., Anilkumar, A. C., & Shaban, K. (2017). Attention deficit hyperactivity disorder (ADHD).

Munir, S., Takov, V., & Coletti, V. A. (2021). Generalized Anxiety Disorder (Nursing). StatPearls [Internet].

Toussaint, A., Hüsing, P., Gumz, A., Wingenfeld, K., Härter, M., Schramm, E., & Löwe, B. (2020). Sensitivity to change and minimal clinically important difference of the 7-item Generalized Anxiety Disorder Questionnaire (GAD-7). Journal of affective disorders, 265, 395-401.