SOAP Note on Schizophreniform Disorder Nursing Comprehensive Nursing Paper Example

SOAP Note on Schizophreniform Disorder Nursing Comprehensive Nursing Paper Example

Client ID: 17-year-old Caucasian male.

Subjective.

Chief complaint: Here for clinical assessment, evaluation, and medication.The client reports that “he fears darkness and cannot go out alone even during the day.” The brother reports that “the son experiences nightmares and flashbacks of the events that transpired when the family was attacked.” (SOAP Note on Schizophreniform Disorder Nursing Comprehensive Nursing Paper Example)

Source of reliability: Reliability of information is good. The client and the brother are in their right state of mind.

Present Illness: The patient reports fears of darkness and going out alone. The patient also experiences nightmares auditory verbal hallucinations (AVH). These experiences began a few days after the family relocated three months ago following a robbery with a violent attack, prompting family relocation. The client had to move into his elder brother’s house to continue schooling in the same neighborhood. The client reports that he sometimes feels like someone is following him. At night, he dreams that “bad” people are after him. The brother is worried that his nightmares are become more frequent, including daytime nightmares. The client reports reduced interest in going to school. He feels agitated and acts aggressively with peers in school. Reports no suicidal or homicidal ideation. No delusions, hopelessness, or worthlessness. He misses the family being together. (SOAP Note on Schizophreniform Disorder Nursing Comprehensive Nursing Paper Example)

Current psych meds:  Melatonin 5mg orally HS over-the-counter medication for insomnia.  

Past psychiatric history: None reported.

Past medical history: Allergies: NKFDA. Denies respiratory, GI, CNS, GU, MSK, and CV. No surgical history.

Substance use/abuse: Does not abuse alcohol or narcotic drugs. No ETOH. Caffeine: Occasionally take coke and drinks tea daily. (SOAP Note on Schizophreniform Disorder Nursing Comprehensive Nursing Paper Example)

Past family, social history: Peaceful family. Had a normal childhood and adolescent development. No legal trauma. No military background. (SOAP Note on Schizophreniform Disorder Nursing Comprehensive Nursing Paper Example)

Family psych hx: Previously lived with the parents. Currently living with the elder brother.  Mother diagnosed with depression following robbery with violence.

Education/Employment/Disability: In Grade 12. High performer. Deteriorated performance in the last assessments.

Primary support system: Parents and brother.

Hobbies: Playing basketball and video games. (SOAP Note on Schizophreniform Disorder Nursing Comprehensive Nursing Paper Example)

Review of systems:

Constitutional: No fever or chills.

Cardiovascular: No chest pains, discomfort, or palpitations.

GI: No nausea, vomiting, cough, or diarrhea. Good appetite and eat three times daily.

GU: Not sexually active.

Pulmonary: Normal breath. No wheezing or cough.

Abdominal: No abdominal pain. Normal bowel sounds and movement.

Neuro: No fatigue or headache.

Musculoskeletal: No muscle tension. Nor joint pain or tingling.

Skin: Normal skin turgor. Nor rash or itchiness.

Objective:

Vitals: BP: 118/73 P: 70 Ht: 65in Wt: 125.3 BMI: 20.2

Appearance: Appear kempt and dressed accordingly. Eye contact avoidant.

Attitude/interaction: Appears upbeat and appropriate. (SOAP Note on Schizophreniform Disorder Nursing Comprehensive Nursing Paper Example)

Activity level/behavior: Interactive. No Agitation or psychomotor impairment.

Orientation: Alert and oriented × 4.

Speech: Fluent and clear.  

Thought content/process/perception: Logical, linear, and goal-oriented. No negative perception was noted.

Mood/affect: Upbeat, expansive, and congruent. Judgment/insight/cognitive/memory: Normal insight and judgement. Cognition and memory are grossly intact. (SOAP Note on Schizophreniform Disorder Nursing Comprehensive Nursing Paper Example)

Attention: Attention and concentration intact.

Testing UDS negative. CAPS-5 positive for PTSD.

Assessment:

1. Post-traumatic Stress Disorder (PTSD). ICD-10 codeF43.10. The client experiences fear-based experiencing a traumatic event (robbery with violence), nightmares, and emotional reactions (agitation and aggressiveness) associated with physical assault. The clinical presentations indicate PSTD (Blevins et al., 2015).  This is the primary diagnosis. (SOAP Note on Schizophreniform Disorder Nursing Comprehensive Nursing Paper Example)
2. Acute stress disorder (ASD). ICD-10 code F43.0. ASD develops from witnessing a traumatic event. Patient experiences recurring distressing memories and dreams, sleep disturbance, and dissociative symptoms synonymous with ASD (American Psychiatric Association, 2013). Other symptoms include intense psychological distress and persistent negative mood. This diagnosis is refuted. (SOAP Note on Schizophreniform Disorder Nursing Comprehensive Nursing Paper Example)
3. Major depressive disorder (MDD). ICD-10 codeF33.1. Primary symptoms of MDD include depressed mood or loss of interest in doing things (American Psychiatric Association, 2013). The client reports being depressed following nightmares and a lack of interest in going to school. Other MDD symptoms include daily retardation, fatigue, and feeling of worthlessness, suicide ideation, and significant weight loss. This diagnosis is refuted.
4. Separation Anxiety Disorder (SAD). ICD-10 code F93.0. The primary symptom of SAD includes excessive distress in anticipation of separation and persistent fear and anxiety that lasts about four weeks. This diagnosis is refuted. (SOAP Note on Schizophreniform Disorder Nursing Comprehensive Nursing Paper Example)
5. Schizophreniform Disorder. ICD-10 code F20.81. Primary symptoms include delusions, hallucinations, and diminished emotional expression not associated with substance abuse or medication. This diagnosis is refuted. (SOAP Note on Schizophreniform Disorder Nursing Comprehensive Nursing Paper Example)

Plan:

Continue Melatonin 5mg orally HS for insomnia. Prescribe Sertraline 50 mg once a day. Sertraline is effective for treating symptoms of PTSD (95% CI) (Huang et al., 2020). Recommend CBT to help the client gain awareness of thoughts and negative thinking associated with PTSD. CBT for PTSD focuses on thoughts, feelings, and behaviors to improve functioning (American Psychological Association, July 2017). Educate the client’s brother on how to help the sibling overcome his fears and how to approach and calm him when he is agitated, aggressive, or scared. (SOAP Note on Schizophreniform Disorder Nursing Comprehensive Nursing Paper Example)

Referral: Psychologist.

Next Visit: 4 weeks

References

Blevins, C. A., Weathers, F. W., Davis, M. T., Witte, T. K., & Domino, J. L. (2015). The post-traumatic stress disorder checklist for DSM‐5 (PCL‐5): Development and initial psychometric evaluation. Journal of traumatic stress, 28(6), 489-498. (SOAP Note on Schizophreniform Disorder Nursing Comprehensive Nursing Paper Example) https://doi.org/10.1002/jts.22059

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). American Psychiatric Publishing, Inc.   (SOAP Note on Schizophreniform Disorder Nursing Comprehensive Nursing Paper Example)

Huang, Z. D., Zhao, Y. F., Li, S., Gu, H. Y., Lin, L. L., Yang, Z. Y., … & Luo, J. (2020). Comparative efficacy and acceptability of pharmaceutical management for adults with post-traumatic stress disorder: a systematic review and meta-analysis. Frontiers in pharmacology, 11, 559. https://doi.org/10.3389/fphar.2020.00559

American Psychological Association. (July 2017). Clinical guidelines for the Treatment of Posttraumatic Stress Disorder. Cognitive Behavioral Therapy (CBT).(SOAP Note on Schizophreniform Disorder Nursing Comprehensive Nursing Paper Example) Retrieved 13 September 2021, from https://www.apa.org/ptsd-guideline/treatments/cognitive-behavioral-therapy