CASE STUDY 2 Psychiatric SOAP Note Template, Exams of Nursing

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Case Study Johan Bello IHuman week 13 Regis College Class: NU-664C- 02 - 20PCFA FamilyPsychiatric Ment.Hlth I

Psychiatric SOAP Note Template Criteria Clinical Notes Subjective (^) Patient name: Justin Johnson Gender: Male Age: 19 y/o Chief complaint: c/o problems at school HPI (History of present illness): The patient (Justin Johnson) is a 19 y/o male who presents was accompanied by his mother and presented with c/o problems at school. The patient reports that he was expelled from college two months ago for breaking into a building on campus and shouting that the dean wanted to steal his intellectual property. The patient’s mother reports that his behavior started changing about six months ago after he stopped taking his medication (methylphenidate) for Attention-deficit hyperactive disorder. Additionally, the patient admits he had stopped attending classes and began to smoke more marijuana. Moreover, he states that he was detached from social interaction and seemed to be “obsessed” with research, specifically in academic plagiarism. His mother reports that she had observed manifestations of paranoid ideation as well as ritualistic behaviors in the patient over the past two months while at home, he had neglected his personal hygiene, slept during the day, and avoided engaging in activities that were previously enjoyable. Notably, the patient had repetitive head-tilting movements, staring spells, and scratching of the left ear. Past medical and psychiatric history: The patient has a h/o childhood asthma (he used an albuterol inhaler and his last episode of asthma occurred when he was ten years old) and ADHD. Additionally, the patient had a single and brief episode of fear to leave the house and talking to himself at the age of thirteen years, which was attributed to the type of ADHD medication he was using. However, his behavior returned to normal after his medication was changed. Social history: Justin is a male student who

Attitude: Uncooperative Affect: Flat affect Thought processes: Illogical and unfocused Thought content: Delusional thinking noted Suicidal ideation: No suicidal/homicidal ideation Insight: Fair Physical exam Vital signs: BP: 118/82 mmHg (Supine/sitting), 116/74 mmHg (Upon standing) Temp: 98.6F (Oral) HR: 74 bpm (Regular) RR: 16 Ht: 5’10’’ Wt: 180lbs BMI (percentile): 25.8 SpO2: 100% on room air General: Overweight male who is poorly groomed and has poor hygiene with a strong body odor Skin: Warm, dry HEENT: Normocephalic/atraumatic, starring at the wall, head tilted to the left, scratching behind the ear. Flat affect. no nasal discharge Neck: No thyromegaly, JVD, or thyroid masses Lungs: CTA (Clear to auscultation) bilaterally Cardiovascular: RRR (Regular, rate, and rhythm), no murmur or gallops Gastrointestinal: Soft and non-tender Neurological: CN II-XII intact Musculoskeletal: No dystonia or joint tenderness Psychological: A & O X 3, disorganized speech, delusions noted Lab results Name Value Detection time Amphetamines None detected 5 days Benzodiazepines Barbiturates Cannabis (THC) Codeine positive None detected Positive None 6 weeks 21 days 4 - 6 weeks 5 days

detected Cocaine None detected Heroine None detected LSD None detected MDMA (ecstasy) None detected 7 days 5 days 8 hours 24 hours Methamphetamine (Meth) Methaqualone (Quaalude) None detected None detected 3 - 5 days 2 weeks Phencyclidine None detected Morphine/Opium None detected 5 days 4 - 5 days Assessment (^) Differential diagnoses

1. Paranoid schizophrenia (ICD- 10 code: F20. 0)
2. Substance-induced psychotic disorder (ICD-10 code: F19. 150)
3. Major depressive disorder (ICD- 10 code: F33. 1)
4. Bipolar I disorder (ICD- 10 code: F31.
5. Obsessive-compulsive disorder (ICD- 10 code: F42. 9) Primary diagnosis
6. Paranoid schizophrenia (ICD- 10 code: F20. 0) Based on the physical examination findings, objective data, and laboratory evidence, and subjective data, paranoid schizophrenia features as the primary diagnosis for this client. This diagnosis is supported by the presence of auditory hallucinations, paranoid delusions as well as negative symptoms like lack of eye contact, social withdrawal, self-neglect, and poor hygiene (Chan, 2017). The DSM- 5 criteria for this diagnosis include; the presence of paranoid delusions, disorganized speech, hallucinations, negative

Non-pharmacological treatment: Psychosocial interventions like family therapy, individual therapy, and social skills training are the main non-pharmacological interventions used in the treatment of this disorder it is very important (Catts & O’Toole, 2016). Thus, the non-pharmacological treatment of this client will involve family and individual therapy as well as social skills training and including mother in the treatment plan. For instance, social skills training will help in enhancing his communication as well as social interactions that would foster his active engagement in the usual activities (Catts & O’Toole, 2016). Social interaction it is very important in this type of patient. Patient education: The patient will be taught about this disorder and that will help him to understand his condition and need to adhere to his treatment plan. He will also be educated about the need to avoid the use of marijuana, alcohol, or other recreational drugs and the community resources that would assist him in coping with this disorder. Referrals: The patient will be referred to a psychotherapist for the needed psychosocial interventions in 1 week or less. Follow-up care: The patient’s follow-up care will involve mainly clinical appointments that will assist in monitoring his progress.

References American Psychiatric Association. (2020). The American psychiatric association practice guideline for the treatment of patients with schizophrenia. American Psychiatric Pub. Biedermann, F., & Fleischhacker, W. W. (2016). Psychotic disorders in DSM- 5 and ICD-11. CNS spectrums , 21 (4), 349-354. Catts, S. V., & O’Toole, B. I. (2016). The treatment of schizophrenia: Can we raise the standard of care?. Australian & New Zealand Journal of Psychiatry , 50 (12), 1128-1138. Chan, V. (2017). Schizophrenia and psychosis: Diagnosis, current research trends, and model treatment approaches with implications for transitional age youth. Child and Adolescent Psychiatric Clinics of North America. Kane, J. M., Agid, O., Baldwin, M. L., Howes, O., Lindenmayer, J. P., Marder, S., ... & Correll, C. U. (2019). Clinical guidance on the identification and management of treatment- resistant schizophrenia. The Journal of clinical psychiatry , 80 (2), 0-0. Lally, J., Gaughran, F., Timms, P., & Curran, S. R. (2016). Treatment-resistant schizophrenia: current insights on the pharmacogenomics of antipsychotics. Pharmacogenomics and personalized medicine , 9 , 117.