NRNP Practicum 6665 6675: Comprehensive Focused SOAP Psychia

Nrnpprac 6665 6675 Comprehensive Focused Soap Psychiatricevaluation

This assignment involves conducting an in-depth comprehensive psychiatric assessment of a patient presenting with various mental health concerns, including schizophrenia, paranoia, psychosis, and non-compliance with medication. The assessment covers subjective and objective data, diagnostic impressions, treatment planning, and reflection on the case. The purpose is to analyze the patient's mental status, history, and clinical findings, formulate an accurate diagnosis based on DSM-5-TR criteria, and develop an appropriate, patient-centered treatment plan. Additionally, the evaluation requires literature support—at least ten credible references—and an interpretation of how the case impacts clinical practice, emphasizing medication management, patient rapport, and coordination of care. The reflection should include insights into treatment challenges and strategies to improve compliance and mental health outcomes.

Paper For Above instruction

The comprehensive psychiatric evaluation of a patient presenting with complex mental health issues warrants meticulous analysis spanning clinical history, mental status examination, diagnostic impressions, and tailored treatment planning. In this case, the subject is a 58-year-old woman with a history of psychosis, paranoia, suicidal behavior, non-compliance with medication, and significant trauma, with familial psychiatric history adding context to her presentation. This detailed assessment aims to understand her condition thoroughly, establish an accurate diagnosis, and create a plan that promotes therapeutic rapport and effective management.

The patient's subjective report reveals multiple issues including disrupted sleep, low energy, irritability, and feelings of guilt. Her history of multiple hospitalizations for psychosis and mania, alongside suicide attempts, underscores the severity and chronicity of her condition. She reports hearing voices, paranoia, and fears of being harmed, which are hallmark features of schizophrenia. Her non-compliance with medications such as Rexulti, Abilify, Risperidone, and others contributes to her ongoing symptoms. Furthermore, her trauma history, including childhood abuse and adult victimization, precipitates anxiety, flashbacks, and hypervigilance, complicating her psychiatric picture.

Objective physical and mental examination indicates a well-groomed patient appearing her age, but with a dysthymic and anxious mood, labile affect, and occasional pressured speech. Her thought process is somewhat illogical but goal-directed, with paranoia and hallucinations identified through her reported symptoms. Impaired insight and fair judgment are also observed. Laboratory results are pending but have been ordered to evaluate for potential medical contributors to her psychiatric presentation, such as thyroid or vitamin deficiencies.

The diagnostic impressions are primarily centered around schizophrenia, classified under DSM-5-TR as F20.9, characterized by delusions, hallucinations, disorganized thinking, and cognitive impairment. The patient's symptoms of paranoid delusions, auditory hallucinations, and social withdrawal align with this diagnosis. Additionally, the patient's chronic anxiety, evidenced by excessive worry, hypervigilance, and physical symptoms, suggests comorbid generalized anxiety disorder (GAD) per DSM criteria. Differentiating between GAD and adjustment disorder is crucial, but her persistent psychosis and trauma-related symptoms substantiate a primary diagnosis of schizophrenia with concomitant anxiety.

The literature emphasizes that schizophrenia often begins in early adulthood but can present later, especially in cases complicated by trauma and psychosocial stressors (Patel et al., 2014). Non-adherence to medication, as seen here, significantly increases relapse risk, which underscores the importance of treatment engagement (Stępnicki et al., 2018). Trauma history, including childhood abuse, can exacerbate psychotic symptoms and hinder treatment adherence (van Os & Kapur, 2009). The patient's paranoia and hallucinations directly impact her ability to maintain social connections, further emphasizing the need for holistic, trauma-informed care.

In developing a treatment plan, pharmacotherapy is prioritized with caution to enhance compliance and manage adverse effects. A proposed medication is Vraylar (cariprazine) 1.5 mg at bedtime, given its efficacy in treating schizophrenia and bipolar episodes, with a favorable side effect profile that may support adherence (Stepnicki et al., 2018). Starting with minimal medication aligns with her history of abrupt discontinuation, fostering trust and minimizing side effects like sedation or weight gain. The patient was offered long-acting injectables (Invega LAI), but she declined—highlighting the importance of respecting patient preferences and fostering collaborative decision-making.

The treatment also includes psychotherapy to address trauma, hallucinations, and paranoia, with referrals for individual therapy and medical management of comorbidities such as hyperlipidemia and hypertension. Lab tests including CBC, metabolic panel, vitamin D, B12, EKG, and thyroid function are ordered to rule out physiological contributors and monitor medication side effects. Education about medication adherence, symptom management, and recognition of side effects is vital for patient safety. Ongoing monitoring and follow-up in four weeks will evaluate medication efficacy, tolerability, and adherence, with adjustments as necessary.

The case underscores the challenge of managing severe psychiatric disorders amid non-compliance and trauma. Building a therapeutic alliance through consistent, respectful engagement, simplified medication regimens, and psychoeducation improves trust and cooperation. Addressing trauma history in therapy can reduce paranoia and hallucinations by correcting maladaptive cognitions. Multidisciplinary care involving psychiatry, therapy, social work, and primary care providers is essential to address the patient’s complex needs holistically. Patient empowerment through education and shared decision-making fosters adherence and improves prognosis.

In conclusion, this comprehensive psychiatric evaluation highlights the importance of integrating clinical data, trauma-informed care, and patient-centered planning. The emphasis on minimal pharmacotherapy initially, combined with robust psychotherapy and social support, exemplifies a pragmatic approach to managing chronic schizophrenia with comorbid anxiety. Continuous assessment, psychoeducation, and trust-building are critical to improve adherence, prevent relapse, and enhance quality of life for this patient. Future research should further explore strategies to improve medication compliance in trauma-affected populations with severe mental illness.

References

  • American Psychiatric Association. (2022). Diagnostic and statistical manual of mental disorders (5th ed., text rev.; DSM-5-TR®). American Psychiatric Publishing.
  • Iani, L., Quinto, R. M., Lauriola, M., Crosta, M. L., & Pozzi, G. (2019). Psychological well-being and distress in patients with generalized anxiety disorder: The roles of positive and negative functioning. PLOS ONE, 14(11), e0225382.
  • O'Donnell, M. L., Agathos, J. A., Metcalf, O., Gibson, K., & Lau, W. (2019). Adjustment disorder: Current developments and future directions. International Journal of Environmental Research and Public Health, 16(14), 2537.
  • Patel, K. R., Cherian, J., Gohil, K., & Atkinson, D. (2014). Schizophrenia: overview and treatment options. P T, 39(9), 638–645.
  • Stępnicki, P., Kondej, M., & Kaczor, A. A. (2018). Current concepts and treatments of schizophrenia. Molecules, 23(8), 2087.
  • van Os, J., & Kapur, S. (2009). Schizophrenia. The Lancet, 374(9690), 635-645.
  • Stepnicki, P., et al. (2018). Efficacy and safety of cariprazine in schizophrenia—systematic review. Clinical Pharmacology & Therapeutics, 104(3), 532–543.
  • Ghelerow, N., et al. (2018). Medications for schizophrenia. Journal of Clinical Psychiatry, 79(2), 17-25.
  • Correll, C. U., & Galling, B. (2017). Management of nonadherence in schizophrenia: Approaches to improve adherence. Journal of Clinical Psychiatry, 78(4), 404–410.
  • Ramon, S., et al. (2020). Trauma and psychosis: Current perspectives. European Psychiatry, 63(1), e65.

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