Nrnpprac 6665 6675 Comprehensive Focused Soap Psychiatric

Nrnpprac 6665 6675 Comprehensive Focused Soap Psychiatricevaluation

Perform a comprehensive focused SOAP psychiatric evaluation report for a patient presenting with psychiatric issues. Include subjective data, objective data, diagnostic impression, treatment plan, and reflection sections. The report should be detailed, approximately 3 to 5 pages in length, and demonstrate an understanding of psychiatric assessment, diagnoses, and treatment planning based on clinical data provided. Incorporate relevant literature and references to support diagnostic reasoning and treatment strategies.

Paper For Above instruction

The psychiatric evaluation process is a critical component in diagnosing and formulating an effective treatment plan for patients presenting with complex mental health issues. In this comprehensive assessment, the evaluation focuses on a 58-year-old female patient with a history of psychosis, paranoia, non-compliance with medication, and multiple psychiatric hospitalizations. The detailed subjective and objective data, diagnostic impressions, and treatment plan are paramount in addressing her needs and managing her condition effectively.

Introduction

This evaluation aims to synthesize the clinical information to establish an accurate diagnosis and formulate an appropriate treatment plan. The patient’s history, current presentation, mental status examination, and relevant medical data are analyzed to determine the most fitting diagnoses based on DSM-5 criteria. The goal is to create a patient-centered, minimally invasive treatment approach, considering her history of non-compliance and multifaceted psychiatric issues.

Subjective Data

The client, a 58-year-old African American female, reports a recent episode where she ran out of her medications after switching providers. She expresses ongoing concerns about sleep disturbances characterized by interrupted sleep and difficulty maintaining sleep. She reports fair concentration, occasional agitation, and irritability. The patient experiences low energy, fatigue, and difficulty completing tasks without interruption, often feeling overwhelmed and stressed by her son, whom she describes as a “narcissist”. She reveals multiple suicide attempts and hospitalizations related to her feelings of despair. Despite these, she denies current suicidal plans or intent but admits to persistent suicidal thoughts.

The patient endorses symptoms of psychosis and mania, with hallucinations and delusional thoughts evident during interview. She describes paranoia, fearing harm from others, and visual images of people staring at her in her sleep. Her trauma history is significant, including verbal, physical, and sexual abuse during childhood and adulthood, leading to flashbacks, nightmares, hypervigilance, and avoidant behaviors. She reports discomfort in social settings, palpitations, sweating, trembling, and panic in crowds or unfamiliar environments. Her mental health is complicated by her substance use—smoking a pack of cigarettes daily, caffeinating regularly, and alcohol use holidays, though recent abstinence is noted.

Objective Data

The mental status examination reveals a well-groomed, age-appropriate appearance with fleeting eye contact. Her mood is described as dysthymic, anxious, and labile, with affect congruent. Speech is sometimes pressured. Thought process is normal but occasionally illogical. Thought content reveals paranoia, ruminations, and hallucinations—specifically auditory hallucinations and delusional paranoid ideas. Insight is poor, and judgment is fair. The patient’s laboratory results are pending, with blood tests ordered to evaluate her physical health, including CBC, metabolic panel, thyroid function, and vitamin levels.

Diagnostic Impression

Based on the clinical presentation, the primary diagnosis is F20.9 Schizophrenia. This diagnosis is supported by hallucinations, delusions, disorganized thinking, and impaired functioning consistent with DSM-5 criteria. Her history of multiple hospitalizations, non-compliance, and paranoid thoughts align with chronic schizophrenia. Additionally, the patient's symptoms suggest comorbid generalized anxiety disorder (GAD), characterized by excessive, uncontrollable worry, sleep disturbances, irritability, and hypervigilance. Her trauma history and avoidant behaviors further complicate her psychiatric profile, although these do not meet criteria separately but influence her overall functioning. Adjustment disorder may be considered but is less likely as her symptoms include psychosis and delusions that extend beyond typical response to stress.

Treatment Plan

The treatment approach emphasizes building trust and ensuring medication adherence while minimizing side effects to improve compliance. The primary medication prescribed is Vraylar (cariprazine) 1.5 mg at bedtime, targeting schizophrenia and potentially mitigating negative symptoms. The choice of a single agent aims to foster trust and reduce polypharmacy risks. Patients are educated on side effects such as sedation, weight gain, and akathisia, with instructions to report adverse effects promptly.

Given her reluctance towards long-acting injectables, the plan includes close follow-up in 21 days, with a reassessment of medication efficacy and tolerability. Additional psychotherapeutic referrals are arranged for individual therapy to address trauma, paranoia, and coping skills. Family involvement is considered, especially to support medication adherence and social functioning.

Laboratory investigations include CBC, metabolic panel, vitamin D and B12 levels, and an EKG to monitor cardiac status due to her history of palpitations and blood clots. Thyroid function tests are ordered, given the overlapping symptoms of fatigue and mood disturbances. Future medication adjustments may include adding anxiolytics or mood stabilizers if symptoms persist. A multidisciplinary approach is essential, integrating psychiatric, medical, and counseling services.

Reflection

This case highlights the complexity of managing chronic psychosis with comorbid trauma and anxiety. Poor medication adherence remains a significant barrier. Establishing rapport through minimal medication and a focus on trust can facilitate compliance. The importance of psychoeducation, trauma-informed care, and regular follow-up cannot be overstated. Recognizing the patient’s past trauma influences her paranoid and avoidant behaviors, guiding the clinician to adopt a compassionate, patient-centered approach. Collaborating with mental health specialists and providing consistent support can reduce relapse risk and enhance quality of life.

Conclusion

This evaluation underscores the importance of an integrated approach to psychiatric care that combines pharmacological management with psychotherapy and social support. Accurate diagnostic assessment, ongoing monitoring, patient education, and therapeutic alliance are essential for achieving positive outcomes in patients with complex psychiatric profiles. Future research should focus on enhancing adherence to treatment among such populations while addressing underlying trauma and social determinants of health.

References

• American Psychiatric Association. (2022). Diagnostic and statistical manual of mental disorders (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).
• 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.
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