Schizophrenia - Psychiatry Case Presentation

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Psychiatry Case Presentation Candice Reyes, MS III Pacific Hospital of Long Beach

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Week 5: Focused SOAP Note and Patient Case Presentation College of Nursing-PMHNP, Walden University NRNP 6675: PMHNP Care Across the Lifespan 2 Practicum Introduction Psychosis is a mental condition in which a person's ideas and perceptions are disrupted, and the individual may have difficulty distinguishing between what is real and what is not. A health condition, medications, or drug usage can all contribute to psychosis. Delusions, hallucinations, incomprehensible speech, and agitation are all possible signs; the patient has incorrect beliefs and sees or hears things that others do not see or hear. The person suffering from the disease is usually unaware of his or her actions. Medication, psychotherapy, peer support, family support and education, and talk therapy are all options for treatment. More or less every mental intervention is backed by evidence accumulated during the patient's initial interview; each patient's therapy begins with a thorough medical and mental health evaluation, the incorporation of trust, and a discussion of past mental health history, substance misuse history, family mental health history, and so on. In this example, the patient's evaluation was documented, and a diagnosis was made based on the information collected from the patient during the evaluation. When the case was being developed, a therapeutic approach was designed. The patient is a 53- year-old Caucasian male who was scheduled for an initial screening for a psychotic disorder after his sister recommended a visit to the psychiatrist because patient's behavior changed since the mother passed away. Patient Initial: S.T Age: 53 Gender: Male Subjective Data: CC: "I was brought here by my sister because since my mother passed away, I was living on my own and not bothering anyone. Those people outside my window they are after me. They just want me dead". HPI: When patient was asked " what people?". Patient said " the government sent them to get me because my taxes are high". Suddenly patient asked the provider if she can see the birds or hear any loud noise. The provider responded by redirecting the patient that she does not hear any voice or see anything. When the provider how long he is been hearing the voices or seeing things, patient said " for weeks, weeks and weeks". Patient also said the sister tapped her phone with the government. When asked about sleep, patient said " I have not slept well because the voices keep me up for days. I try to watch the TV, they poison my food on TV, I locked everything down in the fridge". Suddenly patient asked " Can I smoke?". Provider said "no you can't smoke here". Patient admit that he smokes all day about 3 packs a day. Drinks alcohol which his sister purchased for him to last him for weeks. Patient denies use of drugs. Admit to history of marijuana use 3 years ago before the m ...

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Running head: ASSIGNMENT 2: PRACTICUM – ASSESSING CLIENTS 1 10 ASSIGNMENT 2: PRACTICUM – ASSESSING CLIENTS Assignment 2: Practicum – Assessing Clients Part 1: Comprehensive Client Family Assessment Demographic information: T.C is a 73 years old African American male who was admitted after being discharged from another local hospital. Presenting problem: The patient’s present problem is increased psychosis with auditory hallucination (AH). History or present illness: The patient has a history of multiple hospitalizations, of which he refused to give further details. He was however diagnosed with increased psychosis with auditory hallucination and reports of being capable of hurting himself and others. He was planning to harm himself with an ice pick on the neck. He claims that he has been having auditory hallucinations telling him to harm himself. He was unable to state the onset of the symptoms of the presenting illness. He was not cooperating with the clinician. Past psychiatric history: The patient has a history of multiple hospitalizations, which he refused to discuss further. Diagnoses: Chronic mental illness Suicidal gestures or attempts: None Medical history: Cerebrovascular accident (CVA), Hypertension (HTN), chronic obstructive pulmonary disease(COPD), Seizure, Congestive heart failure (CHF). Surgical history: None Allergies: No known drug allergies Current Medication: · Aspirin oral 81 mg TC, PO daily for the management of CAD · Rivaroxaban oral 10mg tablets PO daily for the management of CAV/MI Substance use history: The patient claims to be using cocaine as much as he can, once a month. He claims to have started using the drug when he was 19 years old. He, however, refused to give the last day that he used the drug. He also smokes marijuana once a day and started using it when he was 17 years old. He smokes cigarettes at least 3 to 4 times a day. Developmental history: The patient is a 73-year-old African American male. He is homeless. He is a Christian. His past daily activities include playing soccer and taking an active role in community services. All his early motor, social, language in addition to emotional milestones were within normal limits before being diagnosed with a psychological disorder. Family psychiatric history: Negative family psychiatric history. There is no known history of any of the family members suffering from any psychiatric disorder, or under psychiatric medications or hospitalization. No other family member has ever displayed suicidal behavior or substance abuse. Psychosocial history: The patient has a history of chronic mental illness and is non-compliant to medical treatment. History of abuse/trauma: The patient has no reported history of abuse or trauma. Review of systems: General: No weight change, generally appears to be confused. He presented with poor insight and unable to respond to most questions during an assessment. He does not exercise as much as he used to. Sk ...

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Initial Psychiatric Interview/SOAP Note Template Criteria Clinical Notes Informed Consent Informed consent given to patient about psychiatric interview process and psychiatric/psychotherapy treatment. Verbal and Written consent obtained. Patient has the ability/capacity to respond and appears to understand the risk, benefits, and (Will review additional consent during treatment plan discussion) Subjective Verify Patient Name: Susan DOB: not provided Minor: NA Accompanied by: self Demographic: NA Gender Identifier Note: Female CC: “I have been feeling anxious, depresssed, high blood pressure, irregular heartbeat, elevated body temperature, crying spells for the last 2 days” . HPI: Susan is a midde aged woman who reports to the healthcare clinic reporting several symptoms that she has observed over the period of the last two days. She reports having high blood pressure, an irregular heartbeat, depression, anxiety, and an increase in body temperature. Susan doesn't realize that she shows signs of alcohol dependence and physiological dependence, which downplays the seriousness of her alcohol usage. This diagnosis is supported by the withdrawal symptoms that appear to be becoming more tolerable as well as by the sustained and increased alcohol consumption despite the harm it does to social interactions and job performance. She has also increased her alcohol consumption to ease withdrawal symptoms. s He has a history of drinking, which has caused him to skip work and even get arrested. She downplays her alcohol consumption and justifies how often and how much she drinks. Pertinent history in record and from patient: Alcohol withdrawal During assessment: Patient is cam and corparative Patient seemed to be suffering from serious cases of both anxiety and despair judging from her crying spells. Patient denies hallucinating. The patient has nomal thought process. . SI/ HI/ AV: patient denies signs of suicidal ideation and violent behavior. Allergies: NKDFA. (medication & food) Past Medical Hx: Medical history: Denies cardiac, respiratory, endocrine and neurological issues, including history head injury. Patient denies history of chronic infection, including MRSA, TB, HIV and Hep C. Surgical history no surgical history reported Past Psychiatric Hx: Previous psychiatric diagnoses: NKDA Describes stable course of illness. Previous medication trials: not reported Safety concerns: History of Violence to Self:none reported History of Violence t o Others: none reported Auditory Hallucinations: not reported Mental health treatment history discussed: History of outpatient treatment: not reported Previous psychiatric hospitalizations: not reported Priorsubstance abuse treatment: not reported Trauma history: Client reveals no history of traumatic experiences (such as abuse, domestic violence, or exposure .

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Give an example from your own experience or research an article or the media in which a business executive did something of significance that is morally right. Use APA format to cite your material from your sources. Is there a relationship between obesity and socio-economic status? Should obese people be considered a protected class under Title VII of the Civil Rights Act? 1: 2: 3. 4. 5. Comprehensive SOAP Exemplar Purpose: To demonstrate what each section of the SOAP Note should include. Remember that nurse practitioners treat patients in a holistic manner, and your SOAP Note should reflect that premise. Patient Initials: _______ Age: _______ Gender: _______ SUBJECTIVE DATA: Chief Complaint (CC): Coughing up phlegm and fever History of Present Illness (HPI): Sara Jones is a 65-year-old Caucasian female who presents today with a productive cough x 3 weeks and fever for the last 3 days. She reported that the “cold feels like it is descending into her chest.” The cough is nagging and productive. She brought in a few paper towels with expectorated phlegm – yellow/brown in color. She has associated symptoms of dyspnea of exertion and fever. Her Tmax was reported to be 102.4 last night. She has been taking Ibuprofen 400mg about every 6 hours and the fever breaks, but it returns after the medication wears off. She rated the severity of her symptom discomfort at 4/10. Medications: 1.) Lisinopril 10mg daily 2.) Combivent 2 puffs every 6 hours as needed 3.) Serovent daily 4.) Salmeterol daily 5.) Over-the-counter Ibuprofen 200mg -2 PO as needed 6.) Over-the-counter Benefiber 7.) Flonase 1 spray each night as needed for allergic rhinitis symptoms Allergies: Sulfa drugs - rash Past Medical History (PMH): 1.) Emphysema with recent exacerbation 1 month ago – deferred admission – RX’d with outpatient antibiotics and hand held nebulizer treatments. 2.) Hypertension – well controlled 3.) Gastroesophageal reflux (GERD) – quiet, on no medication 4.) Osteopenia 5.) Allergic rhinitis Past Surgical History (PSH): 1.) Cholecystectomy 1994 2.) Total abdominal hysterectomy (TAH) 1998 Sexual/Reproductive History: Heterosexual G1P1A0 Non-menstruating – TAH 1998 Personal/Social History: She has smoked 2 packs of cigarettes daily x 30 years; denied ETOH or illicit drug use. Immunization History: Her immunizations are up to date. She received the influenza vaccine last November and the Pneumococcal vaccine at the same time. Significant Family History: Two brothers – one with diabetes, dx at age 65, and the other with prostate CA, dx at age 62. She has one daughter in her 30s, healthy, living in nearby neighborhood. Lifestyle: She is retired, has been widowed x 8 years, and lives in the city in a moderate crime area with good public transportation. She is a college graduate, owns her home, and receives a pension of $50,000 annually – financially stable. She has a primary care nurse practitioner provider and goes for annual and r ...

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