Focused Soap Note For Anxiety Ptsd And OCD

Focused Soap Note For Anxiety Ptsd And OCD

Subjective:

CC (chief complaint): The patient (Sherman Tremaine) claims that individuals are watching him outside his window. According to him, he can hear them and see their shadows.

HPI: Sherman Tremaine was born on November 3, 1968. He complains primarily about being monitored outside his window. The patient claims to be able to hear and see the shadows of people outside his window. The patient’s mother passed away while she was still living with him. The patient said the government had sent the people to watch him. His taxes have increased as a result of this. According to the patient, he has been seeing these people for a while. The patient claims to have seen and heard an imaginary bird and heavy metal music while speaking with Dr. Moore. Additionally, loud sounds have been the source of the patient’s insomnia. Every day, Sherman smokes three packs. He admits to drinking alcohol. He claims that his sister purchases him a 12-pack weekly. Three years have passed since Sherman last smoked marijuana. He claims to never have used cocaine. Additionally, he has never experienced seizures, blackouts, or hallucinations induced by drugs. The patient wants to quit taking his prescriptions because he believes they are toxins. Risperidone, Seroquel, Haldol, and Thorazine are some of the drugs that the patient has been taking. Sherman’s family history shows that his mother experienced anxiety while his father had paranoid schizophrenia. The patient does not have suicide ideas, and his family has not reported any incidents either. The patient is using Metformin to manage diabetes mellitus. The patient claims that his father treated them harshly up to his death.

Substance Current Use: Sherman smokes three packs daily. Furthermore, he drinks a 12-pack every week.

Medical History:

Current Medications: Metformin for diabetes mellitus. He reports having stopped taking Risperidone, Seroquel, Haldol, and Thorazine because he believes that they are poisons due to their adverse effects.

Allergies: No known drug and food allergies.

Reproductive Hx: No pertinent history

ROS:

GENERAL: No fever, chills, malaise, or weakness.

HEENT: Normocephalic, no blurred vision, no retinal edema, no diplopia, no conjunctivitis, no hearing impairment, no nasal congestion or rhinorrhea, no pharyngitis or exudate.

SKIN: no bruising, pruritus, or ulcers. Normal turgor without rashes.

CARDIOVASCULAR: No arrhythmia, hypertension, or heart gallops.

RESPIRATORY: No respiratory distress, shortness of breath, or dyspnea.

GASTROINTESTINAL: No nausea, vomiting, diarrhea, or constipation.

GENITOURINARY: No discharge, masses, dysuria, nocturnal enuresis, or polyuria.

NEUROLOGICAL: No headache, syncope, or ataxia. Normal proprioception.

MUSCULOSKELETAL: No arthritis, myositis, or myalgia. Normal range of motion.

HEMATOLOGIC: No anemia, leukocytosis, or leukopenia.

LYMPHATICS: normal lymphatic drainage and distribution.

ENDOCRINOLOGIC: insulin resistance due to diabetes mellitus, no hyperhidrosis.

Objective:

Diagnostic results: The patient is well-oriented to time and placed in time and space. He participates in the interview and answers the questions correctly. However, the patient demonstrates disorganized speech and auditory and visual hallucinations. In this scenario, laboratory tests are not necessary.

Assessment:

Mental Status Examination: The patient’s physical characteristics match his reported age. He answers all of the examiner’s questions cooperatively. He displays circumstantiality. Furthermore, the patient experiences auditory and visual hallucinations, as evidenced by his sighting and hearing of an imaginary bird and music. Additionally, the patient demonstrates disorganized speech.

Diagnostic Impression: Three potential diagnoses can be developed for this patient: schizophreniform disorder, paranoid schizophrenia, and schizoaffective disorder. In this context, the patient presents with disorganized speech and auditory and visual hallucinations. According to the DSM-5-TR, a patient with paranoid schizophrenia should present with at least two symptoms identified by the diagnostic criteria (Florida Medicaid Mental Health.org, 2019). The symptoms should be present for more than six months. Additionally, there must be symptoms for at least one month throughout the preceding six months. These symptoms include delusions, hallucinations, disorganized speech, catatonic behavior, and avolition (Florida Medicaid Mental Health.org, 2019). Patients with paranoid schizophrenia experience persecutory and paranoid delusions. They are likely to believe that close relatives are out to harm them or that they are being targeted by federal agencies (Florida Medicaid Mental Health.org, 2019). In the context of Sherman Tremaine, his symptoms are harmonious with this diagnostic criteria. Notably, the patient has visual and auditory hallucinations and displays paranoid delusions. He believes his sister has collaborated with government officials to tap his phone. As such, Sherman Tremaine has paranoid schizophrenia.

According to the DSM-5-TR, a patient with the schizophreniform disorder should present with symptoms lasting between 1 and 6 months. These symptoms include delusions, hallucinations, disorganized speech, avolition, and disorganized behavior (Khan & Dankha, 2021). The duration of the symptoms should be less than six months for a definitive diagnosis to be made (Khan & Dankha, 2021). I ruled out this diagnosis because the patient’s symptoms have been present for more than six months.

According to the DSM-5-TR, a patient with schizoaffective disorder should display a manic or depressive episode and at least two other symptoms that meet the diagnostic criteria of schizophrenia (Joshua & Saadabadi, 2022). These other symptoms include delusions, hallucinations, disorganized speech and behavior, and avolition (Joshua & Saadabadi, 2022). These symptoms should be present for at least one month. Furthermore, the episode of major depression should entail a depressed mood. The manifestations of manic or depressive episodes should be present during the prodromal and residual phases (Joshua & Saadabadi, 2022). I ruled out this diagnosis because the patient did not report any manic or depressive episodes.

I selected paranoid schizophrenia as the primary diagnosis for Sherman Tremaine because his symptoms are harmonious with the DSM-5-TR diagnostic criteria for paranoid schizophrenia. The patient displays paranoid delusions, as evidenced by the belief that his sister and the government are out to harm him. In addition, the patient has auditory and visual hallucinations.

Reflections: If I could redo the session, I could emphasize comprehensive history taking. This would address aspects such as a more specific time of onset of the symptoms. This would be necessary to rule out some differential diagnoses, such as schizophreniform disorder. Additionally, I would have considered ordering tests to rule out other conditions. For example, brain imaging would help to rule out brain tumors. Furthermore, I would collaborate with members of the interdisciplinary team to evaluate the prognosis of the patient’s diabetes mellitus. This is relevant because poorly managed diabetes mellitus is associated with both microvascular and macrovascular complications. If I followed up with the patient, I would evaluate his response to treatment. This would reveal the levels of adherence to the treatment plan and the effectiveness of the chosen treatment plan. This consideration is important because it can facilitate modification of the treatment plan or emphasize the relevance of adherence to it. It also provides an opportunity to monitor certain drugs’ toxicity profiles, including the possibility of allergies or significant adverse effects. I would embrace beneficence and nonmaleficence when dealing with the patient. To achieve this, I would select the best evidence-based treatment plans for the patient. I would embrace justice by avoiding prejudices, stereotypes, and discriminatory actions towards the patient. For example, I would ensure that the patient and his family receive comprehensive education on paranoid schizophrenia and the importance of adherence to the treatment plan.

Case Formulation and Treatment Plan:

Sherman Tremaine can be managed using both pharmaceutical and non-pharmaceutical approaches. Pharmaceutical approaches for this patient entail antipsychotic drugs, Serotonin-Dopamine Activity Modulators, benzodiazepines, and oral hypoglycemic medications for diabetes mellitus. The patient should be educated on the anticipated adverse events caused by antipsychotic medications. For example, first-generation antipsychotic agents are associated with extrapyramidal side effects and neuroleptic malignant syndrome (Maroney, 2020). On the other hand, second-generation antipsychotic agents are associated with a high incidence of metabolic dysfunctions, including weight gain (Maroney, 2020). In this scenario, second-generation antipsychotic agents such as clozapine, lurasidone, and iloperidone will be used (McCutcheon et al., 2020). Regular follow-ups will be conducted to avoid worsening diabetes mellitus because second-generation antipsychotics have adverse metabolic effects. Significant metabolic adverse effects will warrant treatment modification to first-generation antipsychotics such as fluphenazine and perphenazine (Maroney, 2020). Similarly, anticholinergic agents such as benztropine and trihexyphenidyl will be used to counter extrapyramidal side effects caused by first-generation antipsychotics (Maroney, 2020). Other than antipsychotic agents, serotonin dopamine activity modulators such as brexpiprazole will be used (Maroney, 2020).

McCutcheon et al. (2020) report that non-pharmaceutical approaches embrace strategies such as cognitive remediation, transcranial magnetic stimulation, and social recovery therapy. Other approaches include cognitive behavioral therapy and individual therapy (McCutcheon et al., 2020). Members of the interdisciplinary team will facilitate patient education. This will address the importance of quitting smoking and drinking and the impact of a sedentary lifestyle. The patient will be reviewed monthly to evaluate his progress and response to treatment. The interdisciplinary team involved in the management of the patient will comprise nurses, dieticians, physicians, and pharmacists.

 References

Florida Medicaid Mental Health.org. (2019). DSM-5 Criteria: Schizophrenia. https://floridabhcenter.org/wp-content/uploads/2021/03/Pages-2019-Psychotherapeutic-Medication-Guidelines-for-Adults_Schizophrenia_06-04-20.pdf

Joshua, T. P., & Saadabadi, A. (2022). Schizoaffective Disorder. https://www.ncbi.nlm.nih.gov/books/NBK541012/#:~:text=The%20specific%20DSM%2D5%20 criteria,episode%20must%20include%20depressed%20mood.

Khan, S., & Dankha, M. (2021). Schizophreniform Disorder after Onset of Menopause. Open Journal of Psychiatry, 11(04), 215–218. https://doi.org/10.4236/ojpsych.2021.114017

Maroney, M. (2020). An update on current treatment strategies and emerging agents for the management of schizophrenia. American Journal of Managed Care, 26(3), S55–S61. https://doi.org/10.37765/AJMC.2020.43012

McCutcheon, R. A., Reis Marques, T., & Howes, O. D. (2020). Schizophrenia – An Overview. JAMA Psychiatry, 77(2), 201–210. https://doi.org/10.1001/jamapsychiatry.2019.3360

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Develop a focused SOAP note, including your differential diagnosis and critical-thinking process to formulate a primary diagnosis. Incorporate the following into your responses in the template:

Subjective: What details did the patient provide regarding their chief complaint and symptomology to derive your differential diagnosis? What is the duration and severity of their symptoms? How are their symptoms impacting their functioning in life?
Objective: What observations did you make during the psychiatric assessment?
Assessment: Discuss the patient’s mental status examination results. What were your differential diagnoses? Provide a minimum of three possible diagnoses with supporting evidence, and list them in order from highest priority to lowest priority. Compare the DSM-5-TR diagnostic criteria for each differential diagnosis and explain what DSM-5-TR criteria rule out the differential diagnosis to find an accurate diagnosis. Explain the critical-thinking process that led you to the primary diagnosis you selected. Include pertinent positives and pertinent negatives for the specific patient case.
Plan: What is your plan for psychotherapy? What is your plan for treatment and management, including alternative therapies? Include pharmacologic and nonpharmacologic treatments, alternative therapies, and follow-up parameters, as well as a rationale for this treatment and management plan. Also, incorporate one health promotion activity and one patient education strategy.
Reflection notes: What would you do differently with this patient if you could conduct the session again? Discuss what your next intervention would be if you were able to follow up with this patient. Also, include in your reflection a discussion related to legal/ethical considerations (demonstrate critical thinking beyond confidentiality and consent for treatment!), health promotion, and disease prevention, taking into consideration patient factors (such as age, ethnic group, etc.), PMH, and other risk factors (e.g., socioeconomic, cultural background, etc.).
Provide at least three evidence-based, peer-reviewed journal articles or evidenced-based guidelines that relate to this case to support your diagnostics and differential diagnoses. Be sure they are current (no more than 5 years old).