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see attachment. Need 2 different short responses from this case. Either agree to the diagnosis or add more information to it. Add 1 or 2 references to it.
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Week 4: Complex Case Study Presentation
Subjective:
CC (chief complaint): “I have been hearing voices and seeing someone talking to me, then
disappeared.”
HPI: J.A. is a 75-year-old Haitian female patient who was referred from another facility for
worsening hallucinations and delusions. Her family reports that the patient argued with a family
member two weeks ago. Since then, she has not been herself.The patient reports that about
two weeks before the admission, she could not sleep; she started hearing voices saying
something to her and then vanishing. She also reports feeling things walking in her body. During
the psychiatric assessment, the patient was disorganized and verbalized that they just killed her
son, and she was here in prison because of the disagreement she had with someone. The
patient denies any previous psychiatric hospitalizations.The patient has a medical history of
HTN, previous thyroidectomy in 1997. She denies any drug or alcohol use. Her urine toxicology
was negative.
Substance Current Use: The patient denied any drug or alcohol use.
Psychosocial history: The patient was born and raised in Haiti. She came to the US eight
years ago. She lives with close relatives. She is single, never married, has three children, and is
unemployed. She depends financially on his son. She never attended school. She denied any
current legal problems.
Medical History: She had no previous psychiatric hospitalizations and had never been been on
any psychotropic drugs. However, the patient had a medical history of HTN, thyroidectomy
(1997),
NRNP/PRAC 6665 & 6675 Comprehensive Focused SOAP Psychiatric
Evaluation Template
•
Current Medications: Levothyroxine 50mcg oral daily, amlodipine 5mg oral daily
•
Allergies: NKDA
•
Reproductive Hx: The patient is single and not sexually active. However, she has three
children via vaginal birth for the same father.one son of 50-year old, two daughters of
42-year-old and 35-year-old. She never used any contraceptive method.
ROS:
•
GENERAL: The patient is disheveled. No weight loss, fatigue, fever, chills, or weakness
•
HEENT: No double, blurred, or loss in vision or yellow sclera. Ears,
Nose, Throat: No hearing loss, sneezing, rhinorrhea, nasal congestion, or sore throat.
•
SKIN: No rash or itching.
•
CARDIOVASCULAR: No chest pain or chest discomfort, no palpitations or edema.
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RESPIRATORY: No difficulty in breathing, shortness of breath, no coughing, or sputum.
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GASTROINTESTINAL: No nausea, vomiting, diarrhea, anorexia, or lack of appetite. No
abdominal pain or blood in the feces.
•
GENITOURINARY: No burning during urination, urgency, hesitancy, or malodorous
discharge.
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NEUROLOGICAL: No syncope, dizziness, headache, paralysis, numbness, or tingling in
the extremities. No change in bowel or bladder function.
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MUSCULOSKELETAL: No back pain, joint pain, muscle pain, or stiffness.
•
HEMATOLOGIC: No anemia, bleeding, or bruising
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LYMPHATICS: No history of splenectomy. No enlarged nodes.
•
ENDOCRINOLOGIC: Hypothyroidism due to thyroidectomy: The patient is on
levothyroxine. No reports of heat or cold intolerance. No profuse sweating, excessive
thirst, or urination.
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NRNP/PRAC 6665 & 6675 Comprehensive Focused SOAP Psychiatric
Evaluation Template
Objective:
Vital Signs: BP 138/83, P 88, R 19, T 98.1F, Height 5’ 6”; Weight 135lbs.
Diagnostic results: Chest X-Ray: normal; CT-Scan Head: normal.
Labs: T3 level: normal; Free T4 level: normal; TSH: 5.730 elevated. Urine toxicology is
negative. CBC and BMP are normal.
Assessment:
Mental Status Examination:
The patient appears appropriate to the stated age. She is disheveled. Cooperative
during the psychiatric assessment. She is alert and oriented to person but not to place and time.
Mood is irritable. Affect is flat. Motor activity is restless. Speech is impoverished. Thought
Process: blocking. Thought Content: She verbalized persecutory delusion and auditory/visual
hallucinations. She denies suicidal or homicidal ideations. Insight and judgment are poor. During
a mini-mental examination, the patient could recall three unrelated objects after five minutes,
and she could draw the clock correctly.
Diagnostic Impression:
Schizophrenia
Witkowski (2023) defines schizophrenia as a mental disorder characterized by
delusions, hallucinations, and disorganized speech in thought content. Following the diagnostic
criteria for schizophrenia outlined in the DSM-5-TR by the American Psychiatric Association
(2022), a minimum of two of the following symptoms is required: delusions, hallucinations, or
disorganized speech, along with grossly disorganized or catatonic behavior, and negative
symptoms, each persisting for at least one month or less if effectively treated. At least one of
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NRNP/PRAC 6665 & 6675 Comprehensive Focused SOAP Psychiatric
Evaluation Template
these must be delusions, hallucinations, or disorganized speech. The patient in question
expresses persecutory delusions, claiming that someone has recently killed her son. She also
describes auditory and visual hallucinations, hearing voices talking to her and seeing an
individual in the window conveying that her son is deceased and then disappearing. All these
psychotic symptoms align with the diagnostic criteria for schizophrenia as per the DSM-5-TR.
That is why I choose Schizophrenia as the definitive impression diagnosis.
Schizoaffective disorder
As outlined by Lintunen et al. (2021), schizoaffective disorder is marked by symptoms
akin to schizophrenia, such as hallucinations and delusions, coupled with affective
manifestations like major depression or mania. According to the American Psychiatric
Association (2022), the DSM5-TR diagnostic criteria for schizoaffective disorder involve periods
in which major depressive episodes coincide with active phase symptoms of schizophrenia.
Delusions or hallucinations should persist for at least two weeks in the absence of a major
depressive episode, and major depressive episodes should be prevalent for the majority of the
overall duration of the illness. In the case under consideration, the patient did not exhibit or
report any major mood episodes concurrent with her delusions and hallucinations despite
mentioning difficulty sleeping. The patient maintained a healthy appetite, showed no signs of
anhedonia, and reported no fatigue, loss of energy, feelings of worthlessness, or guilt. Due to
the absence of those criteria, I ruled out schizoaffective disorder.
Major Depressive Disorder with Psychotic Features
Major depressive disorder (MDD) with psychotic features is a subtype of depression
linked to a heightened suicide risk, particularly prevalent in older individuals with MDD. Adults
experiencing MDD with psychotic features, including delusions and hallucinations, often exhibit
more severe symptoms, have a less favorable prognosis, face an increased risk of relapse, and
encounter a higher mortality rate (Kehinde et al., 2022). MDD is characterized by the presence
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NRNP/PRAC 6665 & 6675 Comprehensive Focused SOAP Psychiatric
Evaluation Template
of at least one major depressive episode, excluding a history of manic or hypomanic episodes.
A crucial aspect of a major depressive episode involves a minimum two-week duration during
which the individual experiences either a depressed mood or a loss of interest or pleasure in
almost all daily activities. Psychotic symptoms, specifically delusions or hallucinations, must be
present along with at least four additional symptoms, such as changes in appetite or weight,
sleep patterns, and psychomotor activity; decreased energy; feelings of worthlessness or guilt;
difficulties in thinking or concentrating; and thoughts of death and suicidal ideation (American
Psychiatric Association, 2022). In the case of J.A., who presented with psychotic symptoms but
denied symptoms of major depressive episodes or a depressed mood, Major Depressive
Disorder with psychotic features was ruled out based on these facts.
Reflections:
A 75-year-old female patient without a previous psychiatric history, referred for a
psychiatric evaluation due to recent experiences of delusions and hallucinations. Two weeks
before admission, following a disagreement with a family member, she began sensing things
moving within her body, hearing voices conversing with her, and then abruptly disappearing.
She has been experiencing difficulty sleeping. The patient manifested persecutory delusions
related to the belief that her son had been killed. With a medical history of hypertension and
thyroidectomy, her disheveled appearance, irritable mood, and flat affect raised concerns.
Thought-blocking, persecutory delusions, and auditory and visual hallucinations were observed.
Initially, the challenge was to differentiate psychosis due to hypothyroidism or dementia from
psychosis of a mental disorder. Three previously mentioned differential diagnoses were
established following a thyroid function test, a CT Scan head, and a mini-mental examination
ruling out both dementia and hypothyroidism as the etiology of her psychosis.
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NRNP/PRAC 6665 & 6675 Comprehensive Focused SOAP Psychiatric
Evaluation Template
In the event of conducting another psychiatric assessment, I would emphasize gathering
additional information regarding the patient’s psychosocial history and her family’s psychiatric
background. Specifically, I would inquire about her whereabouts during the significant Haiti
earthquake, exploring whether she experienced any personal losses or witnessed the traumatic
event. Such experiences could potentially serve as triggers for the onset of a major depressive
episode or posttraumatic stress disorder.
Case Formulation and Treatment Plan:
Medication:
•
Risperidone 1.5mg oral daily for acute and maintenance of schizophrenia treatment.
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Depakote ER 250mg oral twice daily as an adjunctive to accelerate the response to the
antipsychotic therapy.
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Levothyroxine 50mcg oral daily before breakfast for treatment of hypothyroidism.
•
Amlodipine 5mg oral daily for maintenance of hypertension treatment.
•
The patient is instructed to report any adverse reactions, especially EPS, considering the
patient’s age while taking an atypical antipsychotic medication like risperidone.
Laboratory Test:
•
TSH, T3, and T4: to assess the effectiveness of hypothyroidism treatment.
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Liver function test: due to possible adverse effect of valproic acid (Depakote) medication.
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Valproic acid level: to prevent any overdose toxicity of Depakote.
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B12 and Folate levels: to rule out any metabolic conditions.
Q15-minute safety rounding observation:
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Evaluation Template
•
Initiated and maintained.
Education
•
Education was provided to the patient on the benefits of compliance with his medication
regimen. The risks and benefits of medications are discussed, including side effects and
adverse effects.
•
Blood pressure is monitored for effectiveness of her hypertension treatment.
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The patient is monitored for any command hallucinations.
•
Emergency and hotline numbers were given to the patient.
•
Upon discharge, the patient is encouraged to call 911 for any adverse reactions, suicidal
thoughts, or command hallucinations.
•
The patient is encouraged to call 911 or the crisis hotline for any symptoms or signs of
decompensation.
•
Time was allowed for questions, and answers were provided.
•
Supportive listening was provided; the patient verbalized understanding of the treatment
plan.
A copy of medical and medication consent was provided to the patient.
patient is encouraged to ask questions about the treatment plan for clarification.
Referral to Outpatient Mental Health for follow-up care.
Five days after discharge.
Follow up with PCP for HTN and Hypothyroidism.
PRECEPTOR VERIFICATION:
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The
NRNP/PRAC 6665 & 6675 Comprehensive Focused SOAP Psychiatric
Evaluation Template
I confirm the patient used for this assignment is a patient that was seen and managed by the
student at their Meditrek approved clinical site during this quarter course of learning.
Preceptor signature: ________________________________________________________
Date: ________________________
References
American Psychiatric Association. (2022). Depressive disorders. In Diagnostic and statistical
manual of mental disordersLinks to an external site. (5th ed., text rev.).
https://go.openathens.net/redirector/waldenu.edu?url=https://dsm.psychiatryonline.org/d
oi/full/10.1176/appi.books.9780890425787.x04_Depressive_Disorders
American Psychiatric Association. (2022). Schizophrenia spectrum and other psychotic
disorders. In Diagnostic and statistical manual of mental disordersLinks to an external
site. (5th ed., text rev.). https://go.openathens.net/redirector/waldenu.edu?url=
https://dsm.psychiatryonline.org/doi/full/10.1176/appi.books.9780890425787.x02_Schizo
phrenia_Spectrum
Kehinde, F., Bharmal, A. V., Goodyer, I. M., Kelvin, R., Dubicka, B., Midgley, N., Fonagy, P.,
Jones, P. B., & Wilkinson, P. (2022). Cross-sectional and longitudinal associations
between psychotic and depressive symptoms in depressed adolescents. European Child
& Adolescent Psychiatry, 31(5), 729–736. https://doi.org/10.1007/s00787-020-01704-3
Lintunen, J., Taipale, H., Tanskanen, A., Mittendorfer-Rutz, E., Tiihonen, J., & Lähteenvuo, M.
(2021). Long-Term Real-World Effectiveness of Pharmacotherapies for Schizoaffective
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Evaluation Template
Disorder. Schizophrenia bulletin, 47(4), 1099–1107.
https://doi.org/10.1093/schbul/sbab004
Witkowski, G., Januszko, P., Skalski, M., Mach, A., Wawrzyniak, Z. M., Poleszak, E., Ciszek, B.,
& Radziwon-Zaleska, M. (2023). Factors Contributing to Risk of Persistence of Positive
and Negative Symptoms in Schizophrenia during Hospitalization. International Journal of
Environmental Research and Public Health, 20(5).
https://doi.org/10.3390/ijerph20054592.
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