responses
NRNP/PRAC 6665 & 6675 Comprehensive Focused SOAP Psychiatric Evaluation Template
Week 9: Complex Case Study Presentation
Rasheedah Smith
College of Nursing-PMHNP, Walden University
PRAC 6675: PMHNP Care Across the Lifespan II
Lisa Persad
July 22, 2026
“Schizophrenia is a chronic and debilitating disorder that affects one's perception of reality. It is characterized by disruptions in thought processes, perceptions, emotional responsiveness, and social interactions (National Institute of Mental Health). Symptoms typically manifest through a combination of psychotic features, which may include hallucinations, delusions, and disorganized thinking, as well as negative symptoms such as reduced emotional expression and motivation, difficulties in social relationships, and cognitive impairments ” (Salma, 2024)
Subjective:
CC: “I have not been taking my medication”
HPI: J.S 52 y/o American male, admitted on 7/8/2026 for walking in the community naked, he was taking to the hospital, cleared medically and then wa bought to this facility. He has a diagnosis of schizophrenia which he was diagnosed with 2 years ago. J.S states that he was having bizarre and strange occurrences before being diagnosed, which he describes as voices telling him to do things that he knew was wrong but their voice overpowered his mind, he states that he was also seeing things that others weren’t seeing, eg lights shining on him, bugs being in the room and seeing things on the walls, all that others were not able to see. J.S has been to this facility multiple times over the past few months, his last visit was on 5/12/2026-5/16/2026. J.S also states that he has not been compliant with his medication regimen.
Substance Current Use: J.S states that he does not use any illegal substances, his UDA was negative for any illegal substances, however he does drink alcohol at times, he states that he he drinks 3-4 beers several times a week. He denies tobacco use, vaping or any other tobacco substances.
Medical History: J.S has been compliant with his medical follow ups as per records, he has a dx of Hyperlipidemia and is currently taking medication for it.
He does not have any surgical history.
He is up to date with his dental appointments
Current Medications: J.S current medications are as followed:
Risperdal 2mg po QD
Atorvastatin 40mg po QHS
MVI one tab po QD.
He was initially on Risperdal 1mg PO QD, this dose was discontinued and Risperdal 2mg PO QD was started 5/15/2026
· Allergies: NKA, NKDA
· Reproductive History: J.S declined to discuss his reproductive history, he states that he does not have children, but declined to disclose any other information.
· Past phychiatric History: J.S. was diagnosed with schizophrenia 2 years ago. He does not have any other psychiatric disorders. He has been to this facility (inpatient) several times over the past few months, the last visit was 5/12/26-5/16/26 at that time his medication was adjusted. He has been non adherent with outpatient follow ups and has not utilized community resources or therapy.
· Family Psychiatric History: J.S. was adopeted and does not know his biological mother, father or family. He was adopted at the age of 6 months, their agreement was that he not have any communication with his biological family. He is the only child to a single mother.
· Social History: J.S does not have any children, he does not know his biological family, his adopted mother is the the only child to her parents whom passed away. He did not have a good relationship with his adopted family. He graduated high school, he did not attend college. He works at a local grocery store part time. He lives with a friend in a shared apartment. He does not have any hobbies, he does not travel or do anything for fun. He does not have any friends except the people that he works with.
ROS:
· GENERAL: J.S states that his overall health is good, he does has been diagnosed with schizophrenia and hyperlipididemia, he has been non compliant with his Risperdal, he states that he drinks beer and he does not like the way it makes him feel and it makes him feel sleepy. He states that he is compliant with his Atorvastatin. He is up to date with his medical and dental appointments, however he has missedmultiple follow up appointments for his psychiatric therapy.
· HEENT: J.S denies any issues with vision, hearing, smelling, or swallowing, he states that his senses are intact, he also denies any seasonal issues.
· SKIN: J.S denies any skin issues, no rashes, itching, blotches, or pimples, he states that he drinks plenty of water daily, approx. 4-6 glasses.
· CARDIOVASCULAR: J.S states that he does not have any cardiovascular issues, he denies chest pain, pressure, tightness or discomfort, he also denies palpitations or high blood pressure. He does have a diagnosis of hyperlipidemia and take medication daily.
· RESPIRATORY: J.S denies any respiratory issues/illness, he denies seasonal allergies, shortness of breath, coughing/congestion or sinus abnormalities. He denies fever/chills or recent exposure to covid.
· GASTROINTESTINAL: J.S denies any GI related issues, he states that he has bowel movements at least 4-5 times a week, he states that he eats healthy and drink an adequate amount of fluids, he denies any eating disorders, N/V/D. He states that he passes gas regularly. He denies any abdominal pain or discomfort, he states that he eats adequate meals, although they are not always home cooked. He states that he eats out 2-3 times a week. He tries to balance it by making better choices with his selection.
· GENITOURINARY: J.S states that he does not have any voiding issues, he voids throughout the day, his urine is clear yellow with no odor, he denies abdominal pain or discomfort, he denies dysuria/polyuria or urgency.
· NEUROLOGICAL: J.S states that he does not have any neurological issue, he denies dizziness, syncope, numbness, tingling, headaches, memory changes, balance or cognition.
· MUSCULOSKELETAL: J.S denies any MS issues, he states that his balance is good, he is able to move all of his extremities, he can walk, run and climb without difficulty. He states that he does home exercise 2-3 times a week for 20-30 minutes, he denies any joint issues or back/neck pain.
· HEMATOLOGIC: J.S states that he does not have any bleeding, bruising or coagulation abnormalities.
· LYMPHATICS: J.S denies any lymph node enlargement or issues, he denies any newly formed nodules.
· ENDOCRINOLOGIC: J.S denies any abnormal heat or cold intolerance, any temperature regulation abnormalities within the body, he denies excessive sweating or body temperature declines
Objective:
Diagnostic results: J.S has a diagnosis of schizophrenia, his work up would include but not limited to a comprehensive psychiatric interview, mental status examination, diagnosis via DSM-5-TR and a physical examination.
Lab test will be conducted, although they are not specific in providing a clinical diagnosis, complete blood count, thyroid function test, vitamin and folate levels, comprehensive metabolic test and a urine drug screen and toxicology screening.
Imaging include MRI and a CT scan, again these test will not provide a clinical diagnosis, it will rule out underlying factors. Cognitive and neuropsychological testing can also be done.
Screening tools include brief psychiatric rating scale, scale for assessment of positive symptoms, positive and negative syndrome scale and scale for negative symptoms.
J.S UDA was negative for all substances, his BAC was 0.06 which could cause reduced functions and coordination. His vital signs were stable 97.6F, 20, 126/74, 88, 98%r/a.
Assessment:
Mental Status Examination: J.S is a 52 y/o American male who was admitted to the facility due to him walking around in the neighborhood naked. He has a diagnosis of schizophrenia and has had several inpatient stays within the past few month, the last visit was in May. He is seeking treatment for auditory and visual hallucinations. He appears stated age. He was cooperative with the interview and assessment. He appears well groomed and appropriate for the situation. He did not appear to have any grooming issues, he did not present with any body odor, he did not appear disshelved. He does not have any evidence of motor activity dysfunction, he did not present with negative or positive symptoms due to schizophrenia diagnosis. He is AAOx4, he is able to make his needs known. He is understood and understands. His speech is clear, coherent with normal intonation based on the conversation. He does not present with looseness of association, no flight of ideas or speech. His mood is congruent with his affect. He denies at this time hallucinations of any kind. He denies suicidal ideations, homicidal ideations or self harm, or self harm behavior, he states that he feels safe where he lives. His recent recall and memory recall is intact, he is able to focus with good insight.
Diagnostic Impression: Schizophrenia (F20.9) J.S presents with this psychiatric disorder which affects his life significantly by impeding on his functions, specifically emotions, behaviors, and perception. Schizophrenia has also affected his ability to hold a full time job as he currently works part time, academically he does not have any will power or drive which robbed him of excelling or advancing his education. He presents with both positive and negative symptoms. Positive- auditory hallucinations, visual hallucinations. Negative- avolition, anhedonia and social withdraw. J.S has been experiencing hallucinations, he previously experienced delusions but states that he has not had them for a while. He has had impaired work at work, relationships and school. “Schizophrenia is a chronic and debilitating disorder that affects one's perception of reality. It is characterized by disruptions in thought processes, perceptions, emotional responsiveness, and social interactions ( National Institute of Mental Health). Symptoms typically manifest through a combination of psychotic features, which may include hallucinations, delusions, and disorganized thinking, as well as negative symptoms such as reduced emotional expression and motivation, difficulties in social relationships, and cognitive impairments (Hollis et al., 2011; McGrath et al., 2008). The onset of schizophrenia usually occurs in late adolescence to early adulthood and often appears earlier in males than females. If left untreated, the disorder can be severely disabling and persistent ( Hollis et al., 2011; McGrath et al., 2008)” (Salma, 2024).
Schizoaffective disorder, unspecified (F25.9) J.S presents with the psychosis portion of this diagnosis, however he does not present with bipolar or manic episodes. “ An uninterrupted period of illness during which a major depressive or manic episode occurs concurrently with symptoms of schizophrenia. Delusions or hallucinations for at least 2 weeks without a major mood episode. Mood symptoms are present for most of the total duration of the illness. Symptoms are not due to substances, medications, or another medical condition” (Malaspina, 2013).
Schizophreniform disorder (F20.81) J.S has a psychotic disorder with symptoms of schizophrenia, however his symptoms lasted longer than 6 months, therefore this diagnosis can be ruled out. “Schizophreniform disorder is a psychotic disorder characterized by symptoms that are identical to schizophrenia but last at least 1 month and less than 6 months. Some individuals recover completely, while others later receive a diagnosis of schizophrenia or schizoaffective disorder if symptoms persist beyond six months” (Hasan, 2020).
Reflections: J.S case is complex because he was diagnosed a little later in life, the typically range to be diagnosed is in the late teen years to the late 20’s-30’s, J.S was diagnosed at the age of 50, although the onset of the diagnosis ranges. It is more prominent in males than females. J.S stated that he should have gotten checked out prior to him getting checked out, he stated that he use to go to his medical checkups but did not pay his psychologic self any mind in his younger years. His life looks a lot different from many others as previously discussed he was adopted and this alone can be a barrier for many children/adults. Most people want to know their identity and the fact that the family did not want him to know anything about them does affect him, as he still struggles with identity and belonging issues. He has a hard time forming relationships and trusting people. J.S does not have pleasure in doing many things, he does enjoy going to work, but he is not able to work full time due to his diagnosis and some of the challenges that he face with it. Based on my assessment, if he focused on his medication compliance and kept his scheduled follow ups and participated with community resources, he would have a better quality of life.
Prevelance- Approximately 23–24 million people worldwide live with schizophrenia. Lifetime prevalence is approximately 0.3% of the global population. Roughly 1 in 345 people worldwide are affected.Symptoms usually begin earlier in men than in women. (WHO, 2024).
Resources- includes but not limited to National Institute of Mental Health (NIMH), National Alliance on Mental Illness (NAMI), Substance Abuse and Mental Health Services Administration (SAMHSA), 988 Suicide & Crisis Lifeline,World Health Organization (WHO) (WHO, 2024).
Health Determinants that a patient with schizophrenia may include, but not limited to education, housing(many of the patients with schizophrenia are homeless or living with other people), education, transportation, employment and one of the biggest challenges they face is the stigma of the diagnosis.
Case Formulation and Treatment Plan: J.S will continue to be evaluated and monitored for compliance. The treatment plan consists of decreasing hallucination, decrease/eliminate drinking and maintaining medication compliance. Complete medical including labs, nutritional screening, and weight), psychiatric, alcohol assessment/screening and assess readiness to change. J.S will also be offered supportive care inpatient and outpatient related to ETOH abuse. Education related to medication management, follow up and consistent care as well as monitoring side effects of medication and monitoring.
His medication was changed again to a long lating injectable. His initial dosage was 234mg IM once, on day 8 he will receive 156mg IM once. The medication will gradually be decreased based on how his body responds to the medication. Side effects of weight gain, sleepiness and involuntary movement issues will be monitored. This medication will eventually be administered monthly, which will tremendously help with his non compliance. Disulfiram 500mg Po will be giving initially for 1-2 weeks followed by 125mg Po QD. J.S will be educated on theside effects of the medication including, fatigue, drowsiness, headache, mild skin rash and changes in sexual drive. If alcohol is consumed while taking this medication, severe reactions may occur including flushing of the skin, nausea and severe diarrhea, heart palpitations, rapid heart rate and shortness of breath and several other reactions.
Alcohol and the diagnosis of schizophrenia does not mix well together, the combination can cause ineffective treatment, poor clinical outcomes, suicidal ideation and increase psychiatric admissions and many more. J.S will need extensive education related to alcohol use and education related to alcohol and his diagnosis.
Tools used to assess his alcohol use were Alcohol Use Disorders Identification Test, CAGE Questionnaire, and Screening Brief Intervention, and Referral to Treatment. Support groups that J.S will receive information for are the following: Alcoholics Anonymous, SMART Recovery Dual Recovery Local community mental health center dual-diagnosis groups
Psychotherapeutic therapy includes cognitive behavioral therapy, social skill training/retraining/reinforcement, family therapy and education, assertive community treatment, individual therapy and group therapy.
Additional Education to be discussed is stress management techniques, ensuring regular scheduled appointments are scheduled and if there is a need for a prn appointment to schedule that as well. Information related to emergency help and crisis interventions. J.S recommendations are to follow up with outpatient psychiatric services weekly for 1 month, then the schedule will be reevaluated based on his needs, concerns and compliance.
Blooms taxonomy focuses on clinical education that assist with building a clinical diagnosis and focuses on cognitive remedation therapy. These concepts of Remembering, Understanding, Applying and Analyzing has all been applied to this paper to help J.S recover and maintain compliance with his diagnosis.
If I could change one thing, I wish that I had the opportunity to see the progress of J.S, I am hopeful that the tools given to him will help him navigate throught life, he has to want it and work hard to achieve it.
Questions
1. What other interventions would help J.S maintain compliance with his medication regimen, are there any other medication that you would have tried prior to putting him on Invega?
2. How much of J.S childhood do you think played a role in his upbringing and his schizophrenia diagnosis?
3. Do you agree with his diagnosis, if not what would you diagnosis hime with and why did you choose that diagnosis?
PRECEPTOR VERFICIATION:
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
Hasan, A., Falkai, P., Wobrock, T., et al. (2020). World Federation of Societies of Biological Psychiatry (WFSBP) guidelines for biological treatment of schizophrenia. World Journal of Biological Psychiatry, 21(1), 4–62. https://doi.org/10.1080/15622975.2019.1689386
Mueser, K. T., Noordsy, D. L., Drake, R. E., & Fox, L. (2022). Integrated treatment for dual disorders. Guilford Press. (Evidence-based text describing integrated care for serious mental illness and substance use disorders).
Malaspina, D., Owen, M. J., Heckers, S., et al. (2013). Schizoaffective disorder in DSM-5. Schizophrenia Research, 150(1), 21–25. https://doi.org/10.1016/j.schres.2013.04.026
Orsolini, L., Pompili, S., & Volpe, U. (2022). Schizophrenia: A Narrative Review of Etiopathogenetic, Diagnostic and Treatment Aspects. Journal of Clinical Medicine, 11(17), 5040. https://doi.org/10.3390/jcm11175040
Pagel, T., Baldessarini, R. J., Franklin, J., & Baethge, C. (2019). Schizoaffective disorder: A review. Harvard Review of Psychiatry, 27(5), 308–322. https://doi.org/10.1097/HRP.0000000000000215
Salma Abdelmoteleb, Jayant Totlani, Salma Ramadan, Mohamed Salem, Ashley Meyer, Tiffany Chang, Madeline Ewing, Luiza Freire, Nathalie Murphy, Sabrina Renteria, Romana Dymkoski, Omer Liran, Rebecca Hedrick, Itai Danovitch, RobertN. Pechnick, Waguih William IsHak,Schizophrenia management: Systematicreview of current medications and Phase-3 agents (2008–2024),Neuroscience Applied,Volume 4,2025,105507,ISSN 2772-4085,https://doi.org/10.1016/j.nsa.2025.105507.
World Health Organization. (2024). Update of the World Health Organization's Mental Health Gap Action Programme guideline for psychoses (including schizophrenia). Schizophrenia Bulletin, 50(6), 1310–1318
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