Focused SOAP Note for Anxiety, PTSD, and OCD

Week 9: Focused SOAP Note and Patient Case

Student Name

College of Nursing-PMHNP, Walden University

NRNP 6675: PMHNP Care Across the Lifespan II

Faculty Name

Assignment Due Date

Week 9: Focused SOAP Note and Patient Case

Subjective:

CC (chief complaint): "I'm seeking a psychiatrist because my primary care physician suggested for me to see a psychiatrist to help me with my anger issues.”

HPI: The patient is a 21-year-old African American female who was seen in the clinic for her initial evaluation via telehealth session with her consent obtained. The patient stated that she was seeking a psychiatrist because her primary care physician suggested for her to see a psychiatrist to help her with anger issues. She stated that she has not being diagnosed for any mental problem before and has never been on any medication before as well. The patient stated that she gets very angry, depressed, and anxious quickly; even she reported that sometimes she would lash out on people without any reason. She said that her siblings get on her nerves sometimes and she gets irritated especially when they are together for so a long period of time. She stated, “I just had my birthday, and I went out for a dinner with my friends, and I had a good time”. The patient reported, “I hear voices, but not that type of crazy voices that tell you to do somethings”. “It is just from my inner thought, maybe thinking in my head and talking out loud to myself”. She said she just gets irritated here and there from some people. She denies suicidal or homicidal ideation or intent presently. She also denies delusional or hallucination presently.

Substance Current Use: None

Family History: Maternal grandmother has depression and dementia.

Psychosocial History: The patient stated that she grew up with both parents but now they are divorced. She now lives with her mother and her siblings. She reported doing good and working two jobs to support herself. She said that she works as a pharmacy technician Monday through Friday and works as a concierge on weekends.

She completed high school and graduated. She has few friends and she is not in any relationship right now. She is not married and has no children.

Medical History: None

· Current Medications: None.

· Allergies: NKDA

· Reproductive Hx: Heterosexual. Currently not sexually active. No children.

ROS:

· GENERAL: Reports poor eating habits. Denies weakness, fatigue, fever, or chills.

· HEENT: Eyes: No visual loss, blurred vision, double vision, or yellow sclerae. Ears,

· Nose, Throat: No hearing loss, sneezing, congestion, runny nose, or sore throat.

· SKIN: No rash or itching.

· CARDIOVASCULAR: No chest pain, chest pressure, or chest discomfort. No palpitations or edema.

· RESPIRATORY: No shortness of breath, cough, or sputum.

· GASTROINTESTINAL: No anorexia, nausea, vomiting, or diarrhea. No abdominal pain or blood.

· GENITOURINARY: No burning on urination, urgency, hesitancy, odor, odd color

· NEUROLOGICAL: No headache, dizziness, syncope, paralysis, ataxia, numbness, or tingling in the extremities. No change in bowel or bladder control.

· MUSCULOSKELETAL: No muscle, back pain, joint pain, or stiffness.

· HEMATOLOGIC: No anemia, bleeding, or bruising.

· LYMPHATICS: No enlarged nodes. No history of splenectomy.

· ENDOCRINOLOGIC: No reports of sweating, cold, or heat intolerance. No polyuria or polydipsia.

Objective:

Vital signs: B/P: 128/66/ Temp. 97.3, Pulse 74, Respiration: 18, Oxygen saturation: 98%

Height: 5’4’’

Weight: 200lbs

Diagnostic results: PHQ-9 15/27. Signifies moderately severe depression.

Assessment:

Mental Status Examination: The patient is alert and oriented x 4 to person, place, time, and the situation. The patient was seen today in the clinic for initial evaluation via telehealth. The patient appeared very clean and dressed neatly. She has normal eye contact with normal psychomotor activity. Her attention is intact and very cooperative. Her speech is normal, her thought process is goal-directed, and her thought contents are circumstantial. Perceptions, insight, and judgment are good, intact cognitive, and language is normal and appropriate. She has euthymic and euphoric moods, and the affect is congruent to her mood. Memory intact, she denies suicidal or homicidal ideation or intent. She denies delusions and hallucinations.

Diagnostic Impression/Diagnostic Differential:

1). Schizoaffective Disorder (with anxiety)

Based on the information provided in the patient case, schizoaffective disorder is highly likely to be the primary diagnosis. To be diagnosed with this condition, the patient must meet the primary criteria (criterion A) for schizophrenia that includes at least two of hallucinations, delusions, disorganized speech, negative symptoms, and grossly disorganized or catatonic behavior (Baryshnikov et al., 2020). The patient must also present with a major mood episode, either depression or mania, lasting for uninterrupted period of time and accompanied with either delusions or hallucinations. Furthermore, the symptoms should not be caused by substance use (Baryshnikov et al., 2020).

In the patient’s case, she meets criterion A for schizophrenia because she presents with auditory hallucinations where she hears voices in her head and starts talking out loud to herself. Also, she presents with negative symptoms because she reports to be depressed. Furthermore, the patient’s symptoms are not caused by substance abuse which is characteristic of schizoaffective disorder (Das-Munshi et al., 2018). The patient also presents with a high degree of irritability which is a common characteristic in patients with schizoaffective and bipolar disorders. This condition presents various behavioral symptoms such as angry outbursts where patients can suddenly erupt in anger, just like it is reported in the patient’s case (Das-Munshi et al., 2018).. Therefore, all this information points to schizoaffective disorder as the primary diagnosis. Anxiety is exhibited by her reports of feeling extremely anxious even for no real reason. Anxiety is a common co-occurring factor with schizoaffective disorder.

2). Schizophrenia

This is also another likely diagnosis for the patient. The condition is highly related to schizoaffective disorder and one may be confused with the other (Holt et al., 2018). The diagnosis is considered because the patient presents with auditory hallucinations and negative symptoms, such as depressed moods. She also presents with irritability yet agitation and irritability are commonly observed among patients with schizophrenia. However, the diagnosis is ruled out because with schizophrenia, the patients cannot tell the difference between reality and fiction during delusions or hallucinations. However, the patient in this case is able to tell the difference between reality and the voices that she has in her head which is usually observed in patients with schizoaffective disorder (Strik et al., 2017). Furthermore, the mood disorder in this patient is front and center yet with schizophrenia, it is usually not a dominant part of the disorder. Finally, the diagnosis is also ruled out because there is no evidence that the condition disrupts either her ability to work or her relationships, which would signify schizophrenia.

3). Generalized anxiety disorder

The diagnosis is considered because the patient admits that she experiences excessive anxiety without any real reason most of the time. The patient also presents with irritability which may or may not be observable among patients with generalized anxiety disorder (Xu et al., 2021). She also reports that she has poor eating habits which is usually a common characteristic of generalized anxiety disorder. However, this diagnosis is ruled out because other hallmark criteria are not met since there is no evidence that the patient’s worry occurs more than not for at least six months; it is not reported that the worry is very challenging to control for the patient; and the worry does not cause bad concentration or restlessness in the case of the patient (Xu et al., 2021).

Reflections:

Recording comprehensive information to be utilized during the assessment and the development of the most likely diagnosis for the patient is important, especially when the patient is presenting with symptoms of schizoaffective disorders. Upholding ethical guidelines can be accomplished by ensuring that the patient has autonomy of her care and that she is educated about her diagnosis. What I could do differently would be to obtain more information about the patient’s family history to assess the risk of mental illness. It would also be important to make sure that the patient consents to treatment before beginning the plan.

Case Formulation and Treatment Plan: 

The patient is a 21-year-old African American female who stated that she was seeking a psychiatrist because her primary care physician suggested for her to see a psychiatrist to help her with anger issues. She stated that she has not being diagnosed for any mental problem before and not on any medication. The patient stated that she gets angry very quickly, depressed, and very anxious, sometimes would lash out on people without any reason. She also reported auditory hallucinations. The primary diagnosis is schizoaffective disorder. The patient is referred to a psychotherapist and will be scheduled to see a therapist weekly. The patient is encouraged to engage in exercise to build up her serotonin. She is also encouraged to be taking deep breathing, not to eat after 7 pm, and keep electronics away at bedtime. Also, she encouraged to keep a journal of her daily activities and will review it next appointment in 4 weeks. She is encouraged to call 911 for suicidal or homicidal ieation or intent. She is also encouraged to call the psychiatrist's office whenever she wants to talk. She verbalized understanding.

Plan of Care:

The patient will have decreased feelings of depression and anxiety over the next 90 days.

The patient is educated on the use of positive coping skills like exercising, deep breathing, and journaling daily.

The patient is referred to a psychotherapist weekly.

Follow up in 4 weeks.

Call 911 for suicidal or homicidal ideation or intent.

Conclusion

Schizoaffective disorder is very difficult to diagnose due to its complicated symptoms. Therefore, providers must obtain comprehensive information about the patient’s case to correctly determine the primary diagnosis of the condition. Providers should also use critical thinking when making the differences between schizoaffective and schizophrenia disorders.

References

Baryshnikov, I., Sund, R., Marttunen, M., Svirskis, T., Partonen, T., Pirkola, S., & Isometsä, E. T. (2020). Diagnostic conversion from unipolar depression to bipolar disorder, schizophrenia, or schizoaffective disorder: A nationwide prospective 15‐year register study on 43 495 inpatients. Bipolar disorders, 22(6), 582-592.

Das-Munshi, J., Bhugra, D., & Crawford, M. J. (2018). Ethnic minority inequalities in access to treatments for schizophrenia and schizoaffective disorders: findings from a nationally representative cross-sectional study. BMC medicine, 16(1), 1-10.

Holt, R. I., Hind, D., Gossage-Worrall, R., Bradburn, M. J., Saxon, D., McCrone, P., ... & Northern, A. (2018). Structured lifestyle education to support weight loss for people with schizophrenia, schizoaffective disorder and first episode psychosis: the STEPWISE RCT. Health Technology Assessment (Winchester, England), 22(65), 1.

Strik, W., Stegmayer, K., Walther, S., & Dierks, T. (2017). Systems neuroscience of psychosis: mapping schizophrenia symptoms onto brain systems. Neuropsychobiology, 75(3), 100-116.

Xu, X., Dai, J., Chen, Y., Liu, C., Xin, F., Zhou, X., ... & Becker, B. (2021). Intrinsic connectivity of the prefrontal cortex and striato-limbic system respectively differentiate major depressive from generalized anxiety disorder. Neuropsychopharmacology, 46(4), 791-798.