Care Across the Lifespan Il

Focused SOAP Psychiatric Evaluation

Focused SOAP Psychiatric Evaluation

Tina Cherry

College of Nursing-PMHNP, Walden University

PRAC-6675-46/PRAC-6675F-46/PRAC-6675C-46 : Psychiatric Mental Health Nurse Practitioner Care Across the Lifespan II

Dr. Nataliya Ishkova

December 18, 2022

Subjective:

CC (chief complaint): Memory loss

HPI: HPI: A.G. is a 79-year-old male patient presenting with symptoms of depression. The patient has memory loss issues and often gets in trouble with his wife because of this condition. Although the patient denies being depressed, He presents depression symptoms. He is currently on medication to treat his memory loss issues.

Past Psychiatric History:

· General Statement: The patient has memory loss issues The Patient hallucinates a lot

· Caregivers (if applicable): The patient caregiver is his wife

· Hospitalizations: No record of previous hospitalization but the patient has previously seen a psychiatrist to aid him with memory loss problems

· Medication trials: The patient is currently on three medications; Wellbutrin 200 mg, Trazadone 50 mg, and Primidone 100 mg

Psychotherapy or Previous Psychiatric Diagnosis: Previously diagnosed with memory loss issues

Substance Current Use and History:

Family Psychiatric/Substance Use History: There is no specific history of family psychiatric issues or substance use.

Psychosocial History: There are no legal issues raised by the patient during the examination.

· Current Medications: Wellbutrin 200 mg, Trazadone 50 mg, and Primidone 100 mg.

· Allergies: Allergic to Risperidone and Seroquel

· Reproductive Hx: The patient has no children

ROS:

· GENERAL: The patient tends to forget simple with a short span of time

· HEENT: The conjunctiva is clear, No sinus infection, and eyesight is not clear

· Mouth: There are no muscossal lesions

· Teeth; brownish-staining

· Neck: thyroid non-enlarged

· SKIN: denies rash and pruritus; skin is not sufficiently moist

· CARDIOVASCULAR: bradycardia

· RESPIRATORY: Bilaterally clear

· GASTROINTESTINAL: denies nausea, diarrhea, abdominal pain, loss of appetite

· GENITOURINARY: Denies dysuria

· NEUROLOGICAL: memory loss issues; denies headache

· MUSCULOSKELETAL: No musculoskeletal issues

· HEMATOLOGIC: No anemia

· LYMPHATICS: No swollen lymph nodes

· ENDOCRINOLOGIC: No endocrinal conditions present

Objective:

Physical exam: Blood pressure 130/90 weight 175 lbs

Diagnostic results: no labs ordered

Assessment:

Mental Status Examination:

The patient is calm and highly cooperative throughout the assessment. The only problem noted is that the patient takes too long to process questions, and sometimes He even forgest the questions and answers to the question during the assessment. The patient has no suicidal ideations neither is he delusional.

Differential diagnosis :

Depression

Depression refers to a mood disorder that triggers insistent feelings of grief and loss of interest. This type of mental condition affects how a person feels, thinks, and behaves and causes various psychological and physical problems (Hasin et al., 2018). The major symptoms of depression include feelings of sadness, tiredness, lack of energy, angry outburst, reduced appetite, and weight loss. The other major symptom of depression is memory loss (Hasin et al., 2018). Studies have shown that depression is linked to memory loss issues such as forgetfulness or confusion (Hasin et al., 2018). Schramm et al. (2020) also asserts that depression can make it difficult for an affected person to concentrate on work or other important tasks, make decisions, and think clearly. Depression is often associated with short-term memory loss. For a person to be diagnosed with depression, feelings of sadness, mood swings, and loss of interest in activities must alter a person's previous level of function and ought to have persistent for at least two weeks (Hasin et al., 2018). The symptoms exhibited by the patient, such as loss of appetite, weight loss, and memory loss, have significantly altered the patient's functioning and hence meet the DSM diagnostic criteria for depression. This is a primary diagnosis for this patient. 

Bipolar disorders 

Bipolar disorder is a mental illness that causes extreme episodes of mania and hypomania. The illness is associated with changes in energy levels, ability to concentrate, sleep pattern, and other features which impact significantly impact a person's life (Kessing et al., 2021). Most persons with bipolar disorder experience extreme moods characterized by high and low episodes. Others experience psychosis which includes paranoia, delusion, and hallucinations. There are two types of bipolar disorders; Bipolar 1 disorder and Bipolar II disorder. According to DSM 5 -TR diagnostic criteria, a person must have experienced a single manic experience and must also have had a previous major depressive disorder, and the patient must rule out other possible disorders like schizophrenia disorders (Kessing et al., 2021). In order to be diagnosed with bipolar II, a person must have experienced at least episodes of depression, one hypomanic episode, and other diagnoses to elucidate mood changes. The significant symptoms and diagnostic criteria highlighted by DSM 5-TR rule out bipolar disorder as the primary patient diagnosis. Thus Bipolar disorder is a secondary diagnosis.

Schizophrenia disorders

Schizophrenia is a chronic server mental illness that impacts how an individual thinks, behaves, expresses emotions, and perceives reality. The DSM-5 -TR diagnostic criteria state that a person must be at least two of the five major symptoms of Schizophrenia to qualify for the diagnosis (Pearson & Berry, 2019). These five symptoms of Schizophrenia are delusional, incoherent speaking, hallucinations, unusual movement, and other undesirable symptoms (Pearson & Berry, 2019). Although this condition causes memory loss, at least two major symptoms that qualify a patient for a schizophrenia diagnosis are not present. 

Treatment Plan

The treatment plan will combine pharmacological and non-pharmacological interventions. For this case, the pharmacological intervention for this patient will include prescribing Selective serotonin reuptake inhibitors. This medication has few bothersome side effects compared to other antidepressant types (Furukawa et al., 2019). Furthermore, the patient in question is an elderly person; thus, the prescribed medication should not intensify comorbidity issues related to his age. The patient will take 10 mg of Citalopram twice a day, that is, in the morning and the evening.

Psychotherapy will be applied as the non-pharmacologic treatment intervention for the patient. In particular, cognitive-behavioral therapy will be used to treat this patient. CBT sessions train the patient to develop compensatory tactics for their lapse in memory, thus helping them to circumnavigate their daily challenges. CBT strives to structure the human brain by establishing neural patterns via neural thinking. This psychotherapy session is effective in treating patients with depression (Zhang et al., 2018). The patient will be encouraged to attend all Cognitive therapy sessions and adhere to prescribed medication. In addition to complying with the recommended medication, the treatment plan also integrates nutritional education. For this patient, I will advise the patient to eat food rich in omega-3 Fatty Acids, vitamin D, Zinc, and protein.

Reflections:

During the assessment, I could not capture sufficient data from the patient to inform proper diagnosis and treatment. In subsequent meetings with patients presenting with comparable symptoms, I woud ensure I gather sufficient data pertaining especially to their psychiatric and substance use history, which also captures the patient family history. I will also apply therapeutic communication to enhance interaction with the patient presenting depressive symptoms. Such communication helps calm the patient and helps create a conducive environment for them to share their vulnerabilities.

References

Furukawa, T. A., Cipriani, A., Cowen, P. J., Leucht, S., Egger, M., & Salanti, G. (2019). Optimal dose of selective serotonin reuptake inhibitors, venlafaxine, and mirtazapine in major depression: a systematic review and dose-response meta-analysis.  The Lancet Psychiatry,  6(7), 601-609.

Guu, T. W., Mischoulon, D., Sarris, J., Hibbeln, J., McNamara, R. K., Hamazaki, K., ... & Su, K. P. (2019). International society for nutritional psychiatry research practice guidelines for omega-3 fatty acids in the treatment of major depressive disorder.  Psychotherapy and psychosomatics,  88(5), 263-273.

Hasin, D. S., Sarvet, A. L., Meyers, J. L., Saha, T. D., Ruan, W. J., Stohl, M., & Grant, B. F. (2018). Epidemiology of adult DSM-5 major depressive disorder and its specifiers in the United States.  JAMA psychiatry,  75(4), 336-346.

Kessing, L. V., González-Pinto, A., Fagiolini, A., Bechdolf, A., Reif, A., Yildiz, A., ... & Vieta, E. (2021). DSM-5 and ICD-11 criteria for bipolar disorder: Implications for the prevalence of bipolar disorder and validity of the diagnosis–A narrative review from the ECNP bipolar disorders network.  European Neuropsychopharmacology,  47, 54-61.

Pearson, N. T., & Berry, J. H. (2019). Cannabis and psychosis through the lens of DSM-5.  International journal of environmental research and public health,  16(21), 4149.

Schramm, E., Klein, D. N., Elsaesser, M., Furukawa, T. A., & Domschke, K. (2020). Review of dysthymia and persistent depressive disorder: history, correlates, and clinical implications.  The Lancet Psychiatry,  7(9), 801-812.

Zhang, Z., Zhang, L., Zhang, G., Jin, J., & Zheng, Z. (2018). The effect of CBT and its modifications for relapse prevention in major depressive disorder: a systematic review and meta-analysis.  BMC psychiatry,  18(1), 1-14.

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