Psychiatric SOAP Note/Interview Comprehensive Nursing Paper Example

Name: XY

DOB: May 30 1996

Demographic: Caucasian

Gender Identifier Note: Male

CC: The client  is concerned with “hearing strange sounds and inability to concentrate.”(Psychiatric SOAP Note Comprehensive Nursing Paper Example)

HPI: No past illness or hospitalization.

Pertinent history in the record and from the patient: Diagnosed with ADHD 5 years ago, manage through medication. Immunization up to date.(Psychiatric SOAP Note Comprehensive Nursing Paper Example)

During assessment: The patient describes his mood as anxious.

Patient self-esteem appears low. He feels disappointed in himself and his frustration, which is getting worse with time. Reports change in concentration, energy, sleep patterns, and appetite.

The patient reports reduction in activity, reports increase in agitation, and risky behaviours. He experiences abnormal fears and panic attacks. He reports delusions and hallucinations.(Psychiatric SOAP Note Comprehensive Nursing Paper Example)

The patient reports symptoms of eating disorders. There is a 2-pound weight loss in the past month.

SI/ HI/ AV: Patient denies homicide and suicide ideation, violent behaviour, and SIBx. The patient reports inappropriate behaviours.(Psychiatric SOAP Note Comprehensive Nursing Paper Example)

Allergies: NKDFA

Past Medical Hx:

Medical history: Patient reports no cardiac, respiratory, head injury, endocrine or neurological issues.

The patient denies a history of chronic infections, including TB, Hepatitis C, HIV, and MRSA.(Psychiatric SOAP Note Comprehensive Nursing Paper Example)

Surgical history: No previous surgical procedure.

Past Psychiatric Hx:

Previous psychiatric diagnoses: Diagnosed with ADHD at age 5. His ADHD condition is stable – managed through medication.

Previous medication trials: No medical trial participated.

Safety concerns:

History of Violence to Self: Reported punching a wall to the point of bruising and bleeding.(Psychiatric SOAP Note Comprehensive Nursing Paper Example)

History of Violence to Others: Reported occasional fights in school.

Auditory Hallucinations: Reports paracusia

Visual Hallucinations: Reports no visual hallucinations.

Mental health treatment history discussed:

History of outpatient treatment: None reported

Previous psychiatric hospitalizations: None reported

Prior substance abuse treatment: None reported

Trauma history: The client reports childhood bullying at school. Denies other sources of trauma, such as parental neglect or abuse,  domestic violence, or other traumatizing events.(Psychiatric SOAP Note Comprehensive Nursing Paper Example)

Substance Use: Denies using or abusing alcohol or nicotine/tobacco products.

The client denies using or abusing ETOH and other illegal drugs

Current Medications:

Methylphenidate 20mg orally daily.

Supplements: Elemental Zinc 10mg

Past Psych Med Trials: None reported.

Family Medical Hx: None reported

Family Psychiatric Hx:

Substance use: Parents consumes alcohol weekly.

Suicides: None reported.

Psychiatric diagnoses/hospitalization: Father diagnosed with diabetes. Other members are healthy.   (Psychiatric SOAP Note Comprehensive Nursing Paper Example)

      Developmental diagnoses: None reported.

Social History:

Occupational History: Unemployed. No previous employment record.

Military service: Denies involvement with the military.

Education history:  Bachelor of Commerce graduate.

Developmental History: Had normal childhood development.

Legal History: Reported for initiating and carrying on a fight in the neighbourhood.

Spiritual/Cultural Considerations: Christian

ROS:

Constitutional: No fever. Reports 2-pound weight loss.

Eyes: Vision is intact

ENT:  Hearing and sense of smell intact. No sore throat.

Cardiac: No chest pain, oedema, or breathing difficulty.

Respiratory: No shortness of breath, cough or wheezing

Musculoskeletal: Denies joint pain or swelling

Neurologic: Denies history of seizures, blackout or numbness. Endocrine: No polyuria or polydipsia.(Psychiatric SOAP Note Comprehensive Nursing Paper Example)

Allergy: NKFDA

Include demographics, chief complaint, subjective information from the patient, names and relations of others present in the interview.

HPI:

, Past Medical and Psychiatric History,

Current Medications, Previous Psych Med trials,

Allergies.

 Social History, Family History.

Review of Systems (ROS) – if ROS is harmful, “ROS noncontributory,” or “ROS negative except for….”

Temp:98.5 F

BP: 115/75

HR: 72

R:15

O2: 95

Ht:5’5’’

Wt:130lbs

BMI: 21.6

LABS:

Lab findings: WNL

Tox screen: Negative

Alcohol: Negative

Physical Exam:

MSE:

The client appears anxious yet cooperative and conversant. The client is oriented x 4. The client is appropriately dressed for time and occasion. The client’s psychomotor behaviour seems abnormal.

The client does not maintain appropriate eye contact. The client shows restlessness and fidgeting, with a reported mood of anxiety.

Memory: Immediate, recent, and remote memory intact

Speech: Fast-talking, normal tone with crowded thoughts.

TC: Denies suicide and homicide ideation.

Cognition is grossly intact. Attention and concentration span is limited. The client appears knowledgeable.  The client’s judgment and insight are grossly intact.

Thoughtform: Logical and goal-directed

The client demonstrates an ability to articulate needs. The client is motivated to comply and adhere to the treatment plan. The client reflects a willingness and ability to participate in the psychiatric assessment.

Vitals,

**Physical Exam (if performed, will not be conducted every visit in every setting)

Include relevant labs, test results, and MSE, risk assessment, and psychiatric screening measure results.

DSM-5 criteria for schizophrenia include the following and are presented by XY (APA, 2013): (Psychiatric SOAP Note Comprehensive Nursing Paper Example)

­   Delusions

­   Hallucinations

­   Disorganized speech

­   Disorganize motor activity

Dx: –   Schizoaffective disorders. This diagnosis is refuted.

DSM5 criteria for schizoaffective disorder presented by XY include (APA, 2013):

­   Mood episodes

­   Depression with psychotic features

Dx: –    Delusional Disorder. This diagnosis is refuted.

DSM5 criteria for Delusional disorder presented by XY include (APA, 2013):

­   The presence of one (or more) delusions with a duration of 1 month or longer

­   Impaired function and behaviour(Psychiatric SOAP Note Comprehensive Nursing Paper Example)

­   Other psychological effects do not cause the disturbance.

Dx: –    Attention Deficit Hyperactive Disorder. This diagnosis is refuted.

DSM5 criteria for Delusional disorder presented by XY include (APA, 2013):

­   Abnormalities of attention

­   Hyperactivity – Impulsivity

­   Difficulty sustaining focus

­   Disorganized

­   Lack of comprehension

­   Low frustration tolerance

­   Irritability

The client appears to have the capacity to respond to psychiatric medication. This creates a possibility for a consensus with the client, consequently encouraging psychotherapy (Angell & Bolden, 2015). The client appears to comprehend the need for psychotherapy and is willing to adhere to the proposed medication.(Psychiatric SOAP Note Comprehensive Nursing Paper Example)

Informed Consent Ability

(Note some items may only be applicable in the inpatient environment)

The patient is not in immediate danger to himself and those around him, as reported in HPI. The following variables tend to affect the likelihood of medical hospital admission of people with schizophrenia (Olfson et al., 2011):(Psychiatric SOAP Note Comprehensive Nursing Paper Example)

­   antipsychotic medication no adherence

­   poor global functioning

­   co-occurring substance use disorders

Safety Risk/Plan:  The client is stable and has control over his behaviours. The client does not pose a significant risk to himself and others. The client denies unusual perceptions and appears the respond abnormally to internal and external stimuli. (Psychiatric SOAP Note Comprehensive Nursing Paper Example)

Pharmacologic interventions:

·         Titrate Methylphenidate to 30mg orally daily. Methylphenidate is effective for treating ADHD and has a high tolerance (Huss et al., 2017).

·         Increase zinc supplement to 20mg daily.

·         Add propanol 40mg for anxiety three times a day before meals and at bedtime. Propanol has a significant effect on anxiety (Steen et al., 2016).

·         Refer for CBT. CBT is effective for managing auditory hallucinations and delusions (Candida et al., 2016).(Psychiatric SOAP Note Comprehensive Nursing Paper Example)

Education, including health promotion, maintenance, and psychosocial needs

• 1. • Importance of psychological health
     • Importance of medication
     • Safety planning

The client is to return to the clinic after every four weeks. The patient is to visit a psychotherapist every two weeks.

Time spent in the interview: 25 minutes.

The visit lasted 40 minutes

Date: 5/18/2021    Time: 0435