Focused SOAP Note
SOAP Note
Information for Patients:
S.T., M, White, 53
S. CC (chief complaint): Forgetfulness, hearing and seeing imaginary things, and losing touch with reality.
HPI: S.T., a 53-year-old patient, is brought to the clinic by his sister because his symptoms of seeing and hearing imaginary people and sounds are worsening. He believes that someone is watching his every move, and he cannot recall the events of that day. For weeks, the symptoms have persisted. He has a history of marijuana use and smoking. For weeks, the symptoms have persisted.
Current Medications: There are no current medications.
There are no known drug allergies.
PMHx: The patient reports hearing imaginary sounds and people for several weeks.
Soc and Substance Hx: The patient has a history of marijuana use and abuse. He denies any involvement with cocaine.
Hx Fam: She lives with her sister.
Surgical history: There is no history of surgical procedures.
Mother has a history of suicidal ideation. Denies any prior history of suicide.
Violence Hx: The father was abusive to his children until his death.
No family history of children or marriage.
ROS: GENERAL: A 53-year-old male who hears and hears voices addressing people. He has no idea what day of the week or month it is.
HEENT: No hearing issues.
SKIN: There are no lesions or itching.
CARDIOVASCULAR: There is no discomfort or pain in the chest.
RESPIRATORY: There is no sputum shortness of breath.
GASTROINTESTINAL: No nausea, vomiting, or diarrhea.
GENITOURINARY: There is no burning when urinating.
NEUROLOGICAL: There is no dizziness or numbness.
MUSCULOSKELETAL: There is no pain or stiffness in the muscles.
HEMATOLOGICAL: There is no bleeding or anemia.
LYMPHATICS: There are no enlarged lymph nodes.
PSYCHIATRIC: Unable to recall the exact date or location. The patient sees and hears fictitious people and sounds. Mother has a history of suicidal ideation. Denies any prior history of suicide.
ENDOCRINOLOGICAL: There is no polyuria.
ALLERGIES: There are no known drug allergies.
Laboratory findings:
There is no laboratory test to diagnose schizophrenia. The patient’s behavior and medical history will be examined by an experienced mental health professional. A complete blood count and urine tests can help rule out conditions that can cause hallucinations and other symptoms associated with schizophrenia.
A. Examination of Mental Status
The patient is a 53-year-old woman who comes to the clinic on the advice of her sister. He is cooperative during the clinic, but he lacks a sense of reality. His memory of the time and date is hazy. He sees things that others do not and hears voices that others do not. He has a history of marijuana use and abuse. The speech is clear and coherent, and it effectively answers questions. The recent and distant memories are not intact.
Differential Diagnoses: F20. 9: Unspecified Schizophrenia
Unspecified schizophrenia spectrum disorder can coexist with other psychotic disorders. An individual’s life is affected until they are unable to function normally. Schizophrenia symptoms include delusions, hallucinations, and abnormal behavior (Archibald et al., 2019). The patient most likely has schizophrenia because he hears voices from people that others, such as his sister, cannot hear. For example, she hears loud music that her sister and others cannot hear (Archibald et al., 2019). The patient may have schizophrenia, as well as other co-occurring disorders. – Thesis Writing Service In Canada
F23: Temporary psychotic disorder
The condition is characterized by psychotic behavior that includes delusions and hallucinations. Psychosis is characterized by a loss of touch with reality (Smith et al., 2020). For example, the patient believes that someone is after him and has spent money to spy on him. The condition can occur, with the possibility of relapses in the future (Smith et al., 2020). Due to the patient’s behavior of losing touch with reality, he or she may be suffering from a brief psychotic disorder.
Delusional Disorders (F22)
Delusion behavior occurs, impairing patients’ cognition. Individuals are affected to the point where they are unable to distinguish between the imagined and real worlds (Miola et al., 2020). Because of the conversations about time and place, the patient may be suffering from delusional disorders (Miola et al., 2020). For example, the individual claims that some people are out to get him and harm him.
2 Bipolar I Disorder with Psychotic Features F31.
Mania, depression, hallucination, disconnection from reality, and disordered thinking are all symptoms of the condition. Individuals suffering from bipolar disorder may struggle due to hallucinations (Trisha et al., 2018). Severe mania and depression can, in some cases, lead to dangerous behavior.
Plan
The patient should begin psychotherapy sessions right away. To address the delusions and hallucinations, the psychotherapists will employ cognitive behavior therapy. Psychotherapists can schedule 10-12 sessions. A session with the sister or another important member of the family is essential for increasing family support. Depending on the outcome and health of the patient, a combination of medications to address hallucinations and delusions may be recommended (Trisha et al., 2018). Each week, the patient should attend therapy sessions and complete homework assignments at home. It is critical to submit a weekly report for review. It is critical to educate the patient about the dangers of drugs that can cause hallucinations, such as marijuana.
Reflection
If I were to conduct the treatment interview again, I would inquire about previous psychiatric treatment. I would inquire about the patient’s experience with drugs such as marijuana. I would inquire about the severity of the hallucinations from the patient. I’ll also try to interview the sister, who will explain how serious the condition is. The sister will explain any home interventions and the patient’s behavior at home. I’ll also order urine tests to see if the patient is using other drugs that might be causing hallucinations.
I will ensure that I follow up with the patient to ensure that they are improving. I would combine therapy and medication to maximize the positive outcomes.
During the course of providing care, I will maintain confidentiality by not disclosing information to third parties without the patient’s permission. I will demonstrate veracity by telling the truth, for example, about the effect of marijuana on hallucinations (Rainer et al., 2018). I will observe justice and fairness by ensuring the patient is treated kindly and professionally without bias. To avoid harm, it will be critical to ensure non-maleficence and beneficence (Rainer et al., 2018). Therapy decisions and medication prescriptions should be made professionally and with caution.
The health promotion activities will encourage the patient to avoid drugs and substances that can affect the brain chemicals (Archibald et al., 2019). For instance, it will be crucial to caution against abusing marijuana and other prescription drugs. I will encourage the patient to observe an environment free of stress and conducive to allowing the brain to function at optimal levels.
References
Archibald, L., Brunette, M. F., Wallin, D. J., & Green, A. I. (2019). Alcohol use disorder and schizophrenia or schizoaffective disorder. Alcohol research: current reviews, 40(1).
Miola, A., Salvati, B., Sambataro, F., & Toffanin, T. (2020). Aripiprazole for the treatment of delusional disorders: A systematic review. General Hospital Psychiatry, 66, 34-43.
Rainer, J., Schneider, J. K., & Lorenz, R. A. (2018). Ethical dilemmas in nursing: An integrative review. Journal of Clinical Nursing, 27(19-20), 3446-3461.
Smith, C. M., Komisar, J. R., Mourad, A., & Kincaid, B. R. (2020). COVID-19-associated brief psychotic disorder. BMJ Case Reports CP, 13(8), e236940.
Trisha, C., Golnoush, A., Jan-Marie, K., Torres, I. J., & Yatham, L. N. (2018). Cognitive functioning in first episode bipolar I disorder patients with and without history of psychosis. Journal of affective disorders, 227, 109-116.
