NRNP/PRAC 6665 & 6675 Comprehensive Focused SOAP Psychiatric Evaluation Template
Week 7 Assignment: Grand Rounds Discussion: Complex Case Study Presentation
College of Nursing-PMHNP, Walden University
PRAC 6675-17: PMHNP Care Across the Lifespan II Practicum
· Present a psychiatric complex case
· Present subjective assessment
· Present objective assessment
· Provide a differential diagnosis and the supporting evidence
· Provide and treatment plan
CC (chief complaint): “I think he needs more medication”
HPI: TF is a 16-year-old Caucasian American who presented for a follow-up assessment with his mother for substance drug-induced psychosis. His mother notes that TF medication, Abilify, is not working for him at the current 10mg and requests an increase in dosing. TF had been involuntarily hospitalized five weeks ago after he became overly paranoid over a gang following. He also heard people knocking on his bedroom window, which prompted his mother to take him to the emergency department after she noted it was all in his head; no gang or people was knocking on his bedroom window. TF admitted using ecstasy and marijuana on and off over the past two years. He was diagnosed with drug-induced psychosis, medically stabilized during the 5-day admission, and discharged on Abilify. TF notes he is fine, but his mother notes TF sometime appears to be listening to something and answers questions from unseen people. She wants an increase in dose to improve the management, given they had been told there might be dose adjustments depending on his response. They report no side effects. TF denies audio and visual hallucinations, suicidal and homicidal ideation
Substance Current Use: Admits use of ecstasy (molly), three tabs weekly over the past two years; admits using twice over the past four weeks; Admits use of marijuana over the past two years; admits use once a week over the past four weeks. He notes he felt too low. Denies use of alcohol, vaping, tobacco, or other illicit substances
· Current Medications: Abilify 10mg PO at bedtime for drug-induced psychosis
· Allergies: No known medication, food or environmental allergies
· Reproductive Hx: Heterosexual male, not currently sexually active, no reproductive health concerns
· GENERAL: No changes in weight or appetite. No chills or fever
· HEENT: No head trauma, no changes in vision, yellowing or reddening. No nasal discharge, drainage, or congestion. No sore throat
· SKIN: No itching, dryness, or lumps
· CARDIOVASCULAR: No palpitations, chest tightness, or congestion, No peripheral edema
· RESPIRATORY: No difficulty in breathing or shortness of breath
· GASTROINTESTINAL: No changes in appetite, vomiting, diarrhea, or constipation
· GENITOURINARY: No increased urinary frequency or urgency. No pain or irritation, or urination
· NEUROLOGICAL: No dizziness, headaches, numbness, or tingling sensations
· MUSCULOSKELETAL: No joint or back pain. No difficulty in movement or fatigue
· HEMATOLOGIC: No unusual or unexplained bruising or bleeding
· LYMPHATICS: No enlarged lymph nodes
· ENDOCRINOLOGIC: No increased thirst, fluid intake, or urination
1. Urine cannabis test- positive
2. MDMA (Ecstasy/Molly) Urine Drug Test- positive
3. Clinician-Rated Dimensions of Psychosis Symptom Severity- Positive for hallucinations (3), delusion (3) and impaired cognition (2)
4. Previous lab findings ruled out an organic basis of psychotic symptoms (CBC, Thyroid-stimulating hormone, CBC, liver function test, lumbar puncture and vitamin B12 test
Mental Status Examination:
A 16-year-old Caucasian male who looks older than the stated age. He is cooperative. He appears well developed, well-nourished, and well-groomed. He is alert and oriented x 3. His mood and affect are congruent. His speech is clear and coherent. His judgment and insight are somewhat impaired. He denies audio and vision hallucination but endorses the presence of unseen people often following him. There is an indication of delusions He denied suicidal and homicidal ideation.
1. Drug-induced psychosis
3. Brief psychotic disorder
The patient had been previously diagnosed with drug-induced psychosis, stabilized, and started on Abilify 10mg. Still, his current symptoms, reported by his mother, hallucination are consistent with the American Psychiatric Association (APA) (2013) DSM-5 diagnostic criteria for Substance-Induced Psychotic Disorder. TF has been using ecstasy and marijuana with subsequent visual and audio hallucinations.
According to the APA (2013) DSM-5, the diagnostic criteria for schizophrenia consider the presence of hallucinations. However, in this case, they are attributable to drug use. Still, the diagnostic criteria for brief psychotic disorder think the presence of hallucinations, with the disturbance lasting at least one day but less than one month. The patient’s symptoms have been present for at least five weeks; hence, it is not a likely diagnosis.
Reflections: One of the things I would have done differently is inquiring more about drug use, given the relapsing episode. While the client admitted to cannabis and ecstasy since discharge, he seemed to hesitate, revealing the frequency of use. Notably, continued substance abuse would jeopardize clinical outcomes despite increasing the dose.
Case Formulation and Treatment Plan:
· Abilify 15mg PO daily (Stahl, 2017)
· Patient education on possible side effects and the importance of adherence
· Continue drug group program for teenagers
· Initiate individual Cognitive-behavioral therapy (CBT) for substance abuse (Kiluk 2019).
· Provided with emergency contact
· Review weekly
Questions to the audience
1. Given your clinical experience, was the assessment comprehensive?
2. Did the subjective and objective assessment support the diagnosis?
3. What should I improve in my presentations?
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: Author.
Kiluk B. D. (2019). Computerized Cognitive Behavioral Therapy for Substance Use Disorders: A Summary of the Evidence and Potential Mechanisms of Behavior Change. Perspectives on behavior science, 42(3), 465–478. https://doi.org/10.1007/s40614-019-00205-2
Stahl, S. M. (2017). Prescriber’s Guide: Stahl’s Essential psychopharmacology. Cambridge University Press
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