A Case Study of a Psychotic Patient is attached in the Files. Assistance is needed to complete the Case Study. Areas have already been prefilled with information. The HIHGLIGHTED sections are to be ad

NRNP/PRAC 6665 & 6675 Comprehensive Focused SOAP Psychiatric Evaluation Template

Week (enter week #): (Enter assignment title)

Student Name

College of Nursing-PMHNP, Walden University

PRAC 6675: PMHNP Care Across the Lifespan I

Faculty Name

Assignment Due Date

Subjective:

CC (chief complaint): Patient refused to to participate in assessment. Patient provides no response, just a blank stare.

HPI: B.S is a 29-year-old African-American male with a past psychiatric history of schizophrenia that was involuntarily admitted to the Pavilion on June 19, 2024, for catatonia. Per intake paperwork, the patient presented to the emergency room with his mother after having an outpatient appointment at Horizons and being in a persistent catatonic state. His mother reported that he had been intermittently catatonic for the past 3 weeks. It is also reported by his mother that he has not been compliant with his psychiatric medications which consist of Abilify 1064 mg IM monthly and fluextine 20 mg daily. He has been also exhibiting some bizarre behaviors like walking around the home naked. B.S has had multiple previous inpatient hospitalizations this year and actually was most recently at the Pavilion from May 30th to June 14th of this year. Of note, mother reported that patient when discharged on Friday, 06/14, was verbal and communicating but has had a steady decline since then and not taking his medication. Today, B.S again presents as nonverbal. He has a blank stare. When provider attempts to interact with him multiple times, B.S does not respond except to look at provider and hold both hands and click together his fingernails as if he is trying to communicate. Although patient is nonverbal, he is moving all of his extremities normally and does follow prompts from staff.
It does appear that B.S does follow with outpatient psychiatric services at Horizon Behavioral Health as noted. It also appears that he currently lives with his mother. No other psychosocial history is able to be obtained due to patient's current catatonic state.

Substance Current Use: Per intake paperwork and reports from mother, patient does not consume alcohol. Patient does partake in marijuana and hashish use daily. Inatke has been poor so unable to assess (UTA) caffeine intake if any

Medical History:

Current Medications: Abililfy 1064 mg IM, Prozac 20 mg daily, lorazepam 2 mg by mouth B.I.D, and risperidone 3 mg by mouth B.I.D
Allergies: Pollen
Reproductive Hx: per mother’s report, single male, never married with no children

ROS:

GENERAL: dishelved, awake sitting in bed in paperscrubs, minimally interactive, rocking back and forth and non-verbal
HEENT: PERRL, extra ocular movement intact, moist mucous membrane
SKIN: warm and dry, no rashes, no lesions, no open wounds
CARDIOVASCULAR: normal S1 and S2, no murmur, regular rate and rhythm
RESPIRATORY: lungs clear, chest wall non tender, no increase work of breathing, no cough
GASTROINTESTINAL: tenderness-none, no masses palpated
GENITOURINARY: no odor or odd color, no dysuria
NEUROLOGICAL: no gross abnormalities, gross sesory intact, ambulates well
MUSCULOSKELETAL: normal active full range of motion, no tenderness, no signs of trauma, no edema
HEMATOLOGIC: no anemia, bleeding or bruising
LYMPHATICS: no enlarged nodes
ENDOCRINOLOGIC: no reports of sweats, colds or heat intolerance

Objective:

Diagnostic results: Include any labs, X-rays, or other diagnostics that are needed to develop the differential diagnoses (support with evidenced and guidelines).

Assessment:

Mental Status Examination: He is a 29 year-old African American male who presets his stated age. Client presents on the malnourished side, slider in frame. He is noted to be malodourous with matted dreads in his hair. Client is cooperative but refuse to speak with provider as he presents in a catatonic state. He stares blankly with an intense lood but remains non-verbal. Psychomotor slowing and currently non-verbal. Thought content blocking and distractible. Attentention span distractible and inattentive as evidence of behavior during interview. Remote memory unable to assess due to catatonic, non-verbal state. Client will raise head and acknowledge when name is being called but unaware of surroundings.Thought process unable to assess but to clients current condition. Insight and judgment are poor. Mood is bizarre, affect flat and bizarre. Speech is non-verball with intense eye contact. Unable to assess if client is experiencing ang suicidal ideation or having auditory/visual hallucinations

Diagnostic Impression: You must begin to narrow your differential diagnosis to your diagnostic impression. You must explain how and why (your rationale) you ruled out any of your differential diagnoses. You must explain how and why (your rationale) you concluded to your diagnostic impression. You will use supporting evidence from the literature to support your rationale. Include pertinent positives and pertinent negatives for the specific patient case.

Reflections: . Reflect on this case and discuss whether or not you agree with your preceptor’s assessment and diagnostic impression of the patient and why or why not. What did you learn from this case? What would you do differently?

Also include in your reflection a discussion related to legal/ethical considerations (demonstrating critical thinking beyond confidentiality and consent for treatment!), social determinates of health, health promotion and disease prevention taking into consideration patient factors (such as age, ethnic group, etc.), PMH, and other risk factors (e.g., socioeconomic, cultural background, etc.).

Case Formulation and Treatment Plan:

Includes documentation of diagnostic studies that will be obtained, referrals to other health care providers, therapeutic interventions including psychotherapy and/or psychopharmacology, education, disposition of the patient, and any planned follow-up visits. Each diagnosis or condition documented in the assessment should be addressed in the plan. The details of the plan should follow an orderly manner. *See an example below. You will modify to your practice so there may be information excluded/included. If you are completing this for a practicum, what does your preceptor document?

Risks and benefits of medications are discussed including non- treatment. Potential side effects of medications discussed (be detailed in what side effects discussed). Informed client not to stop medication abruptly without discussing with providers. Instructed to call and report any adverse reactions. Discussed risk of medication with pregnancy/fetus, encouraged birth control, discussed if does become pregnant to inform provider as soon as possible. Discussed how some medications might decreased birth control pill, would need back up method (exclude for males).

Discussed risks of mixing medications with OTC drugs, herbal, alcohol/illegal drugs. Instructed to avoid this practice. Encouraged abstinence. Discussed how drugs/alcohol affect mental health, physical health, sleep architecture.

Initiation of (list out any medication and why prescribed, any therapy services or referrals to specialist):

Client was encouraged to continue with case management and/or therapy services (if not provided by you)

Client has emergency numbers: Emergency Services 911, the Client's Crisis Line 1-800-_______. Client instructed to go to nearest ER or call 911 if they become actively suicidal and/or homicidal. (only if you or preceptor provided them)

Reviewed hospital records/therapist records for collaborative information; Reviewed PMP report (only if actually completed)

Time allowed for questions and answers provided. Provided supportive listening. Client appeared to understand discussion. Client is amenable with this plan and agrees to follow treatment regimen as discussed. (this relates to informed consent; you will need to assess their understanding and agreement)

Follow up with PCP as needed and/or for:

Labs ordered and/or reviewed (write out what diagnostic test ordered, rationale for ordering, and if discussed fasting/non fasting or other patient education)

Return to clinic:

Continued treatment is medically necessary to address chronic symptoms, improve functioning, and prevent the need for a higher level of care.

PRECEPTOR VERFICIATION:

I confirm the patient used for this assignment is a patient that was seen and managed by the student at their Meditrek approved clinical site during this quarter course of learning.

Preceptor signature: ________________________________________________________

Date: ________________________

References