Comprehensive Focused SOAP Psychiatric Evaluation Template

Subjective:

CC (chief complaint): “Well, my sister made me come in. I was living with my mom,

and she died. I was living, and not bothering anyone, and those people– those people, they just won’t leave me alone.”

HPI: S.T. is a 52-year-old Caucasian male presenting for evaluation of psychosis. Previous prescriptions include Haldol, Thorazine, Risperidone, and Seroquel. He says he is not going to take Haldol and Thorazine because he hates them. Risperidone gave him boobs but Seroquel is okay. The patient also reports that all the drugs are poison and he will not take them. He is complaining that the government sent people to spy on him outside his window. The patient says he can hear and see their shadows. “They think I don’t see them, but I do.” He has been hearing and seeing these people watching him “for weeks, weeks and weeks and weeks.” The patient keeps calling the 911 about the people outside the window but the 911 does not find anyone. He avoids going to the store since the people follow him there and he hears loud heavy metal music in the store He also experiences visual hallucinations by seeing birds and auditory hallucinations by hearing music during the interview.

He reports he does not sleep for days, as the voices are loud. They watch him through the TV when he tries to watch. He also says they come to the house and poison his food. He reports he tricked those people by locking everything in the fridge. He reports that the sister is plotting with the government and tapping his phone to stop the patient from living alone.

Past Psychiatric History:

  • General Statement: Began treatment at 20 when he was hospitalized to receive treatment for psychosis.
  • Caregivers (if applicable): His sister.
  • Hospitalizations: The patient was hospitalized three times when he was 20. He denies past residential treatment or detox. He denies cutting himself or having thoughts of killing himself or others.
  • Medication trials: Patient says Seroquel was okay but he hates Haldol and Thorazine; and Risperidone gave him boobs. He reports he does not take the medications because they are poison.
  • Psychotherapy or Previous Psychiatric Diagnosis: Past schizophrenia diagnosis. No report of past psychotherapy.
  • Substance Current Use: The patient smokes all day, three packs daily. He drinks a 12-pack of alcohol weekly and he had his last drink yesterday. He reports the last time he used marijuana was three years ago when his mother died. He denies ever using illegal drugs. Patient denies seizures or black outs from alcohol.

Family Psychiatric/Substance Use History: The patient’s father was “crazy with paranoid schizophrenia.” Father died in the old state hospital. Mother had anxiety. No history of family suicides or substance use.

Psychosocial History: The patient was raised by his mother and sister. Father resided in the old state hospital until his death. Mother died three years ago. The patient reports he now lives by himself but his sister is plotting with the government to change the arranging the current living situation. He has never married or had children.

Educational Level: He went to the 10th grade.

Hobbies: He says he does not work so he smokes and drinks pop for fun.

Work History: Unemployed.

Legal history: The patient denies any legal issues or DUIs. He reports 911 said they would arrest him for calling all the time about the people he sees watching outside his window.

Trauma history: No childhood or adult trauma.

Violence Hx: He reports that his father was rough on them until his death. No other reports of physical, sexual, emotional abuse. Negative for seizures, surgeries, or head injuries.

Medical History: The patient has diabetes. He also reports he had a fatty liver but they never found it “so I don’t know unless the aliens told them.”

  • Current Medications: He takes metformin for diabetes but he does not report the dosage or frequency. No reports of taking include OTC or homeopathic products.
  • Allergies: No report of environmental, food, or medication allergies.
  • Reproductive Hx: No reports of intercourse, contraceptive use, or sexual concerns.

ROS:

  • GENERAL: Negative for chills, fever, weight changes, fatigue, or weakness.
  • HEENT: Eyes: Negative for vision loss, yellow sclerae, blurred or double vision. ENT: Denies problems with hearing, runny nose, congestion, or sore throat.
  • SKIN: Denies itching or rash.
  • CARDIOVASCULAR: Negative for palpations, edema, chest discomfort, pressure, or pain.
  • RESPIRATORY: No sputum production, breathing difficulties, or cough.
  • GASTROINTESTINAL: The patient sometimes fails to eat when he thinks the people watching him are poisoning his food. No appetite changes, nausea, diarrhea, vomiting, or stomachache.
  • GENITOURINARY: No hesitancy, urgency, or burning on urination Negative for odd urine color or odor.
  • NEUROLOGICAL: Negative for bladder or bowel control changes. Denies paralysis, numbness, dizziness, or headache.
  • MUSCULOSKELETAL: Negative for muscle ache, joint stiffness or pain, or back pain.
  • HEMATOLOGIC: Denies bruising, bleeding, or anemia.
  • LYMPHATICS: Denies splenectomy or enlarged nodes.
  • ENDOCRINOLOGIC: Reports diabetes and he is taking Metformin to manage it. Negative for heat or cold intolerance or excessive sweating.
  • PSYCHIATRIC:  History of schizophrenia and sleeping difficulties because of auditory hallucinations.

Objective:

VS: BP 109/69; P 74; RR 18 non-labored; T 94.5 orally; 98%; Wt 135 lbs; Ht 5’5

General: Patient is oriented to person and place. He is disoriented to time. Cooperative.

HEENT: No head scars or swellings. Eyes: Clear with no yellow sclerae. ENT: No ear discharge. Pink and moist oral and nasal mucosa.

Neck: No palpable nodes or pain; Full range of motion.

Chest/Lungs: Symmetrical chest expansion. CTA bilaterally.

Cardiovascular:  No gallop, edema, murmurs, or rub. RRR; S1 and S2 audible; negative for murmurs, edema, rub or gallop.

Gastrointestinal: Quality bowel sounds on four quadrants. Negative for palpable masses or liver.

Neurological: Disorganized speech/word salad noted. Intact cranial nerves II – XII.

Skin: No itchiness, scars, or rashes.

Endocrinology: Thyroid glands are not enlarged or tender.

Diagnostic results:

Normal head CT scan

Urine drug test negative for FENT, THC, COC

Normal complete blood count (CBC) results

A score of 35 on the Brief Psychiatric Rating Scale (BPRS)

A head CT scan is vital to rule out brain tumor that can mimic psychotic or schizophrenic symptoms (Ganguly et al., 2018). Secondly, numerous medical conditions are associated with psychosis and the CBC results will rule out such illnesses. Drugs can also cause psychotic symptoms; hence, a urine drug test will exclude substance abuse for the patient (Ganguly et al., 2018). The results of the complete blood count (CBC) are vital in considering other medical conditions including nutritional, endocrine, neurologic, and autoimmune disorders that might cause symptoms similar to what the patient is experiencing. Lastly, clinicians use BPRS to measure schizophrenia and other psychotic disorders in patients (Kim et al., 2020). Notably, scoring more than 30 on the BRPS is an indication of major symptoms.

Assessment:

Mental Status Examination:

He is a 52-year-old Caucasian male who looks his stated age. He is dressed inappropriately for the weather. He has long unkempt hair. No odd body odor. He is cooperative with the examiner. There is evidence of tardive dyskinesia. His speech is mainly clear and coherent with normal tone and volume but has disorganized speech in a few sentences. He has logical thought process with no evidence of flight of ideas, circumstantiality, tangentiality, or looseness of association. His mood is anxious and his affect is flat. He does not maintain eye contact. He reports visual and auditory hallucinations. He displays persecutory delusional thinking. He denies current self-harm, suicidal, or homicidal thoughts. He is oriented to place and person. Disoriented to time.  His concentration is normal. Recent and remote memory are good. His insight and judgement are poor.

Diagnostic Impression:

  1. Schizophrenia

The patient is likely to have schizophrenia according to the BPRS. Moreover, the patient’s symptoms meet the DSM-5 criteria for schizophrenia. According to DSM-5, a person must experience a minimum of two symptoms that include hallucinations, delusions, negative symptoms, disorganized speech, catatonic or disorganized behavior for at least a month (Kim et al., 2020). The patient has auditory and visual hallucinations, as he hears voices and music and sees people that other people around him cannot see or hear. Secondly, he has persecutory delusions, since he falsely believes that the government and his sister are plotting against him. He also believes that there are people planning to poison his food. The patient also displayed some disorganized speech during the interview when he was saying “no drugs ever, clever, ever” and “no, no, never a clever ever.” The negative symptoms he displayed include dressing inappropriately for the weather and unkempt hair. Additionally, tardive dyskinesia is an abnormal psychomotor behavior that the patient displayed during the interview. Another criterion is for the individual to have the symptoms for more than 6 months. The patient has been experiencing the symptoms for years. He reports being hospitalized three times in the past.

  1. Brief Psychotic Disorder

Displaying delusions, hallucinations, or disorganized speech is a symptom of brief psychotic disorder in the DSM-5 (Haddad et al., 2020). The second criterion is having the symptoms for a minimum of one day but less than one month. Therefore, brief psychotic disorder has been excluded since the patient has had the disturbance for more than one month.

  1. Substance-induced psychotic disorder

Taking substances including alcohol, marijuana, and illicit drugs can induce hallucinations, delusions, abnormal psychomotor activity, and disorganized speech according to DSM-5 (Tandon & Shariff, 2019). The patient denies taking drugs except marijuana three years ago. Besides, the urine drug test was negative. He also drinks low amount of alcohol and he denies experiencing any disturbance after taking alcohol.

Reflections:

I agree with the preceptor’s diagnostic impression that the patient has schizophrenia because he meets all the criteria for the condition as outlined in DSM-5. This case study shows that genetics play a big role in the development of schizophrenia. The patient’s father had paranoid schizophrenia that increased the client’s risk of developing the same condition. Furthermore, managing schizophrenia is complicated, as delusions might lead to medication non-adherence. For instance, the patient in this case study says he will not take the medications because he thinks they are poison. The patient said Seroquel was okay. Hence, if I performed the session again, I would ask the patient if he is willing to take Seroquel again. Knowing the Seroquel dosage that the patient was taking is also important.

Legal/Ethical Considerations

            Autonomy and respect of persons are crucial ethics in psychiatry (Noordsy, 2016). Therefore, the clinician needs to inform the patient of his diagnosis and possible treatments. As such, the patient will be able to give informed consent to treatment. The patient has refused to take the anti-psychotics he was prescribed in the past. The clinician cannot force him to take the medications, as he has the right to refuse treatment. However, state allows permit involuntary commitment if the patient is a danger to him or herself and others (Noordsy, 2016). Confidentiality of patients with schizophrenia is also required unless when sharing of medical records is necessary for medical or legal reasons. Moreover, non-maleficence and beneficence ethics will require the clinician to provide treatment that offers the patient more benefits than risks.

Health Promotion and Disease Prevention

            Schizophrenia does not only affect a person’s mental health but also physical health. Schizophrenic patients are at an increased risk of developing diabetes, cardiovascular disease, obesity, and hypertension among other medical illnesses (Ganguly et al., 2018). The patient already has diabetes. Considering the patient is above 50 years old, it is crucial to manage his schizophrenia effectively to prevent additional medical conditions. If the psychosis is managed, the patient would be more likely to engage in self-care activities such as engaging in physical activity and eating healthy foods. Moreover, it is important to assess and monitor the patient for suicide risk, as older schizophrenic individuals might have higher likelihood of suicide thoughts and attempts.

Case Formulation and Treatment Plan:

Cognitive-behavioral therapy (CBT) is recommended for schizophrenia to help patients to cope with stress, hallucinations, suicidal ideations, and delusions (Ganguly et al., 2018). Social skills training will enable the patient to communicate and socialize with others. Psycho-education will also be provided to the patient and his sister to increasing the understanding of the diagnosis and the management of the disorder. Additional therapy for schizophrenia is exercise particularly yoga. According to Ganguly et al. (2018), yoga acts as a form of entertainment and recreation and it increases the overall wellbeing of a person with schizophrenia. The patient does not have a job or a hobby and yoga would be beneficial to him.

Client advised to continue taking Metformin for diabetes.

Initiate 300 mg/day PO Seroquel tablet, extended release for schizophrenia. Seroquel is a second generation antipsychotic that is effective in managing the negative and positive symptoms of schizophrenia with few side effects (Iqbal et al., 2019).

Discussed benefits and risks of Seroquel including non-adherence. Possible side effects of Seroquel discussed with the patient include headache, dizziness, fatigue, dry mouth, constipation, increased appetite, increased blood pressure, dyskinesia, back pain, tremor, and abdominal pain (Iqbal et al., 2019). The patient was informed to report any adverse side effects.

Client advised not to stop medication abruptly without discussing with clinicians.

Informed the client of the risks of mixing medications with herbal, illegal, OTC, drugs, and alcohol. Discussed the effect of alcohol and drugs on sleep, mental, and physical health. Patient advised not avoid this practice and encouraged to abstain.

Client advised to call 911 or visit the ER if he develops suicidal or homicidal thoughts.

Allowed time for questions and provided answers. Client agreed to adhere to treatment including taking Seroquel. Client gave verbal agreement.

Labs ordered and reviewed are: HbA1C test, ECG, and blood test. The patient is on Metformin for diabetes; thus, a HbA1C test, ECG, and blood test to check Vitamin B12 are crucial to monitor diabetes and associated risks. The clinician will order the diagnostic tests before prescribing medications.

Return to clinic in one week to review response to Seroquel and possibly titrate it.

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