NRNP 6665 Week 7 Soap Note Paper

CC (chief complaint): “my parents booked this appointment last week for me but I don’t know what it is about”

HPI: Mr. Feldman is a 20-year-old Caucasian male who was booked for an appointment by his parents because he has had difficulties in school. During this appointment, Mr. Feldman doesn’t understand why he is at the clinic but believes that the parents know. Mr. Feldman is a freshman at the States College taking advanced placement courses. He is currently taking advanced calculus and theoretical physics. In the past six months, Mr. Feldman has had problems with grasping the knowledge from his classes. He described the courses he is taking as ‘mysteries.’ Whenever he thinks he has understood the courses, they disappear from memory grasp. He believes that the totality of life doesn’t allow him to repeat regaining the knowledge.

NRNP 6665 Week 7 Soap Note Paper

However, he plans to do double majoring for the courses by combining physics and philosophy. At the college, he stays with his roommate whom he is not willing to speak about he the roommate owns a microwave oven in the hostel, and he that illegal. Mr. Feldman also believes that the interview room is spying on them and the tormentors will spare the interviewer because of Mr. Feldman’s presence. He reports sleep problems citing being spied on by unknown people who are after destroying human destiny. These unknown people speak about bleeding humanity from their rightful destiny.

He hasn’t been admitted to any psychiatric hospital for any mental illnesses. He has never been managed for any psychiatric illness in the outpatient clinic either. Mr. Feldman reports good relationships with the parents and siblings. He, however, dislikes coursemates for unclear reasons. At home, he lives with his parents who are well. There are no known genetic illnesses in the family. No family member suffers from any psychiatric illness.

Substance Current Use: Mr. Feldman doesn’t smoke tobacco or take alcohol. He doesn’t use illicit substances of abuse including cocaine, heroin, marijuana, or stimulants

Medical History: He is not diabetic, hypertensive, or epileptic. He reports no major hospitalizations or surgeries. He also denies being managed for any chronic illness.

  • Current Medications: Mr. Feldman is currently on no medications
  • Allergies: Feldman reports no food or drug allergies or reactions that he is aware of.
  • Reproductive Hx: Feldman reports being sexually inactive. Ge has not engaged in sexual activity, has no sexual partners, denies any sexual interests

ROS:

  • GENERAL: no fever, fatigue, weight loss, or malaise
  • HEENT: no headache, blurry vision, double vision, vertigo, tinnitus, ear discharge or pains, nasal bleeds, pain or congestion, facial pressure or pain, snoring, mouth breathing, sore throat, or any flu symptoms
  • SKIN: no rashes, skin itchiness, abnormal skin pigmentation, or scaling
  • CARDIOVASCULAR: no palpitations, left-sided chest pain, neck vein engorgement, swelling of the legs or abdomen.
  • RESPIRATORY: no chest tightness, cough, sputum production, difficulty in breathing, shortness of breath, or hemoptysis
  • GASTROINTESTINAL: no loss of appetite, difficulty in swallowing, nausea, vomiting, diarrhea, abdominal pain, constipation, burping, or yellowing of eyes
  • GENITOURINARY: no genital itchiness or ulcerations, no urinary frequency, urgency, retention, incontinence, or hesitancy. No nocturia, dysuria, hematuria, or pus in the urine
  • NEUROLOGICAL: no weakness, tremors, convulsions, paralysis, history of stroke, bladder or bowel incontinence
  • MUSCULOSKELETAL: no muscle weakness, back pains, neck pains, joint weakness, stiffness, or abnormal sounds with movements
  • HEMATOLOGIC: no anemia, easy bruising, nosebleeds, or frequent infections
  • LYMPHATICS: no limb swelling or pain
  • ENDOCRINOLOGIC: no intolerance to heat or cold weather, no polyuria, polydipsia, or polyphagia with weight loss, no goiter

Objective:

Diagnostic results: no diagnostic tests were ordered or completed

Assessment:

Mental Status Examination: Mr. Feldman is a 20-year-old Caucasian male who looks his stated age. He is alert and oriented to time and person. He is fairly groomed and the hair is well-kempt. He has dressed appropriately for his age and occasion. He has fairly long black hair and brown eyes. No signs of tremors or abnormal movements disorders were noted. He has a clear spontaneous speech with regular rates, rhythm, and tone. He cooperates fairly with the examiner and doesn’t maintain good eye contact with the examiner. He is easily distracted by the surroundings and shows signs of active auditory and visual hallucinations. He looks suspicious and holds his hands together. His mood is subjectively anxious and the affect is flat. Pieces of evidence of delusional thinking were noted. He has a flight of ideas and his thought process is illogical. His insights and judgments are poor. His recent and short-term memories are intact

Diagnostic Impression: Mr. Feldman shows signs of hallucinations, paranoia, lack of insights, and problems with thinking. My primary diagnosis is schizophrenia, the paranoid type. Differential diagnoses include paranoid personality disorder, delusional disorder, brief psychotic disorder, schizotypal personality disorder, and schizoid personality disorder.

Primary diagnosis: Schizophrenia 296.90 (F20.9). The fourth edition of the Diagnostic and Statistical Manual for Mental Disorders (DSM IV) classified various types of schizophrenia and included the paranoid type. However, this was dropped in the DSM-5 (American Psychiatric Association, 2013). Mr. Feldman’s clinical presentation has met the majority of the criteria for diagnosis of schizophrenia according to the DSM-5. He has delusions, auditory and visual hallucinations, and flattening of affect. He also expressed dysfunction in social and cognitive domains. His parents reported that he had problems with schoolwork. Socially, he has few friends and no sexual relationships. The academic deterioration has been noted for 6 months since joining college.

Paranoid Personality Disorder 300.1(F60.0): this differential can only be deduced from the behavior of Mr. Feldman. He portrays mistrust between him and his roommate. It appears that he has grudges with his roommate for owning a microwave oven. He is suspicious of the surroundings and perceived unknown people following him. The diagnosis of paranoid personality disorder (PPD) can be ruled out on basis of lack of evidence of other key characteristics such as hypersensitivity to criticism, doubting of other’s loyalty, and hostility according to DSM-5 (Niederland, 2017).

Delusional Disorder 297.1 (F22): Mr. Feldman showed evidence of non-bizarre delusional thinking. He talked about bleeding degeneration of blood cells and termination of rightful human destiny. From his delusions, he became paranoid and thought that the room is spying on him. This has affected his functioning at college and socially. However, schizophrenic and psychotic symptoms dominate his presentation.

Schizoid personality disorder 301.20 (F60.1): Mr. Feldman showed disinterest in close relationships. These include sexual relationships. These patterns cannot be evaluated from the patient’s history to distinguish them from schizotypal personality disorders (Liu et al., 2021 NRNP 6665 Week 7 Soap Note Paper).

Reflections: Mr. Feldman’s clinical presentation is dominated by psychotic symptoms. Delusional thinking, hallucinations, and negative symptoms are present. Poor insights and flattening of affect are also seen. My primary diagnosis was schizophrenic and the patient met the majority of the criteria for diagnosis of schizophrenia by the DSM-5 (American Psychiatric Association, 2013). Some features of personality disorder are presented. If I was to redo the interview with this patient, I would include the input of the parents because her version would provide the symptoms that Mr. Feldman had portrayed before this admission. Mr. Feldman is not aware he is mentally ill and he is unsure why his parents booked him this appointment. This corroboration in history would help me in distinguishing my primary diagnosis from the differential diagnoses.

Case Formulation and Treatment Plan:

Pharmacotherapy: the patient will be made aware of his condition, and consent sought from the parents to initiate treatment.  Abilify 10mg/day PO BID will be prescribed. The family will be taught about Blackbox warnings and the potential side effects of Abilify. The patient will be re-evaluated in two weeks for dose adjustment if necessary (Maroney, 2020). The patient will be taught about potential weight gain and frequent headaches that would result from this medication. Dizziness and occasional tremors (Shukla et al., 2021)will be made known to the patient. The family will be advised to watch out for suicidal tendencies and seek emergency care.

Psychotherapy: adjunctive cognitive-behavioral therapy (CBT) will be prescribed. Three times weekly counseling sessions will be prescribed for the patient as well. The specific forms of CBT that Mr. Feldman will receive will include cognitive remediation and cognitive enhancement therapies. Outcomes will be expected to manifest in social relationships, schoolwork, and independent living

NRNP 6665 Week 7 Soap Note Paper References

  • American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (DSM-5 (R)) (5th ed.). American Psychiatric Association Publishing.
  • Liu, J., Yang, T., Zhou, L., Gong, J., He, Y., Cui, X., Luo, X., & Wu, J. (2021). Association between schizotypal personality traits and emotional instability: mediation and moderation analysis among Chinese college students. Journal of Affective Disorders291, 83–92. https://doi.org/10.1016/j.jad.2021.04.079
  • Maroney, M. (2020). An update on current treatment strategies and emerging agents for the management of schizophrenia. The American Journal of Managed Care26(3 Suppl), S55–S61. https://doi.org/10.37765/ajmc.2020.43012
  • Niederland, W. G. (2017). The schreber case: Psychoanalytic profile of A paranoid personality. Routledge.
  • Shukla, A. K., Mehani, R., & Sadasivam, B. (2021). Abilify MyCite (aripiprazole): A critical evaluation of the novel dosage form. Journal of Clinical Psychopharmacology41(1), 93–94. https://doi.org/10.1097/JCP.0000000000001334