Assignment 2: Focused SOAP Note and Patient Case Presentation/PRAC 6665: PMHNP Care Across the Lifespan I Practicum

Duration of Session: 50 Minutes General Information Given by: Patient Information Given by: Patient Legal Status: Voluntary Chief Complaint: Reason for Admission: (from crisis unit provider on 07-11-22 at 14:57 ) Patient is a 27 year old male with PPHx of schizoaffective disorder, polysubstance abuse (marijuana, cocaine), medication noncompliance presents involuntarily to Crisis via Ex-Parte by patient’s mother for aggressive behavior and psychotic symptoms. Mother is listed as patient’s legal guardian. History of multiple hospitalizations at JBHH, last here from 04/04-04/19 with similar presentation. On exam, patient is found sitting calmly in the milieu, grossly delusional, disorganized thought process, perseverating on taking his medications and being discharged. Patient states his name is Bodi, he is 41 years old, and is here because his “daughter” wants him to take his medications. Denies SI/HI/AVH. No evidence of depression, mania, intoxication/withdrawal. Patient required ETO (Haldol 5 mg, Ativan 2 mg, Benadryl 50 mg) while on unit due to agitated behavior, threatening towards staff. Per patient’s mother ,patient is noncompliant with his medications, does not care for himself, actively psychotic and fears for her safety. She reports that he is frequently walking around with a knife in his hand saying he is going to kill her. She states she can no longer live like this and does not want him discharged home to her. She reports she has video evidence of his aggressive behavior and would provide it if helpful to his management. She reports that patient is severely delusional as patient believes that his mother is his daughter. HPI: This is a 27 year old male with priorbehavioral health history of Schizoaffective disorder, and SUD that was brought in to the JMHBH ED by police ex partee due to psychosis. The patient was aggressive with the mother. The patient has multiples admissions for similar behavior, non-compliant with medications. The patient has history of State Hospital for 6-months. He is also pending of charge for aggression on the street (as per mother statement). Upon arrival to the crisis unit, this patient initial presentation consisted of aggressive behavior toward staffing, requiring the administration of a ETO. In the unit the patient seen and evaluated in the common area requesting a discharge, perseverations, delusional thinking about her mother that is his daughter. The LG was contacted (mother) and she is coming in the evening today to sign for medications and treatment. Target Symptoms: Quality –psychosis, Duration –days to weeks Timing –increasing Severity – mild Context –adjustment in medications, Modifying factors: Aggravating: medication noncompliance, Alleviating: hospitalization, compliance with medications , good sleep hygiene Interfering with daily functioning: Yes Interfering with safety of self/others: Yes Causing self-neglect: Yes Associated signs and symptoms: · Suicidal ideation –No · Command type hallucination –No · Delusions –Yes · Depression/helplessness/hopelessness –No · Sleep disturbances –No Past Psychiatric History: Past inpatient hospitalizations: Multiple previous JBHH admissions Past state hospitalizations: yes Past outpatient: private provider (patient don’t recall name) Compliance: non-compliance ECT: No Individual/group therapy: No Past suicide attempts: denied Past violence: denied Past Substance Abuse History: Type of Substance: * Patient will not voluntarily provide this information at this time. Tobacco Prevention Metrics: Have you smoked tobacco in the last 30 days: No If yes Counseling provided during the hospital stay N/A. Was nicotine replacement therapy provided: N/A Patient received nicotine replacement therapy. N/A Patient declined nicotine replacement therapy N/A Allergy to all FDA-approved tobacco cessation medications. N/A FDA smoking cessation medication: None Past Marchman Act: No Past Rehabilitation Unit admissions: Yes Past Detoxification Unit admissions: No Past Outpatient Substance Use: No AA/NA participation: No Compliance: N/A Past Medical History: TBI / LOC / Black outs: None Seizures: No Allergies: NKA Past Surgical History: None Abuse and Neglect: 1. Trauma History: None 2. Physical Abuse: None 3. Domestic violence: None 4. Emotional Abuse: None 5. Neglectful relationship: None 6. Financially exploited: None 7. Exploitation: None Homicide Risk assessment: 1. Thoughts of harming someone: None 2. Having you ever been so upset or angry that you thought of killing or harming someone: None 3. Have you ever tried to kill or harm anyone: None A. Were you arrest:N/A Nutritional Assessment: 1. Has there been a weight loss or gain of 10 pounds or more in the past three months: None 2. Changes in appetite: None 3. Dental problems in the last 3 to 6 months: None 4. Eating habits: None Pain Assessment: Pain present: No actual or suspected pain Numeric score, if present (1-10): 0 Location if present: Quality if present: Family History: Family history: negative Mental illness: would not elaborate as to specific family member. Suicide attempts: denies Substance abuse: denies Medical problems: denies Dementia: denies Social/Legal History: Legal: Pending charges Employment:Unemployed living situation: with parents support system: Fair REVIEW OF SYSTEM: General: Denies Fever, chills, dizziness, weakness. Eye: Denies redness, discharge, visual loss, blurred vision, vision change. ENT: Denies Sore throat, Nosebleed, Rhinorrhea, Throat swelling, hearing loss. Cardiovascular: Denies Chest Pain, Rapid heartbeat, lower extremities swelling, palpitations, orthopnea. Respiratory: Denies SOB, productive cough, hemoptysis. Gastrointestinal: Denies nausea, vomiting, diarrhea, constipation, bloating, melena. Genitourinary: Denies dysuria, frequency, flank pain, hematuria. Muscular: Denies myalgia, neck/back pain, arthralgia, redness. Skin: Denies rash, swelling, lacerations, abrasions. Neurologic: Denies headaches, numbness, change LOC, weakness, paresthesia, change in speech. Hematologic: No bruising, no petechiae, no bleeding. Mental Status Exam: Appearance: limited hygiene and groomed Attitude toward examiner: demanding defensive, Alert and oriented : to person time, place, Eye contact: normal Speech: pressured Mood: elevated Affect: labile Thought process: Disorganized, tangential Thought content: delusions Perceptual disturbances: None Suicidal ideation/intention/plan: No Homicidal ideation/intention or plan: No Insight: lnone insight Judgement: dangerous Attention and Concentration: fair Columbia Suicide Severity Rating Scale Since Last Visit Wish to be Dead: Since Last Visit Wish to be Dead: No Since Last Visit Suicidal Thoughts: No Since Last Visit Idea w-Method No Intent: No Since Last Visit Idea w-Intent No Plan: No Since Last Visit Suicide Intent w-Plan: No Since Last Visit Suicide Behavior: No Medications: Medication List Active Medications Ordered Al hydroxide/Mg hydroxide/simethicone: 30 mL, ORAL, Q6H, PRN: Dyspepsia. diphenhydrAMINE: 50 mg, 1 mL, IM, Q4H, PRN: See MH ETO Restrain Seclusion Form. haloperidol: 5 mg, 1 mL, IM, Q4H, PRN: See MH ETO Restrain Seclusion Form. LORazepam: 2 mg, 1 mL, IM, Q4H, PRN: See MH ETO Restrain Seclusion Form. magnesium hydroxide: 30 mL, ORAL, Q12H, PRN: Constipation. nicotine: 2 mg, 1 lozenge, TRANSMUCOSAL, Q2H, PRN: See Comment. Medications Inactivated in the Last 72 Hours diphenhydrAMINE: OVERRIDE, ONCE. haloperidol: OVERRIDE, ONCE. LORazepam: OVERRIDE, ONCE. Immunizations: No Immunizations Documented This Visit Vital Signs/Measurements/Pain Intensity:Vitials/Ht/Wt

Height Description: Estimated

Height: 180.3 cm

Weight Description: Estimated

Weight: 70 kg

Body Mass Index: 21.53

Temperature Oral: 36.4 DegC Low

Peripheral Pulse Rate: 95 bpm

Respiratory Rate: 18 br/min

Systolic Blood Pressure: 132 mmHg

Diastolic Blood Pressure: 79 mmHg

SpO2: 100 %

Lab Results: Diagnosis: Schizoaffective disorder, unspecified (F25.9) Assessment/Plan: Disposition: Admit to inpatient treatment Problem #1: psychosis Response to treatment: Worsening Medications, Labs and Plan: Haldol and Will consider the use of a LAI during the course of present admission. Problem #2: mania / Mood dysregulation Response to treatment: Worsening Medications, Labs and Plan: Depakote Therapy: Milieu/ brief supportive Consultations: n/a Risk: low , No suicidal ideations. Goals of treatment while in inpatient: Increased level of functioning Reestablish healthy coping skills Identify external support system Increased self esteem Improved mood and affect Monitor medication compliance Develop effective social relationships Improve communications skills Decreased agitation if present Decreased delusional/paranoid thought pattern if present Provide safety for patients Decrease hallucinations if present Decrease feelings of suicidality if present upon admission COUNSELING/PSYCHOEDUCATION: Provided with: Patient Diagnostic results Risk and Benefits of treatment options Medication management including treatment options, potential benefits and side effects Importance of compliance with chosen treatment options Drug-drug interactions Risk factor reduction Prognosis Patient Instructions: Encouraged compliance with medications Benefits and side effects of medications re-discussed Encouraged reporting side effects to nursing and medical staff Nursing Instructions: Universal Social Work instructions: assessment for placement/aftercare Precaution: behavioral observation

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