Psychiatric Progress Note (SOAP) Sample Essay

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Psychiatric Progress Note (SOAP) Sample Essay

NAME: N.D                  DATE: 04/5/2020 

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Subjective:

CC: I am having delusional thought and I am thinking of suicide”

N.D presents to the crisis unit complaining of having delusional and suicidal thoughts. She is a psychiatric patient with a history of substance abuse. She has tardive dyskinesia symptoms presenting with flight of ideas. She notes that she is homeless, depressed, unemployed and with a history of bipolar and schizoaffective disorder. She has a history of hypertension but has not been compliant with the management medication. She provides no history of the father but explains that hermother has history of hypertension. She is a mother of four children who she describes as being alive and well. She contacts her first daughter while others ask her to worry about herself and not them. The client is homeless since she was kicked out in a shelter. Psychiatric Progress Note (SOAP) Sample Essay

Objective MSE:Vitals, review of testing and lab work, MSE

The patient is poorly groomed and unkept. She appears disturbed and hopeless. She does not maintain eye contact and is in a sad mood. She is cooperative even though she doesn’t maintain alertness. She appears bored, self-concerned, tired and inattentive. N.D has disorganized suicidal and homicidal thoughts. Her skin appears cold and she has sweaty arms with dry tongue and mouth.

A Beck Depression Inventory (BDI) filled by the patient indicated severe depression. Her vital signs were as follows BP142/98mmHg, RR 10, P 15, BMI 22, T 98.3. Psychiatric Progress Note (SOAP) Sample Essay

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Assessment:

The client is suffering from a relapse of schizoaffective comorbid with alcohol addiction. Schizoaffective disorder describes a mental health condition combining mood disorder and schizophrenic symptoms. This is evident in the patient’s symptoms whereby she has a past history of bipolar and current oppressive symptoms such as suicidal thoughts. According to the DSM5 criteria, schizoaffective disorder is confirmed by the presence of depression symptoms characterized by depressed mood (Baethge, 2020). The patient has delusional and suicidal thoughts according to her chief complain. She is also disorganized from living in the streets after being kicked out of the shelter. The client also meets the criteria for episodes of mood disorder including being bipolar, having feelings of hopelessness and alcohol abuse.

Schizophrenic disorder has a high hereditary risk. There is a 40% chance of co-twins, 10% chance of siblings and 40% of both parents in developing the illness (Archibald et al., 2019). Drug abuse may also increase the risk of contracting the disease and hence, the patient’s condition could have been worsened by alcohol abuse. The current treatment plan for the patient is indicated for treatment of schizophrenia. This might not be effective in resolving her problem since she suffers from schizoaffective disorder. Psychiatric Progress Note (SOAP) Sample Essay

The neurobiological mechanisms of the disease include dysfunction in brain reward circuitry. The grey matter is diffusely distributed and its density lost. According to Baethge (2020), the temporal, anterior/middle cingulate cortex and frontal regions are the most affected. There is an imbalance in neurotransmitters which assist nerve cells to send messages.

Current Medications:

  1. Seroquel 100mg at bedtime,

Plan:

The plan for management of the patient should involve a prescription of 3mg Invega. The dosage is began at this dose and increased with time. This is the only drug approved by Food and Drug Administration for management of schizoaffective disorder (Muñoz-Negro, Cuadrado & Cervilla, 2019). The neurochemistry of the drug is associated with antagonism that interferes with the communication of neurotransmitters in the brain. The side effects of this medication include reactions to injection sites, tremors and shaking, restlessness, dizziness and drowsiness (Baethge, 2020). The expected benefits is elimination of symptoms and prevention of relapses. It is contraindicated in the elderly since it can cause their death as well as persons with a known sensitivity to Risperdal Consta or risperidone (Muñoz-Negro, Cuadrado & Cervilla, 2019). Follow up is done after every two weeks to monitor their progress. The patient will be taught on management of positive mental wellness, importance of drug compliance, and healthy drug administration. Psychiatric Progress Note (SOAP) Sample Essay

References

Archibald, L., Brunette, M. F., Wallin, D. J., & Green, A. I. (2019). Alcohol Use Disorder and Schizophrenia or Schizoaffective Disorder. Alcohol research : current reviews40(1), arcr.v40.1.06. https://doi.org/10.35946/arcr.v40.1.06

Baethge, C. (2020). How reasonable is it to uphold the diagnostic concept of schizoaffective disorder?.

Muñoz-Negro, J. E., Cuadrado, L., & Cervilla, J. A. (2019). Current evidences on psychopharmacology of schizoaffective disorder. Actas Esp Psiquiatr47(5), 190-201. Psychiatric Progress Note (SOAP) Sample Essay

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