Because the patient’s reported hallucinations are not persecutory, as a clinician, what medications would you start with? 2. What treatments (pharmacological and non-pharmacological)

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

© 2022 Walden University Page of

Week #9: Case Study Presentation

Stephanie Patterson

College of Nursing-PMHNP, Walden University

PRAC 6675: PMHNP Care Across the Lifespan II

Dr. Karen Taylor

October 25, 2023

Objectives of Presentation:

1. The audience will analyze the comprehensive focused SOAP note for this patient in order to identify the signs and symptoms of psychosis.

2. The audience will evaluate this patient case to determine the most accurate primary diagnosis and rule out diagnoses.

3. The audience will apply the information from this SOAP note, their clinical knowledge, and use the DSM-5 to help determine rule out diagnoses related to psychosis.

4. The audience will assist in creating an appropriate treatment plan using pharmacological and non-pharmacological methods based on the patient’s presenting signs and symptoms.

Subjective:

CC (chief complaint): “I am here because I need to establish care for my medicines and hallucinations”

HPI: T.H. is a 64 year old Caucasian female that presents for psychiatric care related to medication management and management of psychosis symptoms. The patient presents alone. Pt reports that she has a significant history of psychiatric issues. Pt states, “In 2007 I started having hallucinations”. Pt reports that she has a previous diagnosis of “schizophrenia”. Pt reports she began having periods of depersonalization/derealization as a child due to sexual trauma. The pt states, “my uncle would touch me inappropriately”. The patient also reports experiencing sexual and mental abuse as an adult from two abusive relationships. Pt reports that she has ongoing paranoia, visual, auditory and tactile hallucinations that have occurred since 2007. Pt reports she hears voices at times and states, “sometimes the voices are my children and my mother”. Pt reports she was primary caregiver for both of her parents until her dad passed away in June. The pt reports she is living with and still caring for her mother who is ill. The pt reports having a strenuous relationship with her mother, that her mother can be very demanding of her at times and say things that are “not very nice” to her. The pt reports that her mother convinced her at one time to stop taking all of her psych meds which resulted in the patient feeling “worse and very depressed”. The patient reports being hospitalized once for three days in May of 2023 for “depression”. Pt reports she started taking medications again after being discharged and states she is compliant with taking her currently prescribed medications. Pt reports that she has taken Vraylar, Geodon, Seroquel and Haldol unsuccessfully. The pt reports “I didn’t like how any of them made me feel and they did not work for me. Pt states she feels “tired a lot” and has a hx of insomnia. Pt reports her past hallucinations have included “seeing purple monsters” and “having sexual intercourse with ghosts”. Pt explains that she could feel herself being “sexually aroused” and “even reaching orgasms” during these hallucinations. Pt reports she still sees things at times such as “people talking but they are not really saying anything to me” but states, the hallucinations have “gotten better”. The patient expresses an extensive history of sexual trauma caused by her ex-husband who she reports forced her to perform sexual acts with other people (men and women) or that he would threaten her and tell her he would not have sex with her unless she did what he told her to do. Pt reports that the task of caring for her mother and her mother being “verbally abusive” causes her to feel depressed and at times even “hopeless and sad”. Pt reports feeling guilt about the delusions/hallucinations. Pt reports a family psych history, “my brother has PTSD and schizophrenia”. Pt reports that her family moved around a lot when she was a child and reports she never really had any “true friends”. The pt reports she completed highschool education. The pt reports she is retired and she enjoys spending time with her two grandchildren and attending church.

Substance Current Use: Pt denies history of substance use. Pt denies current substance use.

Medical History: Pt has a medical diagnosis of HTN controlled and under care of PCP

• Current Medications:

Alprazolam 0.5mg bid

Aspirin 81mg EC daily -OTC

Docusate Sodium 100mg daily – OTC

Vit D 50,000 U each week – Vitamin

Caplyta 42mg daily

Trazodone 100mg @ hs

Lisinopril 10mg daily

• Allergies: NKA

• Reproductive Hx: Patient has two children and reports having a hysterectomy at age 39. Pt reports that she is not sexually active at this time.

ROS:

• GENERAL: Pt denies weakness, fever, or chills

• HEENT: Pt reports wearing glasses for vision correction but denies double vision. Pt denies drainage from ears or difficulty hearing. Pt denies cough, sore throat or nasal congestion.

• SKIN: Pt denies redness, itching, rashes or open sores

• CARDIOVASCULAR: Pt reports a dx of HTN but denies chest pain. Pt denies swelling to extremeties

• RESPIRATORY: Pt denies shortness of breath. Pt denies hx of asthma

• GASTROINTESTINAL: Pt denies stomach pain, nausea, vomiting or diarrhea

• GENITOURINARY: Pt denies abnormal urinary frequency. Pt denies burning or pain with urination.

• NEUROLOGICAL: Pt denies frequent headaches, hx of seizures or memory loss

• MUSCULOSKELETAL: Pt denies muscular pain or deformities, pt reports hx of left foot surgery that feels “sore sometimes” but does not cause constant pain. Pt reports she is able to move all extremities within normal limits for her.

• HEMATOLOGIC: Pt denies unsual bruising or bleeding

• LYMPHATICS: Pt denies swollen lymphnodes.

• ENDOCRINOLOGIC: Pt denies excessive heat or cold intolerance.

Objective:

Diagnostic results: Obtained lab results from previous hospitalization in May. These labs include CBC, CMP, TSH, Vit D, lipid panel and HgA1C. The practitioner will obtain consent from the patient to perform the PANSS assessment and include collateral information from the patient’s son that lives locally. The practitioner may also use MRI to rule out brain abnormalities seen in patients with schizophrenia.

Assessment:

Mental Status Examination: Pt is a&o x3. No confusion noted. No evidence of a/v hallucinations throughout interview. Pt is able to make needs known using clear speech. Speech volume and tone are normal. Pt appears clean, neatly groomed and dressed appropriately for her age, season and occasion. The patient is able to maintain eye contact throughout pt interview. Pt affect is full with congruent mood. However, pt appears anxious and restless at times. Pt reports decreased depression with medication. Pt is not easily distracted and able to maintain focus throughout interview. No cognitive impairment or flight of ideas noted, no paranoia noted at this time. Pt reports visual, auditory and tactile hallucinations frequently but not every day/night. Pt denies mania. Pt denies s/h ideations. Pt is cooperative with fair insight and judgement.

Diagnostic Impression:

Depressive disorder with psychotic features (F33.3) was chosen as primary diagnosis. According to the DSM-5, the patient meets criteria for this diagnosis based on reports of depressive mood most days and lasting for longer than two weeks at a time, feelings of sadness and hopelessness, fatigue, and sleep disturbance (2022). Although the patient reports her depression is currently controlled with medication, she has a history of depressed mood and hospitalization due to depression. Based on the patient impression and presenting symptoms, it seems that the hallucinations most commonly happen when she is having a depressive episode. However, it should be considered that the hallucinations are ongoing and that further information is needed to determine schizoaffective disorder over depressive disorder with psychotic features as the primary diagnosis for this patient.

PTSD (F43.10) was chosen as a differential diagnosis as evidenced by the patient reports of extensive trauma history. The patient reports sexual trauma in childhood, experiencing the loss of her father, and experiencing sexual, physical and emotional trauma in two intimate relationships as an adult. Criteria that is met to justify this diagnosis includes, directly experiencing the traumatic events, recurring, intrusive memories of the events, negative alterations in cognition, sleep disturbance, depersonalization and derealization (2022). While the patient meets most diagnostic criteria for this diagnosis, the extent of the psychosis does not justify PTSD as primary diagnosis. The DSM-5 refers to PTSD psychosis as “auditory, psudeohallucinations” (2022). This does not align with the patient reports of auditory, visual and tactile hallucinations.

Schizophrenia (F20.9) The patient has received a schizophrenia diagnosis from a previous clinician and is therefore to be considered and further explored. The DSM-5 diagnostic criteria for schizophrenia includes hallucinations and delusions which this patient does meet (2022). However, at this time, the patient does not present with common features of schizophrenia such as catatonic behavior, disorganized speech, inappropriate affect, cognitive impairment or lack of insight (Hany et al., (2023). The patient reports having periods of paranoia, however, she is alert,oriented, able to actively participate in conversation and function independently. Another criteria listed includes ruling out schizoaffective disorder and depressive or bipolar disorder with psychotic features (2022). However, the patient does meet diagnostic criteria for depressive disorder with psychotic features. Therefore, based on this clinical impression, there is not sufficient evidence to support a diagnosis of schizophrenia at this time and it should be ruled out.

Reflections:

While this patient has a previous diagnosis and noted family history of schizophrenia, I agree with the more conservative approach taken to discover the etiology of the psychosis in this case. The patient’s experienced trauma and depression along with the pharmacological treatment already in place, presented challenges when choosing a primary diagnosis. However, the reported sexual trauma and hallucinations of a sexual nature cause me to feel strongly that her depression and traumatic experiences play a significant role in the etiology of her psychotic symptoms. As a clinician, I feel exploring the cause of psychosis by using a trauma informed approach to rule out other diagnoses vs going directly to a label such as schizophrenia is both wise and ethical practice. I also feel it is important to continue gathering information such as obtaining previous psychiatric records (with patient consent), to gain a better understanding of why this patient was previously diagnosed with schizophrenia.

Recent focus on trauma informed care has raised awareness for practitioners about the implications of trauma (Monique Tello, 2018). In fact, studies have shown that depression and psychosis can be a result of trauma (Compean & Hamner, 2019). Using a trauma informed approach with this patient resulted in a better understanding of why she may be experiencing difficulty regarding her mental health. But it has also been helpful in developing a more focused, individual treatment plan that using both pharmacological and nonpharmacological interventions.

One social determinate of health to consider for this patient is having access to proper resources due to living in a rural area. Other things to consider when treating this patient are her age when prescribing psychotropic medications and her current support system. She mentions that she has two children but only one lives locally. The relationship with her mother is strenuous and her mother has already expressed disapproval in the patient’s need to take psychotropic medications. The patient is not currently in therapy, however, she was not opposed to this treatment option. More information is needed to determine if a lack of support from her mother will hinder the patient’s option of using psychotherapy as a treatment method. The patient has a history of psychotropic medication use. However, when prescribing medications for the elderly population, special considerations such age related, physiological changes and pharmacokinetics must be taken into account (Barry & Hughes, 2021).

Case Formulation and Treatment Plan:

The treatment plan for this patient includes gathering information by obtaining medical records from the patient’s PCP and previous psychiatric provider. The patient will continue with her current medication regimen with the addition of Zyprexa 2.5mg in A.M. and 5mg at hs. Will defer to PCP for Xanax. Therapy was discussed during this visit and the patient verbalized that she is not opposed to this. However, further discussion is needed in subsequent visits to determine which specialty would most benefit the patient. Options discussed this visit include trauma based CBT. Education provided on the s/e of new medication, Zyprexa, including weight gain and tardive dyskinesia. Pt instructed to report any s/e to provider and to not discontinue any psychotropic medications without prescriber notification. Pt verbalized understanding.

Pt provided with local emergency contact numbers and instructed to call 911 or go to the nearest emergency room if she becomes suicidal or experiences adverse effects from medications.

Discussion Questions:

1. Because the patient’s reported hallucinations are not persecutory, as a clinician, what medications would you start with?

2. What treatments (pharmacological and non-pharmacological) are most effective for patients with extensive trauma history?

3. What symptoms could be co-occurring in relation to PTSD vs schizophrenia for this patient?

4. Define Schizophrenia and the symptoms related to schizophrenia?

Must have 2-3 reference for each questions listed above

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

American Psychiatric Association. (2022). Diagnostic and statistical manual of mental

disorders (5th ed., text rev.).  https://doi.org/10.1176/appi.books.9780890425787

Barry HE, Hughes CM. An Update on Medication Use in Older Adults: a Narrative Review.

Curr Epidemiol Rep. 2021;8(3):108-115. doi: 10.1007/s40471-021-00274-5. Epub 2021

Jul 20. PMID: 34306966; PMCID: PMC8294219.

Compean E, Hamner M. Posttraumatic stress disorder with secondary psychotic features (PTSD-

SP): Diagnostic and treatment challenges. Prog Neuropsychopharmacol Biol Psychiatry.

2019 Jan 10;88:265-275. doi: 10.1016/j.pnpbp.2018.08.001. Epub 2018 Aug 6. PMID:

30092241; PMCID: PMC6459196.

Hany M, Rehman B, Azhar Y, et al. Schizophrenia. [Updated 2023 Mar 20]. In: StatPearls

[Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-. Available from:

https://www.ncbi.nlm.nih.gov/books/NBK539864/

Monique Tello, MD, MPH. (2018, October 16). Trauma-informed care: What it is, and why it’s important. Harvard Health. https://www.health.harvard.edu/blog/trauma-informed-care-what-it-is-and-why-its-important-2018101613562

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