NRNP 6635 Week 7 Assignment: Psychopathology and Diagnostic Reasoning Soap Note
Psychopathology and Diagnostic Reasoning Soap Note: Ms. Branning has no history of psychotherapy but was diagnosed with hypothyroidism that is currently managed daily with Levothyroxine 100mcg twice a day…
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NRNP 6635 Week 7 Assignment: Psychopathology and Diagnostic Reasoning Soap Note
Solution
Subjective
Past Psychiatric History:
- General Statement: Ms. Branning has no history of psychotherapy but was diagnosed with hypothyroidism that is currently managed daily with Levothyroxine 100mcg twice a day.
- Caregivers (if applicable): Not Applicable(N/A)
- Hospitalizations: No known hospital admissions
- Medication trials: No past psychotropic medications have been administered
- Psychotherapy or Previous Psychiatric Diagnosis: Declined to divulge any information regarding past psychotherapy or psychiatric diagnosis.
- Substance Current Use and History:
- Denies taking alcohol or using illegal drugs
- Family Psychiatric/Substance Use History:
- Unknown-Denies any of her family members have mental health issues, remain guarded and declined to respond to questions on past psychiatric history. Similarly, she declined to have the psychiatrist speak to parents for collaborative information.
Psychosocial History:
- Born and raised by both parents as an only child currently living in Santa Monica, CA. She graduated with a bachelor’s in business degree and worked in office supply sales.
- She has a boyfriend, and the relationship does not appear to have any issues contributing to the current psychosis.
Medical History:
- Current Medications: Levothyroxine 100 mcg twice a day to manage hypothyroidism. The patient has enjoyed a relatively healthy life with no medical issues.
- Allergies: Medical tape
- Reproductive Hx: Reports regular monthly periods.
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ROS:
- GENERAL: No fevers, chills, shakes, sweats, or weight changes.
- HEENT: No head trauma, no changes to vision, double vision, eye inflammation or infections, no hearing changes or discharge from ears, No nasal discharge, obstruction, sinus pain, or epistaxis. No hoarseness.
- SKIN: Negative for photosensitivity, no skin discoloration, no new or changing moles, no ulcers or hair loss, no dry skin.
- CARDIOVASCULAR: No edema, intolerance to exercises, no chest pain, shortness of breath, or palpitations.
- RESPIRATORY: No wheezing or shortness of breath, no coughing or sputum.
- GASTROINTESTINAL: No appetite issues, no PICA, no vomiting, no nausea, no blood in stool, no changes in bowel movement
- GENITOURINARY: No history of STIs, no pain, burning sensation, no discharge, no pruritis
- NEUROLOGICAL: No changes in memory, no loss of sensation, no tremors, no seizures, no difficulty speaking.
- MUSCULOSKELETAL: Positive for neck pain that radiates to the back.
- HEMATOLOGIC: No history of easy bruising or bleeding
- LYMPHATICS: No lymphadenopathy
- ENDOCRINOLOGIC: Positive for thyroid disease- hypothyroidism, negative for excessive thirst, urination, no heat or cold intolerance
Objective:
- Physical exam: if applicable
- Vitals: T 98.4 P-80 R 18 BP 128/78 Ht 5’0 Wt. 120 lbs. Patient is a healthy-appearing, well-nourished woman in no acute distress. Her skin has normal turgor, normal texture, warm and dry with no pallor. Eyes have no scleral icterus, have normal pink mucosa. Neck has no lymphadenopathy, and the heart has no thrills or heaves, RRR, S1S2 with no S3 or S4, no murmurs or gallops. Lungs clear to auscultation bilaterally, extremities no edema, clubbing, or cyanosis. Abdomen non-distended, non-tender to palpation, no masses. Neuro Alert and oriented X3 tandem gait normal and symmetric
- Diagnostic results: TSH Test-above 5.7 mIU/L
Assessment:
Mental Status Examination
- Orientation: oriented to person, place, and time
- Appearance woman of Asian ethnicity, executively dressed, hair well groomed.
- Attitude: composed, cooperative
- Speech: clear, constant, normal rate, rhythm, and volume
- Mood: Euphoric, significant grandiosity
- Affect Mood –congruent
- Thought process: Logical, delusional, and grandiose
- Thought content: No hallucinations (auditory or visual), no suicidal/homicidal ideation, significant mixed delusions (of erotomanic- believes Eric her supervisor is in love with her, grandiose –considers herself beautiful and strong and could easily replace her Boss in a few years, somatic believes she has cancer with no medical proof)
- Memory: Remote, recent, and immediate- fair
- Concentration- sufficient
- Intellectual function- average
- Judgement-Significantly impaired
- Insight-significantly impaired
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Differential Diagnoses:
Delusional disorder (in the acute stage) DSM-5 297.1(F22) – confirmed
The patient manifests at least one of the three of the symptoms of psychotic disorders- delusions categorized as delusional disorders. Subsequently, a diagnosis of Delusional disorder (in the acute stage) DSM-5 297.1 (F22) is herein confirmed, although the symptoms have lasted for only three weeks and not one month.
Medically speaking, a delusion is a belief held with a strong conviction, although evidence disproving it is stronger than any evidence supporting the claim (Kulkarni et al., 2016). There are proposed three criteria for delusional beliefs, with the first being that the said belief is held with absolute conviction (certainty).
For example, in the case of Ms. Bramming, she strongly believes that Eric (her supervisor) is in love with her, while on her admission; she reports that each of them has their love partner. She further notes that Eric has never made any inappropriate overtures. She knows of her lust because he gives her the easiest assignments and encourages her to voice her opinions during the weekly meetings.
Eric’s gestures, if true, could be out of concern for her to execute responsibilities within her potential and the need to reach out to her in giving her views. She also thinks that their supposed love is getting in the way of her Boss (who also, by implication, is lusting for her were it not for Eric) hence the latter’s desire to exact his revenge by firing her.
She further admits the Boss has not sexually harassed her, and the Boss is concerned about her wellbeing judging by the last three weeks. The certainty that she has cancer against medical evidence is proof that she would level against the company if they fired her.
The second aspect of N.B.’s delusions is her belief that cannot be changed with proof to the contrary (incorrigibility). For example, when the psychiatrist reassures her that a broken heart is unknown to cause cancer, she posits that one never knows until it happens (Up the groove, 2018).
The third and last criteria of delusional beliefs are that the belief cannot be true (falsity or impossibility) like she knows she being sexually harassed against any evidence. It is important to acknowledge that the patient reports non-bizarre delusions of diverse nature. The three themes that emerge are asexual/ romance involvement (erotomania with Eric, the supervisor, and a Boss who wants to fire her because he (Mr. Neeling) thinks it is her fault.
Nowhere does she report that it is against the company’s policy for employees to fall in love with their workmates. Bates et al. (2019) note that the second theme is grandiosity, where she thinks her strong attitude and beauty threaten the Boss, not to mention her being more competent enough to replace him in a couple of years.
Lastly, there is the somatic change delusion where she feels she has cancer courtesy of neck pain, and the broken heart and suffering are the cause of her health issues. The delusional disorders diagnosis was considered because the patient does not meet Criterion for Schizophrenia as the delusions are not accompanied by hallucinations, disorganized speech, or disorganized behavior. There was also no physiological or organic cause of the patient’s symptoms like drug abuse, side effects of current medication, or other psychotic disorders like depressive or bipolar disorder.
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Schizoaffective Disorder (SAD) -DSM-5 295.70-Refuted
The patient exhibits several psychotic symptoms, which are a prominent feature of schizoaffective disorder. However, according to the American Psychiatric Association (2013), a confirmatory diagnosis of SAD requires illness during which time a major mood episode is exhibited (Parker et al., 2014).
Furthermore, hallucinations must also appear simultaneously with delusions for not less than two weeks. The absence of depression, hallucinations, and mood disorders in Ms. Branning helped rule out SAD (Parker, 2019).
Schizophrenia DSM-5 295.90(F20.9)-Refuted
The Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-5) notes that Schizophrenia manifests with a range of dysfunctions at the cognitive, behavioral, and emotional levels. For a diagnosis of Schizophrenia to be made, the patient must display two or more symptoms of delusions, hallucinations, disorganized speech, and completely disorganized behavior, amongst others. These are used to refute a schizophrenia diagnosis despite delusional beliefs (Patel et al., 2015).
The patient must have experienced one of the first three symptoms together with other psychotic or mood disorders for not less than a month. The signs of disturbance have to continue for six or more months. All these factors were instrumental in my decision to refute a diagnosis of Schizophrenia in Ms. Nijah Branning.
Reflections:
Having diagnosed N.B. as a psychotic disorder categorized as delusional disorder, I concur with my preceptor’s assessment and diagnostic impression of the patient. Several reasons prompted me to agree with the preceptor, but the limited scope of this essay means only a few will be highlighted. Suffice it to say, although not explicitly highlighted, the five components of axial diagnosis should be incorporated (Allsopp, 2017).
To comprehensively understand the five axes, Axis I captures clinical disorders, Axis II personality disorders, Axis III general medical disorders, Axis IV psychosocial and environmental factors. Lastly, Axis V embraces the global assessment of functioning. As stated elsewhere in this SOAP note, psychosis describes a condition that mainly manifests as loss of contact with reality and may involve major disruptions in the individual’s perception, cognition, behavior, and feeling.
Like many other patients, N.B.’s first episode occurs in her early adult life, which is significantly important in developing her identity, relationships, and vocational plans on a long-term basis. It is noteworthy that the patient exhibits positive symptoms that point towards delusions. The trained and experienced psychiatric professional has a legal and ethical responsibility to factor in the possible causes of the patient’s psychosis-like exposure to substance abuse, major stress, acquired or inherited medical conditions, and mood disorders.
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Health Promotion and Disease Prevention of Delusional Disorders and Other Psychosis
The psychiatrist should initiate early interventions that commence with the correct diagnosis, followed by the befitting specialist treatment. The success of the therapeutic interventions largely depends on increasing community understanding of Schizophrenia and other psychotic disorders, how to recognize the early signs, and reducing the stigma associated with these conditions. Confidentiality and involvement of the patient’s family should be incorporated in all phases of the psychotic disorder.
Whether the patient’s cause of the delusional is linked to genetics, biological or environmental factors reducing, the stress experienced by an individual contributes to preventing the onset of delusional symptoms. Therefore, measures that help the patient cope manage, and ultimately reduce stress like exercising, developing a hobby, and building support networks help promote an individual’s health (González-Rodríguez & Seeman, 2020). The individual should also avoid poor lifestyle habits like substance and drug abuse or living a sedentary lifestyle.
Once diagnosed, the psychiatrist should utilize a multimodal approach that combines appropriate medication and psychotherapy (Waller et al., 2015). Medications to use are conventional antipsychotics like chlorpromazine, fluphenazine, and haloperidol, amongst others. In addition, atypical antipsychotics like risperidone and clozapine or tranquilizers and antidepressants should be considered, particularly if the individual has high levels of anxiety and sleep problems.
In addition, various psychosocial treatments like individual psychotherapy, cognitive behavioral therapy, and family therapy have proven effective in treating and managing delusional disorders. A delusional disorder patient outlook largely depends on the individual, the type of delusional disorder, circumstances in the person’s life, support network, and willingness to adhere to the treatment. Failure to seek treatment makes the delusional disorder become a life-long condition.
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References
- Allsopp, K. (2017). The functions of psychiatric diagnosis. The University of Liverpool (United Kingdom).
- Bates, C., Cooper, L. B., & Spears, T. L. (2019). Delusional Disorder: Grandiose Type.
- Bipeta, R. (2019). Legal and ethical aspects of mental health care.
- González-Rodríguez, A., & Seeman, M. V. (2020). Addressing Delusions in Women and Men with Delusional Disorder: Key Points for Clinical Management. International Journal of Environmental Research and Public Health, 17(12), 4583.
- Kulkarni, K. R., Arasappa, R., Prasad, K. M., Zutshi, A., Chand, P. K., Muralidharan, K., & Murthy, P. (2016). Clinical presentation and course of persistent delusional disorder: data from a tertiary care center in India. The primary care companion for CNS disorders, 18(1).
- Parker, G. (2019). How Well Does the DSM-5 Capture Schizoaffective Disorder? The Canadian Journal of Psychiatry, 64(9), 607-610.
- Parker, G. F. (2014). DSM-5 and psychotic and mood disorders. Journal of the American Academy of Psychiatry and the Law Online, 42(2), 182-190.
- Patel, R., Gonzalez, L., Joelson, A., & Korenis, P. (2015). Schizophrenia with somatic delusions: a case report. J Psychiatry, 18(290), 2.
- Upthegrove, R. (2018). Delusional beliefs in the clinical context. In Delusions in context (pp. 1-34). Palgrave Macmillan, Cham.
- Waller, H., Emsley, R., Freeman, D., Bebbington, P., Dunn, G., Fowler, D., & Garety, P. (2015). Thinking Well: a randomized controlled feasibility study of a new CBT therapy targeting reasoning biases in people with distressing persecutory delusional beliefs. Journal of Behavior Therapy and Experimental Psychiatry, 48, 82-89.
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