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NRNP/PRAC 6665 & 6675 Comprehensive Focused SOAP Psychiatric

Evaluation Template

Week #4: Complex Case Study Presentation

Colette Nancy Affiah

College of Nursing-PMHNP, Walden University

PRAC 6635: Psychopathology and Diagnostic Reasoning

Dr. Roel Sepulveda



This is an in-depth comprehensive assessment of a patient who presented to the clinician with complaints of non-compliance with medication and treatment. Pt. has had psychosis and paranoia and presented to the Provider so that new medications can be ordered for her because the old medication as noted by the patient was affecting the patient negatively. A comprehensive focused assessment was done to include the sections on subjective data, objective data, Diagnostic impression, the treatment plan, and reflection. This patient is a 58-year-old Caucasian female with extensive psychiatric problems.


CC “I am here to get my medicine”

Pt. D.A. is a 58-year-old African American female client who presented for psychiatric evaluation and presented with complaints that she ran out of her medication with extensive and had to find a new provider for her mental health. Pt. reported that her sleep is usually interrupted and she is unable to stay asleep. Pt. has fair concentration and gets agitated and irritable at times. The client reports low energy and not being able to complete tasks without interruption and feeling fatigued. Pt. reported that she has been stressed by her son whom she refers to as a “narcissist” because it must be his way at all times. Pt. reported multiple suicide attempts with multiple hospitalizations that stemmed from feeling like nothing was going well for her. Pt. has psychosis and maniac episodes with multiple hospitalizations also. Pt. has trialed different psychotropics and pt. claimed, the medicines have not been effective. Pt. continues to have suicidal thoughts but has denied any plan or intent currently. Pt. endorsed being in a partial hospitalization program for a long time and has had to receive a lot of counseling over the years.

The patient has been non-compliant with her medication and treatment plan. Pt. has had trouble with the law from driving under influence and reported that it happened back in the day when she was younger adding “I don’t drink and drive anymore. Pt. reports she struggles with situations especially crowds and new environments, needs constant reminders report being panicky with dreams or thoughts, and reports having feelings of guilt. Pt. reports past trauma, verbal, physical, and sexual abuse as a child and as an adult, painful experiences, and reports having flashbacks, nightmares, and being hypervigilance, and avoidant phenomena. Pt. reports being frigid around people and feeling uncomfortable and panicky when she is in a big crowd. She experienced palpitations, sweating, and trembling when she meets new people, also has difficulty going out to the grocery store or big box stores and feels unsafe. The patient reports paranoia, always being afraid that someone is going to hurt her and do harm to her in some way.

Pt. also said that she always sees images of people staring at her while she is sleeping.

Substance Current Use: Pt. reports smoking cigarettes a pack a day, at least 2 – 3 cups of caffeine daily, and a history of alcohol during the weekends which has been rare recently

Medical History:

Current Medications: Rexulti 4mg given po nightly, Abilify mg po nightly, Risperidone

1mg po nightly, benztropine, Prenatal vitamins daily, Calcium 600mg po daily, Cymbalta

90mg daily, gabapentin 600mg three times daily, Eliquis 5mg daily, Pepcid 40mg daily,

Valtrex 500mg daily, Topamax 100mg twice daily, Simvastatin 20mg daily, omeprazole

40mg daily,

ibuprofen, Rexulti, Cymbalta and benztropine

Reproductive Hx:
Pt. does not have any children. Pt. practices safe sex but is not in any relationship presently

Family history: Mother used alcohol but is deceased now and mother used to take tranquilizers when the client was young. Sister has depression and anxiety and committed suicide by overdosing on drugs, deceased 2 years ago, Son has attention deficit hyperactivity disorder

Medical history; high cholesterol, joint pain

Surgeries: D & C, Gall bladder removal, Oral Surgery, a stent in the leg for a blood clot


Social History: Pt. was born and raised in South Chicago, Il, and relocated to Indiana back and forth, Florida, and Alaska for seven months. Pt. has five siblings 3 brothers and 2 sisters and was raised by their Mother. The parents were divorced after the patient turned nine years of age. Currently, the patient lives with a cat (Ellie Mae). Pt. worked as a cashier but is now on disability


· GENERAL: Denied fever, weakness, weight loss, increased fatigue

· HEENT: Pt. reports being hit on the head when she was younger, pain in her both eyes, redness, reports impaired vision and wearing reading glasses to read, reports mild loss of hearing, dry sinusitis, and postnasal drip, reports hoarseness or a frequent need to clear her throat, wakes up with an acid taste or bitter taste to her mouth

· SKIN: denies easy bruising, reports skin rash, on her arms

· CARDIOVASCULAR: report irregular heartbeat, sudden changes in heartbeat and palpitations, reports heart murmur, denies cramps in her legs when walking

· RESPIRATORY: report shortness of breath, difficulty breathing at night

· GASTROINTESTINAL: denied any nausea, vomiting, or diarrhea

· GENITOURINARY: Pt reports incontinence and denies difficulty urinating or blood with urination. However, the client is unable to hold urine for prolonged periods.

· NEUROLOGICAL: reports migraines headaches

· MUSCULOSKELETAL: Pt. reports joint and muscle pain, reports muscle weakness

· HEMATOLOGIC/LYMPHATIC: no anemia, easy bruising, bleeding, or swelling, pt. has

a stent in her leg due to a blood clot

· ENDOCRINOLOGIC: Client denies intolerance to hot or cold, no diabetes


Diagnostic results:

No laboratory results to read but were ordered during this clinic visit to include, labs were ordered during this session. Results are to be analyzed in four weeks following the next appointment. See the Treatment plan for specific labs ordered.


Mental Status Examination:

Pt. appeared well groomed, and dressed appropriately, with fleeting eye contact and ageappropriate appearance: Well groomed, dressed appropriate, fleeting eye contact, Age appropriate> Pt. was calm, and cooperative. The mood was dysthymic, anxious, and labile. Affect congruent and speech is sometimes pressured. The thought process is normal, somewhat illogical, and goal-oriented. Thought content: the patient has ruminations, and paranoia, positive phobias. Positive auditory hallucination and suicidal thoughts but no accompanying plan or intent. Judgment is fair and insight is poor

Diagnostic Impression:

F20.9 Schizophrenia

Schizophrenia is a mental disease or illness with complexities and it is known to be a chronic illness DSM-5-TR claims this disorder is characterized by delusions, hallucinations, disorganized thoughts or behaviors, and impaired cognitive function. Patel et al. (2014) postulate that the disorder may begin gestationally due to complications, emergency cesarean, and bleeding while the fetus is in the uterus. Other causes as noted by Patel et al. may arise from any trauma that may have occurred to a child, social isolation and economic lack, and discrimination may cause delusion or paranoid thinking in an individual. This disorder as speculated disrupts the
capacity for an individual to participate in social gatherings and develop good relationships. The false reality is formed in a person’s mind and that becomes the
basis from which the person operates. This patient in the case study has had multiple hospitalizations due to suicide attempts, and severe non-compliance with the treatment plan developed for the patient. Patel et al. also claimed that schizophrenic patient experiences a relapse when they are not taking their medications as prescribed by the clinician. Pt also has a history of psychosis and mania as evidenced by several hospitalizations including treatments at a PHP for a long period. Pt. also avoidance from socialization or participation in a large crowd or around where a lot of people are for fear of being hurt or harmed by them depicts the delusional thinking that is operational in this patient’s mind.

F41.1 Generalized anxiety disorder

Generalized anxiety disorder is the presence of excessive worry to an extent that the intensity of worrying cannot be controlled. Anxiety also causes irritability, difficulty
concentrating, irritability, sleep alterations, and muscle tension. Generalized anxiety disorder as remarked by Iani et al. (2021) is marked by excessive worrying and persistence in nature about different events in a person’s life or environment. Worrying as noted by Iani et al. (2021) is a common caharetics of individuals today but it is abnormal when it becomes excessive that it impairs persons functioning level. Anxiety that causes ruminations may mimic delusional thinking whereby rumination as Iani et al. state is when there is a repetition of negative thoughts or maladaptive thinking. Though there are intrusive thoughts about negative events with this diagnosis, GAD is more involved with the excessive nature of worrying and always thinking there is an impending danger but the patient in the case has paranoia, and psychosis and therefore has negative feelings associated with the diagnosis of Schizophrenia.

Adjustment disorders

Adjustment disorder, on the other hand, deals with having an abnormal emotional or behavioral response to a stressful occurrence that becomes difficult for the sufferer to adjust to after the experience of the trauma. According to O’Donnell et al. (2019), stressful events can either be the type that potentiates traumatic effects on a person or non-traumatic events for example illness of a close friend. The difference between adjustment disorder and Schizophrenia is the fact that in the latter diagnosis, there is the presence of delusion, hallucinations, and disorganized thoughts that are not experienced in adjustment disorder. As a result of this


This client has extensive psychiatric issues with a family history of psychiatric disorder, and prior suicidal attempts with present suicidal thoughts though no plans or intents, but considering the variables, which also include a family history of completed suicide, it is important to encourage and refer patient to be seen by a therapist to help the patient build positive coping skills. Compliance in treatment places this case at risk for relapse even after a positive result due to a successful treatment. Reflecting on this treatment plan, my preceptor and I developed the best treatment plan for this case. Considering the non-compliance with psychiatric medications, it was necessary to prescribe only one medicine as this patient stops taking her medications abruptly without any consideration of the nature of her diagnosis. To build rapport and increase compliance, the medications must be kept at a minimum as much as possible.

Case Formulation and Treatment Plan:

The plan is to start Vraylar 1.5mg po at bedtime and return in twenty-one days or less for a follow-up. According to Vraylar, cariprazine was approved by FDA in 2015 for the treatment of schizophrenia with negative symptoms and for the treatment of situations like mania or mixed episodes which are associated with bipolar disorder. As noted by Stepnicki et al. (2018), side effects of this medicine include sedation, akathisia, weight gain, nausea, constipation, anxiety, and dizziness. Therefore, the patient should be informed to take this medicine at bedtime to also help with insomnia. In this case, therefore, warrants not pounding the patients with multiple treatment modalities so that trust and rapport can be built between the patient and the patients. As a result of the continual need for patient and clinician trust relationship, it is pertinent to note that psychotropic medications should be ordered minimally as in this case only

Vraylar, an antipsychotic medicine, is ordered for the patient. In the future, other medications for anxiety for example will be ordered for the patient if needed.

Pt. was offered Invega Long Acting injectables (LAI), but the patient declined from taking them.

Follow-up in four weeks for individual psychotherapy and medication management.

Referrals for initiation of therapy as well as for a medical provider for the management of comorbid medical conditions were also set up.

The patient was encouraged to eat a well-balanced and healthy diet, especially with high cholesterol and heart disease

Labs were ordered for a complete blood count check, chemistry, vit d, vitamin b12, and EKG to check for the heart and thyroid stimulating hormone tests to rule out hypothyroidism which may mimic anxiety symptoms

Pt. will be informed to report any side effects to the clinician promptly.

NRNP/PRAC 6665 & 6675 Comprehensive Focused SOAP Psychiatric

Evaluation Template

© 2021 Walden University Page 10 of 12


Association, A. P. (2022). Diagnostic and statistical manual of mental disorders, fifth edition, text revision (dsm-5-tr(tm)) (5R ed.). American Psychiatric Association Publishing.

Iani, L., Quinto, R. M., Lauriola, M., Crosta, M. L., & Pozzi, G. (2019). Psychological well- being and distress in patients with generalized anxiety disorder: The roles of positive and negative functioning.
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O’Donnell ML, Agathos JA, Metcalf O, Gibson K, Lau W. Adjustment Disorder:

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Patel KR, Cherian J, Gohil K, Atkinson D. Schizophrenia: overview and treatment options. P T. 2014 Sep;39(9):638-45. PMID: 25210417; PMCID:


Stępnicki P, Kondej M, Kaczor AA. Current Concepts and Treatments of Schizophrenia.

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30127324; PMCID: PMC6222385.

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