Subjective What Details Question & Answer Guide (With Explanation)

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Original Question

Subjective: What details did the patient provide regarding their chief complaint and symptomology to derive your differential diagnosis? What is the duration and severity of their symptoms? How are their symptoms impacting their functioning in life? Objective: What observations did you make during the psychiatric assessment? Assessment: Discuss patient mental status examination results. What were your differential diagnoses? Provide a minimum of three possible diagnoses and why you chose them. List them from highest priority to lowest priority. What was your primary diagnosis, and why? Describe how your primary diagnosis aligns with DSM-5 diagnostic criteria and is supported by the patient’s symptoms. Plan: What was your plan for psychotherapy? What was your plan for treatment and management, including alternative therapies? Include pharmacologic and nonpharmacologic treatments, alternative therapies, and follow-up parameters, as well as a rationale for this treatment and management plan. Include at least one health promotion activity and one patient education strategy. Reflection notes: What would you do differently with this patient if you could conduct the session over? If you are able to follow up with your patient, explain whether these interventions were successful and why or why not. If you were not able to conduct a follow-up, discuss what your next intervention would be. ========================================================== Subjective: CC (chief complaint): “Doing good.” HPI: A 26-year-old African American male presenting for a follow-up appointment. Beginning of the interview, the patient reports that he wants to “stop the shot.” Discussed with the patient that I would not be stopping this injection. The patient was unable to sit still and was agitated as stated patient reports that “I do not like how it makes me feel.” The patient goes on to state he does not have Schizophrenia. The voices that he hears are “real voices.” The patient continues to negotiate to stop the injection and continue with just the oral form of the medications. The provider discussed with the patient that due to his history of noncompliance with medication, I would not be stopping the injection. Concerned that the patient would stop attending appointments, it was agreed to decrease the injection dose slightly. The patient continued to attempt to negotiate further, and the patient was told again, as he has in the past, that long-acting injections would be continuing. If he wishes to seek out another provider, he is welcome to do so, but I would not grossly change the treatment plan. The patient has been on multiple medications in the past and has done well on other medicines, but soon after starting, the patient will come in stating he does not like the medication and would like to try something different. At previous visits, the patient was instructed that he was initiated on haloperidol decanoate before this last hospitalization and that I would not be changing his medication plan. The patient cannot voice any specific side effects from the medication other than stating, “I just do not like how it makes me feel.” Discussed with the patient that although all medicines may have some subtle side effects, he fails to realize that his medication has kept him out of the hospital. The patient states that he went to the hospital only to make his mother happy. Discussed with the patient that there were times he bought himself to the hospital because he heard voices, and the patient stated, “it was not because I was hearing voices, it was because I was mad.” The patient continued to attempt to negotiate. The provider closed the visit by instructing the patient that I did decrease the injection dose and he was to continue with the medication injection; I could get him to take the injection, unlike I expected him to. The patient left unsatisfied, stating, “I understand; I get a copy of my medical records and get somebody else.’ His sleep is poor due to racing thoughts at night. Appetite is fair, energy is fair, and any illicit substance or alcohol use is denied. The patient denies suicidal and homicidal ideation. Denies visual hallucinations but endorses auditory hallucination and states, “I still hear voices anyways.” The patient was experiencing increased auditory hallucinations. Medications Current Medications: Benztropine (Cogentin) 2 mg tablet, take one tablet by mouth 2 (two) times a day. Haloperidol (Haldol) 5 mg tablet; take one tablet by mouth daily Haloperidol Decorate (Haldol Decorate) 100 mg/ml injection, inject 1 ml (100 mg total) into the shoulder, thigh, or buttocks every 28 (twenty-eight) days. The next injection is about February 10 or 11. Trazodone (Desyrel) 100 mg tablet, take one tablet (100mg total) by mouth every night. Current Facility-Administered Medications: Haloperidol Decorate (Haldol Decanoate) injection 100 mg, 100mg, intramuscular, once. Past Psychiatric History Previous psychiatric hospitalization in the patient unit, most recently from 10/14/21-10/26/21 In the emergency department under involuntary commitment for paranoid delusions and homicidal ideations at home. Earlier reports stated that the patient has been experiencing command auditory hallucinations instructing him to kill others and was medication non-compliant for the last two weeks. Since in the ED, the patient has received as-needed medications due to agitation and aggression. Under similar circumstances, the patient was last seen in the emergency room on 12/9/2021; He had to command auditory hallucinations to fight his neighbors. The patient last requested to see the physician. After speaking with his family members, the patient reported that he is starting to believe that he has delusions of inference. He stated that he would like to try the long-acting injectable again. Suicide attempt: Self-injury behavior Diagnosed: Evidence of delusional thoughts and evidence of hallucinations and Paranoid Schizophrenia. Substance Current Use: The patient denies any current substance. Allergies: The patient has no known allergies Reproductive Hx: Never married; the patient has no children and no relationship. ROS: HEENT: No headache, no head injury, no dizziness, no light headaches, no vision changes. No hearing problems. No tinnitus, no vertigo, no earaches, no nasal stuffiness, no nasal discharge, no nosebleeds, no sinus SKIN: No rash or itching, no skin infections. No open skin area CARDIOVASCULAR: S1, S2, no murmur was noted No chest pain or discomfort, no palpitation, no dyspnea, no orthopnea, no paroxysmal, nocturnal dyspnea, no edema. RESPIRATORY: Lung sounds clear auscultation. GASTROINTESTINAL: No trouble swallowing, no heartburn, no nausea, no vomiting, no diarrhea, no rectal bleeding or tarry stool, no constipation, no abdominal pain, no food intolerance. GENITOURINARY: Bladder and bowel regularity and no problems. urinary urgency, NEUROLOGICAL: No complaints of headaches, numbness, or ataxia HEMATOLOGIC: No complaints of abnormal bleeding or bruising LYMPHATICS: No complaints of swollen or painful lymph nodes Objective: Psychiatric ROS Mood: “Worried.” Affect: mood incongruent. Thought Content: paranoid and delusions. Anxiety: mild to moderate anxiety Sleep: variable Psychotic symptoms: Evidence of delusional thoughts and evidence of hallucinations Appetite: variable Behavior: The patient was agitated and irritable Trauma: Denies history of sexual abuse, physical abuse, or emotional abuse. Vital Temperature 98.1, Pulse 80, Respiration 20, and B/P 125/81 Diagnostic results: No diagnostic is completed at this time. Laboratory Date Available: The provider did not request any labs. Recent Results collection on 01/01/2022. Urine drug and alcohol screen negative. CBC and CMP within normal ranges. Salicylate level within normal ranges. ECG 12 lead was collected within normal ranges. Physical Exam: not completed Medications Trials Aripiprazole Maintena 400 mg, intramuscular once for the voices Abilify 20 mg daily Invega Sustenna monthly IM as he started to hear “cracking “noises due to lack of efficacy. The patient reports that the voices became positive when he was on Abilify in the past. He reported daily compliance with Abilify (increased to 20 mg daily during the last visit with his outpatient provider on 11/20/21) but has been taking it inconsistently over the past couple of weeks. Hydroxyzine HCL (Atarax) 12.5-25 mg oral BID PRN Nicotine Polarilex (Nicorette) gum 2mg prn Zyprexa and Ativan as needed for any further incident related to his psychosis Diphenhydramine, 50 mg, oral, once to prevent EPS Trazodone 100 mg at bedtime Ativan 2 mg oral every 6-hour PRN or IM every 6 hours PRN Benztropine 2mg po BID Surgical History: No past surgical history Family History: No family suicide. No family history of substance uses Social History: He reports he smokes one pack a day. He uses cigars. He has never used smokeless tobacco. He stated previous alcohol use. He said he had previous drug use. He denies giving way or doing any drugs or alcohol. He said he graduated from high school. He receives SSI, and his mother is his payee. He denies a history of probation or parole, but he has been in jail for a couple of days in the past for possession of stolen goods and damage to property. Currently unemployed and received disability. Assessment: Mental Status Examination: The client is a 26-year-old African American male who appears to be of the claimed age and is dressed in casual clothing, adequately groomed, and male. Behavior is normal posture and within normal limits—patient with fair eye contact. Speech is disorganized. Thought processes are hallucinations. Thought content is paranoid and delusional. The mood is “worried and agitated. “The affect is blunt; Perceptions reveal auditory hallucinations. The patient denies suicidal ideations and denies homicidal ideations. The level of consciousness is awake and alert. Cognition is oriented. Knowledge assessment reveals intelligence appears normal. Insight is partial. Judgment is fair. Reliability reveals patient reliability in interview information. Diagnostic Impression: Schizophrenia (F 20.9): The patient demonstrates the imminent risk of harming oneself or others. The patient was approaching neighbors; said he could hear them talking about him from several apartments. He heard voices responding to internal stimuli. The patient came toward his mother with a butcher knife. DSM-5 classifies characteristic symptoms like delusions, hallucinations, and disorganized speech for a significant portion of time, less than one month if successfully treated. The period of the disturbance, the level of functioning in one or more significant areas, such as the onset is in childhood or adolescence; there is a failure to achieve the expected level of interpersonal, academic, or occupational functioning (APA, 2013). Schizophrenia is a chronic, debilitating neuropsychiatric disorder. Multiple transcriptomic gene expression profiling analysis has been used to identify schizophrenia-associated genes (Huang et al., 2019). Schizophrenia subtype: The subtype of Schizophrenia is defined by the predominant symptomatology at the time of evaluation. Generalized Anxiety Disorder, GAD (F41.1): Extreme anxiety and worry more days and struggle in controlling worry, and endorses easily fatigued, and endorses difficulty concentrating, and endorses irritability, and endorses sleep disturbances. The patient reports severe symptoms of worrying, restlessness, and racing thoughts most of the time. The client endorses feeling on edge most of the time. According to DSM-5, GAD is described by different signs such as extreme worry. Often, with generalized anxiety, the level of worry is inconsistent with the actual risk; the client reported that he has random racing thoughts before bedtime that cause sleep disturbance. The uneasy worry must be challenging to control and needs to occur for at least six months to diagnose GAD. It can be associated with at least three of the criteria physical or cognitive symptoms, change in energy, poor concentration, agitation, or irritability (APA, 2013). The patient completed the anxiety Screening Scale and scored seven. Nonadherence to Medical Treatment (Z91.19): Pt has a history of taking medications while in the hospital and not taking them after discharge. The patient reports that he was previously on a long-acting injectable, but it caused his eyes to roll back in his head, so he stopped taking it. DSM-5 stated that when clinical focuses on nonadherence to an essential aspect of treatment for a mental disorder, such nonadherence. It may include discomfort because of medication side effects, the expense of therapy, and personal value judgments (APA, 2013). The patient was admittedly recently noncompliant with his antipsychotic medication with a history of Schizophrenia. The patient acknowledged many of the symptoms but was still somewhat resistant to treatment. The patient was physically aggressive with his family, paranoid at home, and unprovoked. He has increased psychosis and agitation at home with aggressive action and yelling in his community with medication noncompliance. Evidence of negative symptoms are delusional thoughts, unusual behaviors that include delusions (irrational beliefs), and hallucinations (sensory experiences in the absence of the environmental input evidence of hallucinations. Treatment nonadherence is a pernicious problem associated with increased rates of chronic diseases, escalating healthcare costs, and rising mortality in some patients (Hooper et al., 2018). Tobacco Use Disorder: The client reports that he uses cigarettes and cigars daily. According to DSM 5, a problematic pattern of tobacco uses to clinically significant impairment or distress is manifested by at least two following within 12 months (APA, 2013). Regular tobacco smoking has been shown to alter neurotransmitter metabolism in the brain, and studies have found CSF monoamine metabolite concentrations to be substantially lower in smokers (Hjärpe et al., 2018). Nicotine dependence is high in Schizophrenia, and craving is known to impact relapse during quit attempts. Methods: We compared tobacco craving in smokers with Schizophrenia treated with different antipsychotics (Wehring et al., 2017). Reflections: The provider begins the client assessment by introducing himself and acquiring information. The provider explains to the client what medications are for and the medications. The client did not want to hear the benefit of medications. The client was on many different psychotropic medications by oral or injections in the past. Multiple complaints by a patient and every medication did not help him or had side effects that making not want to take them. The provider attempted to explain how critical compliant medications, PO, and injections are. It’s common for patients to be unwilling to take a prescribed medication or follow a prescribed course of treatment. They may not listen to your instructions, and they may even become hostile or hesitant to comply. However, some interventions such as educating the patient can be put into place to promote compliance. The patient has a longstanding history of chronic Schizophrenia. The patient has been on a long-acting injection as a single antipsychotic with minimal benefit and multiple hospital visits for persistent paranoid thinking and delusional thinking. I will encourage him, that people in the past have been treated and managed with the same medications, and even with the side effects, they overcame their fears and are now living a meaningful life despite being schizophrenic. Schizophrenia (SCZ) is a severe psychiatric disorder with a significant genetic component. The neuroprotective functions under stress conditions and appears to play an essential role during the development. The central nervous system agrees with the neurodevelopmental hypothesis of SCZ (Kowalczyk et al., 2022). The history patient believes that people are trying to harm him, including his neighbors, the police, and unknown others. Patients with Schizophrenia have not noticed their cognitive impairments. Misperception of cognitive impairment is an essential factor related to functional outcomes in patients with Schizophrenia. I will engage the patient in a conversation, where I will educate him on the importance of complying with his medication and the dangers of not complying with the medication. The interventions will be successful next session. This is because when the patient was equipped with knowledge of the importance of complying with the medication, he understood better why he should ensure compliance. Increased patient compliance with antipsychotic medications is associated with increased efficacy and reduced rehospitalization rates (Love, 2002). The healthcare worker should take responsibility for helping them. If I could not conduct a follow-up, discuss what my next intervention would be with the patient and his mother. I would contact his mother. The patient is more likely to listen better to his mother. The patient’s family members play a crucial role in detecting patients’ cognitive impairments when unaware (Ebina et al., 2022). Mini-Mental State Examination (MMSE) among patients with schizophrenia or schizoaffective disorders has found that age and education were associated with cognition in adults. However, little is known about how clinical factors the age of illness onset, length of antipsychotic medications at home, and duration of illness are associated with cognitive functioning in patients with Schizophrenia. Initial interventions for cognition, such as physical and mental exercises, should be implemented to better the prognosis (Ong et al., 2016). Case Formulation and Treatment Plan The client has been diagnosed with Schizophrenia and is being treated with anti-psychotropic medications. Haldol Decorate 100 mg IM for psychotic disorder and treat schizophrenic patients. Harold 5 mg by mouth daily. Psychotic symptoms such as hearing voices can improve within one week, but it may take serval weeks for full effect on behavior. Cogentin 2mg po twice a day for EPS (Stahl, 2021). The preceptor reconciled any adjustments to the therapeutic regimen and reflected this in the client. Continue with the current treatment plan, and the risks and benefits of treatment have been discussed with the patient. It is suitable to the medication’s opinion that this patient is not a threat to harm himself or anyone else and can care for himself. Call 911 or ER if there is an acute worsening of symptoms. This patient denies any SI/HI and denies any desire to harm himself or anyone else. In addition, the patient relates future-oriented goals. The client or guardian can call the crisis hotline information on the website. The client is encouraged to call this crisis line if, after hours, the office cannot assist with an emergency. The client was also referred to outpatient counseling service psychotherapy (Yin et al., 2021). CBT for anxiety disorders was associated with significant reductions in SI over time, with no evidence for exacerbation of suicide risk. Clinical suggestions are discussed, and future research directions to further understand the effect of anxiety disorder treatments on SI (Brown et al., 2018). The adequacy of the proportion of patients in the treatment group who withdrew from treatment early, risk factors. Alternative to prescription medicine, risks or medication nonadherence, or refusal of treatment discussion. Moreover, the current client goals were discussed with patient symptom reduction, medication compliance, sustaining therapeutic improvement, restoring the level of functioning, and reducing reliance on medication for symptom management. References American Psychiatric Association. (2013). Diagnostic and statical manual of mental disorder (5th ed.). Washington, DC: Author. Brown, L. A., Gallagher, T., Petersen, J., Benhamou, K., Foa, E. B., & Asnaani, A. (2018). Does CBT for anxiety-related disorders alter suicidal ideation? Findings from a naturalistic sample. Journal of Anxiety Disorders, 59, 10-16. https://doi.org/10.1016/j.janxdis.2018.08.001 Ebina, K., Matsui, M., Higuchi, Y., & Suzuki, M. (2022). Premorbid intellectual ability in schizophrenia influence family appraisal related to cognitive impairments: a cross-sectional study on cognitive impairment and family assessments. BMC Psychiatry, 22(1), 227. https://doi.org/10.1186/s12888-022-03879-2 Hjärpe, J., Söderman, E., Andreou, D., Sedvall, G. C., Agartz, I., & Jönsson, E. G. (2018). No major influence of regular tobacco smoking on cerebrospinal fluid monoamine metabolite concentrations in patients with psychotic disorders and healthy individuals. Psychiatry Research, 263, 30-34. https://doi.org/10.1016/j.psychres.2018.02.036 Hooper, L. M., Huffman, L. E., Higginbotham, J. C., Mugoya, G. C. T., Smith, A. K., & Dumas, T. N. (2018). Associations Among Depressive Symptoms, Wellness, Patient Involvement, Provider Cultural Competency, and Treatment Nonadherence: A Pilot Study Among Community Patients Seen at a University Medical Center. Community Mental Health Journal, 54(2), 138-148. https://doi.org/10.1007/s10597-017-0133-8 Huang, J., Liu, F., Wang, B., Tang, H., Teng, Z., Li, L., Qiu, Y., Wu, H., & Chen, J. (2019). Central and Peripheral Changes in FOS Expression in Schizophrenia Based on Genome-Wide Gene Expression. Frontiers in Genetics, N.PAG. https://doi.org/10.3389/fgene.2019.00232 Kowalczyk, M., Kucia, K., Owczarek, A., Suchanek-Raif, R., Paul-Samojedny, M., Choreza, P., & Kowalski, J. (2022). HSPB1 Gene Variants and Schizophrenia: A Case-Control Study in a Polish Population. Disease Markers, 2022, 4933011. https://doi.org/10.1155/2022/4933011 Love, R. C. (2002). Strategies for increasing treatment compliance: The role of long-acting antipsychotics. American Journal of Health-System Pharmacy, 59, S10. https://doi.org/10.1093/ajhp/59.suppl_8.S10 Ong, H. L., Subramaniam, M., Abdin, E., Wang, P., Vaingankar, J. A., Lee, S. P., Shafie, S., Seow, E., & Chong, S. A. (2016). Performance of Mini-Mental State Examination (MMSE) in long-stay patients with schizophrenia or schizoaffective disorders in a psychiatric institute. Psychiatry Research, 241, 256-262. https://doi.org/10.1016/j.psychres.2016.04.116 Stahl, S.M. (2021). Stahl’s essential psychopharmacology: Prescriber’s guide (7th ed.). Cambridge University Press. Wehring, H. J., Heishman, S. J., McMahon, R. P., Liu, F., Feldman, S., Raley, H., Weiner, E., & Kelly, D. L. (2017). Antipsychotic Treatment and Tobacco Craving in People with Schizophrenia. Journal of Dual Diagnosis, 13(1), 36-42. https://doi.org/10.1080/15504263.2017.1288946 Yin, B., Teng, T., Tong, L., Li, X., Fan, L., Zhou, X., & Xie, P. (2021). Efficacy and acceptability of parent-only group cognitive-behavioral intervention for the treatment of anxiety disorder in children and adolescents: a meta-analysis of randomized controlled trials. BMC Psychiatry, 21(1), 29. https://doi.org/10.1186/s12888-020-03021-0 Please revise underlined sections and proofread. Thank you.

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