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Adult Psychiatric Evaluation SOAP Note Assignment Discussion

Adult Psychiatric Evaluation SOAP Note Assignment Discussion

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Identifying data

Initials: I. C.          Age: 32yo            Sex: Male

Source and Reliability: The client, reliable.

Chief Complaint: “I have been referred by the human resource department for a mental health examination.”

History of Present Illness

The client reported clinical symptoms aligning with the four DSM-5 diagnostic criteria. First, he meets the diagnostic criterion, which involves disregarding for and violating rights of others since the age of 15. This criterion is characterized by stealing of “Child stuffs” at the age of 14, resulting in imprisonment at the juvenile. The client also demonstrated impulsive behavior by fighting with his supervisor. Moreover, the client demonstrated irritability and aggression by hitting his wives. Furthermore, the client disregards safety of self and others by making multiple errors at his previous workplace, which endangered his coworkers. The client also demonstrated a pattern of irresponsibility by withdrawing child support for his two sons, claiming they were liars just like their mothers. Additionally, the client’s features aligns with other diagnostic criteria. The client is 32yo, meeting the diagnostic criterion that requires an individual diagnosed with ASPD to be at least 18 years. Moreover, the client’s antisocial behaviors started at the age of 14, meeting the criterion that requires the ASPD symptoms to present before the age of 15. Lastly, the client denies manic episodes, meeting the diagnostic criterion that requires antisocial behavior not to be associated with schizophrenia or bipolar disorder. Adult Psychiatric Evaluation SOAP Note Assignment Discussion

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Psychiatric Review of Systems:

Mood: The client reported mood swings, describing it as getting “mad real fast.”

Anxiety: Denies anxiety

Mania: The client denies incidents of mania.

Psychosis: The client describes himself as a hell of a carpenter,

Other: No other psychiatric issues were reported.

Psychiatric History:

History of Psychiatric Disorders: Bipolar disorder and ADHD.

Medications: Short-acting benzodiazepine.

Hospitalizations: I. C. denies hospitalization history.

Counselling/Therapy: Denies psychotherapies.

Suicide Attempts: Denies history of suicide attempts.

Substance Use/Abuse

Alcohol: He started drinking alcohol regularly but stopped at 22.

Drugs: The client smoked marijuana as a teenager but quit smoking at 22.

Caffeine: Denies caffeine use.

Tobacco: Denies tobacco use.

Supplements: Denies using supplements.

Medical History:

Illness/Injuries: Denies history of serious medical issues or injuries.

Last medical exam: His last comprehensive health examination was October 23rd 2023.

Surgeries: I. C. denies a history of surgeries.

Current Medications:

Allergies: I. C. denies food or drug-related allergic reactions.

Women only:  Not applicable

Family Psychiatric/Medical History: His sons were diagnosed with ADHD.

Social History: The client is divorced. He lives alone after separating from his two wives. He does not visit his sons, claiming they are liars like their mothers. He was imprisoned in juvenile at the age of 14 after stealing some “kids’ stuff.”

Work/ Educational History: He dropped school at age 15 after being framed to have stolen a car. He attended carpentry school. He has been a carpenter in a large construction business for the last two weeks.

Current Family: He does not have a family after separating from his two wives.

Social Supports/Faith: The client does not have social or religious support.

Adverse life events: Denies history of adverse life incidents. Adult Psychiatric Evaluation SOAP Note Assignment Discussion

Medical Review of Systems

Constitutional: I. C. denies weight loss, increased fatigue, or fever.

HEENT: I. C. denies a history of head trauma. He denies past incidents of yellow sclera. He denies a history of ear pain. He denies a recent incident of nasal blockage. The client denies bleeding gums.

Cardiovascular: I. C. denies a recent incident of edema or shortness of breath.

Respiratory: He denies a history of dry or productive cough.

Gastrointestinal: I. C. denies a history of constipation or diarrhea.

Genitourinary: The client denies painful urination.

Skin: I. C. denies skin rashes or lumps.

Neurological: He denies a history of dizziness or severe headache.

OBJECTIVE

Vital signs: Weight 142 pounds; waist circumference 38 inches; height 5 “4” and body mass 24.4

Mental Status Examination:

Appearance: I.C. appears well-nourished and looks younger than his age.

Orientation: I.C. is oriented to persons, events, places, and times.

Concentration: His concentration throughout the mental health evaluation was reasonable.

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Manner: He is composed and respectful.

Speech: He speaks in an average tone and volume.

Mood: His self-reported mood is “Good.”

Affect: His effect is intact

Thought Process: No delusional thought process was noted.

Thought Content: He demonstrated preoccupations

Perceptions: No hallucinations or illusions were noted

Memory and Cognition: Reported a short memory.

Judgment: His judgment was sound.

Insight: His insight was good Adult Psychiatric Evaluation SOAP Note Assignment Discussion

Physical Exam:

Musculoskeletal: No swollen joints were noted on examination.

Skin: No swollen or red skin was noted during the exam.

Neuro: No mood or anxiety symptoms were noted on examination.

Formulation/Diagnosis:

The client’s diagnosis is antisocial personality disorder (ASPD). This personality disorder is characterized by various symptoms, including repeatedly breaking the law, being deceitful frequently, and being impulsive (Wulandari, 2020). Persons with ASPD also demonstrate aggressiveness or irritability, disregarding personal safety or that of others, lack of remorse, or being irresponsible consistently (Wulandari, 2020). I. C’s most significant pertinent positive involves breaking the law repeatedly. He reported being jailed at the juvenile at the age of 14 for stealing. His principal also framed him for stealing a car at the age of 15. His wives were also issued with restraining orders after reporting that he hit them. Moreover, the client has been irresponsible consistently since he reported withdrawing child support for his sons. Furthermore, his graduation certificates had been forged, and he presented false documents. Additionally, the client meets the DSM-5 diagnostic criteria for antisocial personality disorder. An individual must be at least 18 years old to be diagnosed with antisocial personality disorder with an onset of antisocial disorder before 15 years (Paap et al., 2020)Adult Psychiatric Evaluation SOAP Note Assignment Discussion. Therefore, ASPD is the most appropriate diagnosis for this client since he is 32 years old with the onset of antisocial behaviors at the age of 14.

Treatment Plan:

Medication: The medication therapy for the client’s antisocial personality disorder is Lithium carbonate. This drug regimen is recommended since it has demonstrated effectiveness in controlling symptoms of antisocial personality disorder, including impulsive behavior and aggression (Sesso & Masi, 2023). The client should be informed about potential lithium-related side effects, including urinary frequency, nausea, and vomiting. A written informed consent was obtained from the client before the prescription of this medication regimen.

Diagnostic Testing: The client was prescribed lithium therapy. Regular blood tests were necessary to monitor lithium levels regularly and ensure that the client was taking an appropriate dose.

Client Education: The client was informed about lithium-related undesired effects, including urinary frequency, nausea, and vomiting. Thus, the client would contact the provider if these symptoms became more severe.

Health promotion/disease education: The client was advised to enrol in psychotherapies to reduce the risk of developing other personality disorders.

Risk Assessment: Suicide and self-harm risk assessment should be conducted on this client since persons with ASPD are at a high risk of causing harm to themselves or others (Paap et al., 2020)Adult Psychiatric Evaluation SOAP Note Assignment Discussion.

Self-Assessment of Practice

  • Forgotten components of note: The history of forgotten psychiatric disorders has been included in the template and highlighted with a different colour.
  • Medications: The client was prescribed lithium carbonate, targeted at reducing aggression and impulsive behaviors.
  • Treatment plan and adherence to EBP: The treatment plan adhered to EBP. Lithium carbonate was recommended as the client’s medication therapy since it is an EBP intervention for reducing the severity of aggression and impulsive behaviors in individuals diagnosed with antisocial behaviors.
  • TeamSTEPPS Concept: In the case of disagreement, I would refer to the established clinical practice guidelines for diagnosing and managing a particular condition. TeamSTEPPS conflict resolution technique that I would apply in case of a conflict is formative feedback. This technique would enable me to call attention, protecting the patient from potential risks.

References

Paap, M. C., Braeken, J., Pedersen, G., Urnes, Ø., Karterud, S., Wilberg, T., & Hummelen, B. (2020). A psychometric evaluation of the DSM-IV criteria for antisocial personality disorder: dimensionality, local reliability, and differential item functioning across gender. Assessment27(1), 89-101. https://doi.org/10.1177/1073191117745126

Sesso, G., & Masi, G. (2023). Pharmacological strategies for the management of the antisocial personality disorder. Expert Review of Clinical Pharmacology16(3), 181-194. https://doi.org/10.1080/17512433.2023.2181159

Wulandari, P. (2020). Diagnosis and Treatment of Antisocial Personality Disorder: A Case Report. Scientia Psychiatrica1(3), 64-67. http://scientiapsychiatrica.com/index.php/SciPsy/article/view/15 Adult Psychiatric Evaluation SOAP Note Assignment Discussion

            Adult Psychiatric Evaluation

Reference Kaplan & Sadock Chapters 5

Identifying data

Source and Reliability

Chief Complaint

History of Present Illness (Bold symptoms that meet DSM-5 Diagnostic Criteria)

Psychiatric Review of Systems: (address any area not covered in HPI, all positive findings must be addressed in HPI)

Mood:

Anxiety:

Mania:

Psychosis:

Other:

 

Psychiatric History:

Medications:

Hospitalizations:

Counseling/Therapy:

Suicide Attempts:

Substance Use/Abuse

Alcohol:

Drugs:

Caffeine:

Tobacco:

Supplements:

Medical History:

Illness/Injuries:

Last medical exam:

Surgeries:

Current Medications:

 Allergies:.

 Women only:  LMP and Contraception

Family Psychiatric/Medical History:

Developmental/Social History:

 Work/ Educational History:

Current Family:

Social Supports/Faith:

Adverse life events:

Medical Review of Systems (as appropriate for client’s medical history)

Constitutional:

HEENT:

Cardiovascular:

Respiratory:

Gastrointestinal:

Genitourinary:

Skin:

Neurological:

OBJECTIVE

Vital signs, weight, waist circumference, body mass index, and height

Mental Status Examination: Adult Psychiatric Evaluation SOAP Note Assignment Discussion

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Appearance:

Orientation:

Concentration:

Manner:

Speech:

Mood:

Affect:

Thought Process:

Thought Content:

Perceptions:

Memory and Cognition:

Judgment:

Insight:

Physical Exam: (Musculoskeletal/skin/neuro-if indicated)

Formulation/Diagnosis:

Include criteria in DSM-5 to substantiate diagnoses

Treatment Plan:

Medications) Side effects/client teaching, Informed Consent (written)

Diagnostic Testing (Rational based on medication/diagnosis)

Client Education

Health promotion/disease education

Risk Assessment

Self-Assessment of Practice

  • Identify forgotten or unnecessary components of note (may do above by different color font or underlying). Note here how this was done
  • Medications: Symptoms/behaviors targeted with each medication
  • Treatment plan and adherence to/modification of EBP
  • TeamSTEPPS Concept: Conflict Resolution.  What if other providers or other members of the treatment team disagree with your assessment or plan for a particular patient?  How would you handle this issue?  What TeamSTEPPS conflict resolution strategies could you use in helping to resolve this issue?

MODULE TEN—PERSONALITY DISORDERS

  1. GROUP D: Ike Crocker is a 32-year-old man referred for a mental health evaluation by the human resources department of a large construction business that had been his employer for 2 weeks. At his initial job interview, Mr. Crocker presented as very motivated and provided two carpentry school certifications that indicated a high level of skills and training.  Since his employment began, his supervisors had noted frequent arguments, absenteeism, poor workmanship, and multiple errors that might have been dangerous.  When confronted, he was reportedly dismissive, indicating that the problem was “cheap wood” and “bad management” and added that if someone got hurt, “it’s because of their own stupidity.”  Adult Psychiatric Evaluation SOAP Note Assignment Discussion

When the head of human resources met with him to discuss termination, Mr. Crocker quickly pointed out that he had both attention deficit hyperactivity disorder (ADHD) and bipolar disorder.  He said that if not granted an accommodation under the Americans with Disabilities Act, he would sue.  He demanded a psychiatric evaluation.

During the mental health evaluation, Mr. Crocker focused on unfairness at the company and on how he was “a hell of a better carpenter than anyone there could ever be.”  He claimed that his two marriages had ended because of jealousy.  He said that his wives were “always thinking I was with other women,” which is why “they both lied to judges and got restraining orders saying I’d hit them.”  As “payback for the jail time,” he refused to pay child support for his two children.  He had no interest in seeing either of his twin boys because they were “little liars” like their mothers.

Mr. Crocker said he “must have been smart” because he had been able to make Cs in school despite showing up only half the time.  He spent time in juvenile hall at age 14 for stealing “kid stuff, like tennis shoes and wallets that were practically empty.”  He left school at age 15 after being “framed for stealing a car” by his principal.  Mr. Crocker pointed out these historical facts as evidence that he was able to overcome injustice and adversity.

In regard to substance use, Mr. Crocker said he smoked marijuana as a teenager and started drinking alcohol on a “regular basis” after he first got married at age 22.  He denied that use of either substance was a problem.

Mr. Crocker concluded the interview by demanding a note from the examiner that he had “bipolar” and “ADHD.”  He said that he was “bipolar” because he had “ups and downs” and got “mad real fast.”  Mr. Crocker denied other symptoms of mania.  He said he got down when disappointed, but he had “a short memory” and “could get out of a funk pretty quick.”  Mr. Crocker reported no difficulties in his sleep, mood, or appetite.  He learned about ADHD because “both of my boys got it.”  He concluded the interview with a request for medications, adding that the only ones that worked were stimulants (“any of them”) and a specific short-acting benzodiazepine. Adult Psychiatric Evaluation SOAP Note Assignment Discussion

On mental status examination, Mr. Crocker was a casually dressed white man who made reasonable eye contact and was without abnormal movements.  His speech was coherent, goal directed, and of normal rate.  There was no evidence of any thought disorder or hallucinations.  He was preoccupied with blaming others, but these comments appeared to represent overvalued ideas rather than delusions.  He was cognitively intact.  His insight into his situation was poor.

The head of human resources did a background check during the course of the psychiatric evaluation.  Phone calls revealed that Mr. Crocker had been expelled from two carpentry training programs and that both his graduation certificates had been falsified.  He had been fired from his job at one local construction company after a fistfight with his supervisor and from another job after abruptly leaving a job site.  A quick review of their records indicated that he had provided them with the same false documentation.

Ike Crocker was a 32-year-old man referred for a mental health evaluation by the human resources department of a large construction business that had been his employer for 2 weeks. At his initial job interview, Mr. Crocker presented as very motivated and provided two carpentry school certifications that indicated a high level of skill and training. Since his employment began, his supervisors had noted frequent arguments, absenteeism, poor workmanship, and multiple errors that might have been dangerous. When confronted, he was reportedly dismissive, indicating that the problem was “cheap wood” and “bad management” and added that if someone got hurt, “it’s because of their own stupidity.”

When the head of human resources met with him to discuss termination, Mr. Crocker quickly pointed out that he had both attention-deficit/hyperactivity disorder (ADHD) and bipolar disorder. He said that if not granted an accommodation under the Americans with Disabilities Act, he would sue. He demanded a psychiatric evaluation.

During the mental health evaluation, Mr. Crocker focused on unfairness at the company and on how he was “a hell of a better carpenter than anyone there could ever be.” He claimed that his two marriages had ended because of jealousy. He said that his wives were “always thinking I was with other women,” which is why “they both lied to judges and got restraining orders saying I’d hit them.” As “payback for the jail time,” he refused to pay child support for his two children. He had no interest in seeing either of his two boys because they were “little liars” like their mothers.

Mr. Crocker said he “must have been smart” because he had been able to make Cs in school despite showing up only half the time. He spent time in juvenile hall at age 14 for stealing “kid stuff, like tennis shoes and wallets that were practically empty.” He left school at age 15 after being “framed for stealing a car” by his principal. Mr. Crocker pointed out these historical facts as evidence that he was able to overcome injustice and adversity. Adult Psychiatric Evaluation SOAP Note Assignment Discussion

Diagnosis (include any specifiers): 301.7( F60.2) Antisocial personality disorder Persistent

Criteria A

A1-He had restraining orders taken against him for hitting his past two wives. He also refused to pay child support for his two children. He would steal that resulted him spending time in a juvenile hall facilities during his adolescents.

A2-His record indicated that he had provided false documentation and his graduations certificates had be falsified.

A4-He had been fired from his job at one local construction company after a fistfight with his supervisor and from another job after abruptly leaving a job site.

A5-He made multiple errors that might have been dangerous to his coworkers. When he was confronted, he was dismissive, and he indicated if someone got hurt its because of their own stupidity.

A6-He had been expelled from two carpentry training programs, and he absenteeism, and poor workmanship.

A7- He refused to pay child support for his two children and he had no interest in seeing either of his two boys because they were “little liars” like their mothers. Adult Psychiatric Evaluation SOAP Note Assignment Discussion

Criteria B

He is 32-year-old man.

Criteria C

Evidence shows that conduct disorder began at the age of 14.

Treatment Plan for ASPD

Psychotherapy- Helps to improve behaviors and emotions. It can help a person with ASPD be conscious to others feelings and encourage socially acceptable behaviors.

Cognitive Behavioral Therapy (CBT)- CBT helps change a way that a person behavior and thinks. CBT can be used to help reflect on how their behavior affects others.

Reference:

Barnhill, J.W. (Ed.).  (2014). DSM-5: Clinical cases. American Psychiatric Association Publishing. Adult Psychiatric Evaluation SOAP Note Assignment Discussion

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