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African American Female with a History of Paranoid Schizophrenia
Essay Instructions:
//Use a patient more than 65 years old with a psychiatric illness. Make sure the medication correlates with the diagnosis, use a similar medication, but not the same as the last one. The patient was seen in a psych clinic, not in a hospital.
For this assignment, students will create a written comprehensive psychiatric evaluation of a patient they have seen in the clinic. Your preceptor must sign their initials on this document to confirm they have reviewed and acknowledge this patient was seen in their clinic. Each student will use the Graduate Psychotherapy Note Template.docx to create a detailed psychiatric evaluation document. SOAP is an acronym that stands for Subjective, Objective, Assessment, and Plan. The comprehensive psychiatric evaluation is to be written using the attached template below.
S.O.A.P. Table S - Subjective data: Patient’s Chief Complaint (CC); History of the Present Illness (HPI)/ Demographics; History of the Present Illness (HPI) (Links to an external site.) that includes the presenting problem and the 8 dimensions of the problem (OLDCARTS); Review of Systems (ROS).
O - Objective data: Medications; Allergies; Past medical history; Family history; Past surgical history; Psychiatric history, Social history; Labs and screening tools; Vital signs; Physical exam, (Focused), and Mental Status Exam.
A - Assessment: Primary Diagnosis and two differential diagnoses including IDC-10 and DSM5 codes.
P - Plan: Pharmacologic and Nonpharmacologic treatment plan; diagnostic testing/screening tools, patient/family teaching, referral, and follow-up.
Other: Incorporate current clinical guidelines NIH Clinical Guidelines (Links to an external site.) or APA Clinical Guidelines (Links to an external site.), research articles, and the role of the PMHNP in your presentation.
Reminder: It is important that you complete this assessment using your critical thinking skills. You are expected to synthesize your clinical assessment, formulate a psychiatric diagnosis, and develop a treatment plan independently. It is not acceptable to document "my preceptor made this diagnosis." An example of the appropriate descriptors of the clinical evaluation is listed below. It is not acceptable to document “within normal limits.”
Graduate Mental Status Exam Guide - Comprehensive Psychotherapy Evaluation.docx Download Graduate Mental Status Exam Guide - Comprehensive Psychotherapy Evaluation.docx
Graduate Psychiatric Note Template
Essay Sample Content Preview:
African American Female with a History of Paranoid Schizophrenia
Comprehensive Psychiatric Evaluation Template
With Psychotherapy Note
Encounter date: _Friday 22nd July 2022_______________________
Patient Initials: _M.T_____ Gender: M/F/Transgender _Female___ Age: _67 years____ Race: _African American____ Ethnicity _Haitian___
Reason for Seeking Health Care: Mrs. Taylor is a 67-year-old African American female with a history of paranoid schizophrenia. She is accompanied by her daughter Mary (35 years old) who asserts that the patient started showing signs of a relapse three weeks ago. The patient states that “I have to go back and stop those murderous, thieving neighbors from sacrificing my grandchildren”.
HPI: Mrs. Taylor was diagnosed with paranoid schizophrenia 49 years ago after her first pregnancy. She received treatment for the mental disorder and has been doing quite well, although even with a good response to initial treatment, her symptoms habitually return. Her most recent relapse was seventeen years ago and her daughter claims that there was another relapse preceding the last one. The first relapse happened after the death of her eldest son, who died in a car accident after driving under influence. Her daughter reports that “the death of my elder brother was a shock to us all. He was doing very well for himself and we did not know of his tragic alcohol addiction. My mother was most affected and the extreme life event saw her lose interest in everything and become increasingly irritable. We thought she was just devastated and didn’t notice the early symptoms of her relapse until she started screaming in her sleep that the death of my brother was no accident but a design by our neighbors to reduce the family to poverty. My brother was a bright man. He was the first in our community to go to college. He got a job as an engineer at a leading software firm and was generous with his salary. He had even promised to buy my mother a house in a better neighborhood. My mother immigrated from Haiti as a teenager and continues to hold very strong Voodoo beliefs about the evil eye and human sacrifice disguised as accidents”. Mrs. Taylor was re-admitted and promptly re-introduced to antipsychotic treatment. She managed to regain control of her symptoms and even opened up a grocery store, which she run with her surviving daughter-in-law. Her daughter states that “I believe that being busy at the store was a good thing for my mother. In addition to supporting our family, the constant interaction with family and friends played an important role in her treatment and recovery. She was coping very well with the death of her son and succeeding at building a rich, meaningful life”. Unfortunately, her progress was cut short by a burglary incident where two robbers fired gunshots after entering the grocery store and demanded that Mrs. Taylor (who was at the cash register) hand over everything. Her daughter recalls that “one of the robbers pistol-whipped my mother twice for ‘holding out’. She was rushed to hospital and got seven staples for the head injury”. Mrs. Taylor refused to leave the house after that incident and had difficulty concentrating. Unfortunately, her distrust in her neighbors, something she was slowly doing away with during her remission period at the store, heightened markedly and she became fearful that the “neighborhood was out to get her”. Her daughter states that “my mother claimed that the robbers were sent by her jealous neighbors who did not want to see her happy and prospering”. Mrs. Taylor (who was inattentive up to this point) interjected in an agitated, angry voice: “I have very mean-spirited, evil neighbors working against my family’s blessings. No one believes me but I’m telling you, they took my son, then they robbed my store and nearly killed me in the process. Now they want to have my grandchildren. I’ll sooner die than allow that to happen. I don’t belong here, I need to keep those hateful people away”. Although her symptoms disappeared after her second readmission, she continued to harbor a deep mistrust of everyone outside of her family circle. Her daughter states that even her second re-introduction to antipsychotic treatment did not eliminate Mrs. Taylor’s resentment of her neighbors: “My mother was functional and she did not have any further relapses until three weeks ago. However, I noticed that after her second hospitalization, she became more withdrawn from the community. She closed the store and stopped going to church after the second relapse, although her relationships with family and relatives were just as cordial as before. The silver lining is that she started paying even greater attention to me and my sister-in-law. Our relationships with her improved. She was very eager to help with the children whenever we got tied up. The children are very fond of her”. The patient claims that she complained to her doctor about the pills she was receiving three months ago: “I don’t know why, but those pills started making me fat. My cholesterol levels went through the roof and yet I maintain a healthy diet and move a lot. I am always tending to my garden and chasing after the children. You cannot imagine how fast they are or how tired I get at the end of the day”. Mrs. Taylor claims that the doctor disregarded her concerns by insisting that she continue with the same medication given her high risk of relapse: “I stopped taking his medication after that, and with the children around, and my energy levels high, who wants to keep swallowing pills, anyway?”. Her daughter reports that her mother started becoming disorganized and confused around the time she reports non-adherence with medication. Mrs. Taylor would disappear unexpectedly and leave the children unattended: “I knew that she was relapsing again when she started becoming nervous and irritable, even neglecting her personal hygiene. Early this morning, I walked in on her as she furiously attacked one of our neighbor’s teenage daughter (she had come to babysit the young ones) with a knife, calling her a ‘she-devil’, ‘spy’, ‘destroyer of homes’, and ‘killer’. I managed to pull her away from the terrified girl and convinced her, with great effort, to come to the psychiatric clinic”.
SI/HI: The patient has no history of suicidal ideation. However, she has recurrent thoughts of revenging against her neighbors for the death of her son and the robbery of the store. These thoughts were always vague and never fully formulated until this morning when she attacked one of the neighbor’s daughters without warning and with the intention of causing grievous bodily harm.
Sleep: Poor. The patient reports moderate to severe insomnia
Appetite: The patient reports an aversion to certain foods although her appetite is okay
Allergies (Drug/Food/Latex/Environmental/Herbal): The patient has no known allergiesCurrent perception of Health: Excellent Good Fair Poor
Psychiatric History:
Inpatient hospitalizations:
Date
Hospital
Diagnoses
Length of Stay
3rd May 1973
UTHealth Harris County Psychiatric Center
Paranoid Schizophrenia
3 days
4th December 2004
Houston Methodist
Concussion
2 days
3rd January 2005
Methodist Hospital Psychiatry
Paranoid Schizophrenia and Major Depressive Disorder
3 days
Outpatient psychiatric treatment:
Date
Hospital
Diagnoses
Length of Stay
4th December 2002
UTHealth Harris County Psychiatric Center
Paranoid Schizophrenia
1 day
Detox/Inpatient substance treatment:
Date
Hospital
Diagnoses
Length of Stay
History of suicide attempts and/or self injurious behaviors: The patient has no history of suicide attempts and/or self injurious behaviors
Past Medical History
* Major/Chronic Illnesses: Diagnosed with diabetes and hypertension at 55 years old (current)
* Trauma/Injury: Suffered a head concussion from a burglary incident at her store at 49 years old
* Hospitalizations: Hospitalized at UTHealth Harris County Psychiatric Center for paranoid schizophrenia at 18 years old, at Houston Methodist for a concussion at 49 years old, and at Methodist Hospital Psychiatry for paranoid schizophrenia and major depressive disorder at 50 years old.
Past Surgical History The patient underwent minor surgery after the burglary incident and required seven staples for sustained laceration.
Current psychotropic medications: Abilify 15 mg, 1 tab po qd; Klonopin 1 mg, 1 tab po qhs and ½ tab po prn in cases of heightened anxiety; and Fluoxetine Hydrochloride 20 mg, 1 tab po qd.
Current prescription medications: Metformin 1500 mg/day and Acebutolol 400 mg/day
OTC/Nutritionals/Herbal/Complementary therapy:
Substance use: (alcohol, marijuana, cocaine, caffeine, cigarettes)
Substance
Amount
Frequency
Length of Use
Family Psychiatric History: Mrs. Taylor’s husband had a history of major depressive disorder and committed suicide shortly before her daughter’s birth. Three of the patient’s uncles from her mother’s side (back in Haiti) had mental health issues. However, no clinical diagnosis was conducted and their disorders were largely attributed to “evil spells cast by green-eyed relatives”. The patient never knew her father or his family. Her deceased son had depressive symptoms, something the patient’s daughter correlates with his alcohol addiction problem. Family psychiatric history is otherwise negative and no other case of psychiatric disorder, hospitalization, or suicidal behavior can be traced.
Social History
Lives: Single family House/Condo/ with stairs: Mrs. Taylor lives in a single-family home with stairs together with her daughter and her daughter-in-law
Marital Status: Widowed
Education: High School Diploma
Employment Status: Unemployed Current/Previous occupation type: Shopkeeper
Exposure to: ___Smoke____ ETOH ____Recreational Drug Use: __________________
Sexual Orientation: Heterosexual Sexual Activity: Sexually inactive ____ Contraception Use: ____________
Family Composition: Family/Mother/Father/Alone: The patient is widowed and has no other close relations besides her daughter and surviving daughter-in-law.
Other: (Place of birth, childhood hx, legal, living situations, hobbies, abuse hx, trauma, violence, social network, marital hx): The patient was born in Lakwev, a rural village in Haiti’s northeast region. Her mother was a casual laborer and never told her who her father was. She stopped asking as she grew older because it only upset her. Even though she was an only child, the patient reports having a relatively happy childhood: “During our time, it was not uncommon for children to grow up without knowing their fathers and therefore I did not feel out of place. I was treated like any other normal kid and socialized well enough with my agemates, mostly my cousins. I became a contributing member of our family very early and by 15 years old I was mature enough to know what I wanted in life”. The patient married her deceased husband at 17: “He was already working as a mechanic in Port-au-Prince: It was love at first sight. I actually...
With Psychotherapy Note
Encounter date: _Friday 22nd July 2022_______________________
Patient Initials: _M.T_____ Gender: M/F/Transgender _Female___ Age: _67 years____ Race: _African American____ Ethnicity _Haitian___
Reason for Seeking Health Care: Mrs. Taylor is a 67-year-old African American female with a history of paranoid schizophrenia. She is accompanied by her daughter Mary (35 years old) who asserts that the patient started showing signs of a relapse three weeks ago. The patient states that “I have to go back and stop those murderous, thieving neighbors from sacrificing my grandchildren”.
HPI: Mrs. Taylor was diagnosed with paranoid schizophrenia 49 years ago after her first pregnancy. She received treatment for the mental disorder and has been doing quite well, although even with a good response to initial treatment, her symptoms habitually return. Her most recent relapse was seventeen years ago and her daughter claims that there was another relapse preceding the last one. The first relapse happened after the death of her eldest son, who died in a car accident after driving under influence. Her daughter reports that “the death of my elder brother was a shock to us all. He was doing very well for himself and we did not know of his tragic alcohol addiction. My mother was most affected and the extreme life event saw her lose interest in everything and become increasingly irritable. We thought she was just devastated and didn’t notice the early symptoms of her relapse until she started screaming in her sleep that the death of my brother was no accident but a design by our neighbors to reduce the family to poverty. My brother was a bright man. He was the first in our community to go to college. He got a job as an engineer at a leading software firm and was generous with his salary. He had even promised to buy my mother a house in a better neighborhood. My mother immigrated from Haiti as a teenager and continues to hold very strong Voodoo beliefs about the evil eye and human sacrifice disguised as accidents”. Mrs. Taylor was re-admitted and promptly re-introduced to antipsychotic treatment. She managed to regain control of her symptoms and even opened up a grocery store, which she run with her surviving daughter-in-law. Her daughter states that “I believe that being busy at the store was a good thing for my mother. In addition to supporting our family, the constant interaction with family and friends played an important role in her treatment and recovery. She was coping very well with the death of her son and succeeding at building a rich, meaningful life”. Unfortunately, her progress was cut short by a burglary incident where two robbers fired gunshots after entering the grocery store and demanded that Mrs. Taylor (who was at the cash register) hand over everything. Her daughter recalls that “one of the robbers pistol-whipped my mother twice for ‘holding out’. She was rushed to hospital and got seven staples for the head injury”. Mrs. Taylor refused to leave the house after that incident and had difficulty concentrating. Unfortunately, her distrust in her neighbors, something she was slowly doing away with during her remission period at the store, heightened markedly and she became fearful that the “neighborhood was out to get her”. Her daughter states that “my mother claimed that the robbers were sent by her jealous neighbors who did not want to see her happy and prospering”. Mrs. Taylor (who was inattentive up to this point) interjected in an agitated, angry voice: “I have very mean-spirited, evil neighbors working against my family’s blessings. No one believes me but I’m telling you, they took my son, then they robbed my store and nearly killed me in the process. Now they want to have my grandchildren. I’ll sooner die than allow that to happen. I don’t belong here, I need to keep those hateful people away”. Although her symptoms disappeared after her second readmission, she continued to harbor a deep mistrust of everyone outside of her family circle. Her daughter states that even her second re-introduction to antipsychotic treatment did not eliminate Mrs. Taylor’s resentment of her neighbors: “My mother was functional and she did not have any further relapses until three weeks ago. However, I noticed that after her second hospitalization, she became more withdrawn from the community. She closed the store and stopped going to church after the second relapse, although her relationships with family and relatives were just as cordial as before. The silver lining is that she started paying even greater attention to me and my sister-in-law. Our relationships with her improved. She was very eager to help with the children whenever we got tied up. The children are very fond of her”. The patient claims that she complained to her doctor about the pills she was receiving three months ago: “I don’t know why, but those pills started making me fat. My cholesterol levels went through the roof and yet I maintain a healthy diet and move a lot. I am always tending to my garden and chasing after the children. You cannot imagine how fast they are or how tired I get at the end of the day”. Mrs. Taylor claims that the doctor disregarded her concerns by insisting that she continue with the same medication given her high risk of relapse: “I stopped taking his medication after that, and with the children around, and my energy levels high, who wants to keep swallowing pills, anyway?”. Her daughter reports that her mother started becoming disorganized and confused around the time she reports non-adherence with medication. Mrs. Taylor would disappear unexpectedly and leave the children unattended: “I knew that she was relapsing again when she started becoming nervous and irritable, even neglecting her personal hygiene. Early this morning, I walked in on her as she furiously attacked one of our neighbor’s teenage daughter (she had come to babysit the young ones) with a knife, calling her a ‘she-devil’, ‘spy’, ‘destroyer of homes’, and ‘killer’. I managed to pull her away from the terrified girl and convinced her, with great effort, to come to the psychiatric clinic”.
SI/HI: The patient has no history of suicidal ideation. However, she has recurrent thoughts of revenging against her neighbors for the death of her son and the robbery of the store. These thoughts were always vague and never fully formulated until this morning when she attacked one of the neighbor’s daughters without warning and with the intention of causing grievous bodily harm.
Sleep: Poor. The patient reports moderate to severe insomnia
Appetite: The patient reports an aversion to certain foods although her appetite is okay
Allergies (Drug/Food/Latex/Environmental/Herbal): The patient has no known allergiesCurrent perception of Health: Excellent Good Fair Poor
Psychiatric History:
Inpatient hospitalizations:
Date
Hospital
Diagnoses
Length of Stay
3rd May 1973
UTHealth Harris County Psychiatric Center
Paranoid Schizophrenia
3 days
4th December 2004
Houston Methodist
Concussion
2 days
3rd January 2005
Methodist Hospital Psychiatry
Paranoid Schizophrenia and Major Depressive Disorder
3 days
Outpatient psychiatric treatment:
Date
Hospital
Diagnoses
Length of Stay
4th December 2002
UTHealth Harris County Psychiatric Center
Paranoid Schizophrenia
1 day
Detox/Inpatient substance treatment:
Date
Hospital
Diagnoses
Length of Stay
History of suicide attempts and/or self injurious behaviors: The patient has no history of suicide attempts and/or self injurious behaviors
Past Medical History
* Major/Chronic Illnesses: Diagnosed with diabetes and hypertension at 55 years old (current)
* Trauma/Injury: Suffered a head concussion from a burglary incident at her store at 49 years old
* Hospitalizations: Hospitalized at UTHealth Harris County Psychiatric Center for paranoid schizophrenia at 18 years old, at Houston Methodist for a concussion at 49 years old, and at Methodist Hospital Psychiatry for paranoid schizophrenia and major depressive disorder at 50 years old.
Past Surgical History The patient underwent minor surgery after the burglary incident and required seven staples for sustained laceration.
Current psychotropic medications: Abilify 15 mg, 1 tab po qd; Klonopin 1 mg, 1 tab po qhs and ½ tab po prn in cases of heightened anxiety; and Fluoxetine Hydrochloride 20 mg, 1 tab po qd.
Current prescription medications: Metformin 1500 mg/day and Acebutolol 400 mg/day
OTC/Nutritionals/Herbal/Complementary therapy:
Substance use: (alcohol, marijuana, cocaine, caffeine, cigarettes)
Substance
Amount
Frequency
Length of Use
Family Psychiatric History: Mrs. Taylor’s husband had a history of major depressive disorder and committed suicide shortly before her daughter’s birth. Three of the patient’s uncles from her mother’s side (back in Haiti) had mental health issues. However, no clinical diagnosis was conducted and their disorders were largely attributed to “evil spells cast by green-eyed relatives”. The patient never knew her father or his family. Her deceased son had depressive symptoms, something the patient’s daughter correlates with his alcohol addiction problem. Family psychiatric history is otherwise negative and no other case of psychiatric disorder, hospitalization, or suicidal behavior can be traced.
Social History
Lives: Single family House/Condo/ with stairs: Mrs. Taylor lives in a single-family home with stairs together with her daughter and her daughter-in-law
Marital Status: Widowed
Education: High School Diploma
Employment Status: Unemployed Current/Previous occupation type: Shopkeeper
Exposure to: ___Smoke____ ETOH ____Recreational Drug Use: __________________
Sexual Orientation: Heterosexual Sexual Activity: Sexually inactive ____ Contraception Use: ____________
Family Composition: Family/Mother/Father/Alone: The patient is widowed and has no other close relations besides her daughter and surviving daughter-in-law.
Other: (Place of birth, childhood hx, legal, living situations, hobbies, abuse hx, trauma, violence, social network, marital hx): The patient was born in Lakwev, a rural village in Haiti’s northeast region. Her mother was a casual laborer and never told her who her father was. She stopped asking as she grew older because it only upset her. Even though she was an only child, the patient reports having a relatively happy childhood: “During our time, it was not uncommon for children to grow up without knowing their fathers and therefore I did not feel out of place. I was treated like any other normal kid and socialized well enough with my agemates, mostly my cousins. I became a contributing member of our family very early and by 15 years old I was mature enough to know what I wanted in life”. The patient married her deceased husband at 17: “He was already working as a mechanic in Port-au-Prince: It was love at first sight. I actually...
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