Episodic SOAP Notes

Introduction
The paper seeks to give psychiatric analysis among two different diagnosis of a patient. It discusses the psychological attributions of schizophrenia bipolar type, adjustment disorders, schizoaffective disorder, and unspecified condition that is pegged on substance abuse based on the working and differential diagnosis. There is a need to understand the fact that patients with substance withdrawal and mental illness need to have a clear assessment touching on the suicidal and aggressive behavior in the overall system in one way or the other. This gesture must be carried out regardless of the specific diagnosis done on the patient (Richard-Eaglin & Johnson, 2019). It is also essential for the assessor to be aware of the fact that the patient may admit experiences from some symptoms to help maintain the trust of the client. Finally, the assessor must be sure to fully document the observations in the health record in order to make psychiatrists, nurses, and doctors diagnose more appropriately the specific problem encountered by the patient.

Also Read: Write My Nursing SOAP Note Paper

Working Diagnosis
The patient under analysis in this area is a female of 45 years old who interacts well with other staff in the workplace but gets upset once she finds out that she is pregnant after medical examination. The assessor, in this case, would consider three valuable domains relating to schizophrenia with bipolar type issues. These domains include disorganized speech and thinking, hallucinations, and delusions. However, visual hallucinations may be seen as visual stimuli. For example, a shadow may become e disturbing black dog. Such issues occur with other medical conditions such as depression on the patient due to the sudden realization of her pregnancy (Fowler, Conner & Smith, 2018). It may also be manifested as an aura with a brain or seizure. However, both cases rarely occur at the same time as a patient.
Disorganized speech and thinking may occur circumstantially, where the patient may be slow toward getting to the main point. It may also include the instances of creative thinking where the patient may make literal rather than figurative interpretations in some form of speech and listening skills. There are also instances of gross abnormal and disorganized behavior that could be manifested as unpredictable behavior that would interfere with the completion of a task or that can cause some form of agitation. Others include the aspects of failure to follow specific instructions and also immobility in the patient (Richard-Eaglin & Johnson, 2019). The person may also manifest some type of bizarre position and would also lack both the physical and verbal responses to the others in the workplace. At times, they may just look and stare at other staff members with no apparent reasons.
She vehemently shows instances of sadness and low energy level. This patient shows symptoms of depressive disorder with clear symptoms that would affect the manner in which she feels and thinks. This depression may also have an effect on the work, eating, and sleeping patterns by the person in one way or the other. Important parameters used in the assessment of this patient include the pain management history and the scales and assessment tools used during the process. There is a need to look at the effective and ineffective pharmacological interventions used on the patient (Mendes et al., 2019). The assessor must also provide clear goals for the pain results on the same person. The need to utilize decision-making tools such as the electronic health records on the patient may even become handy in dealing with such problems in the mental health care of the person. Other tools in the decision-making process include high alert medications and the embedded standard communication channels used among the staff in relation to the patient.

Diffrential Diagnosis
The patient is paranoid and may not admit to hearing the voices until they have developed trust in the assessor or until the issues linked to the antipsychotic medication begin to take effect on the patient. It is significant to determine the theme as to which the voices in the patient are trying to relay. For instance, these patients are often worried that something terrible may happen. It is unfortunate that these voices rarely go away completely, even with proper management of the patient on the correct medications (Fowler, Conner & Smith, 2018). There are some negative symptoms associated with this condition such as lack of emotional expressions, lack of interest to the others in the society, and a complete lack of personality in the patient. Others may include avolition, alogia, and anhedonia among the patient.
Avolition refers to the case where the patient lacks the motivation spirit toward some kind of goal-oriented tasks, while alogia refers to decreased speech. Anhedonia refers to the lack of pleasure in the activities that were previously loved by the person. She suffers from a chronic hypertension condition that is under control with medications. There is the need to deal with the withdrawal syndrome linked to the patient based on the available symptoms such as diaphoresis and increased syndrome (Mendes et al., 2019). Others include tremors, insomnia, vomiting, and nausea. Hallucinations may also start as sensitivity toward a bright light and loud sounds. These effects are often visual and tactic in nature.

Conclusion
In summary, the paper has tried to give the mental examination among four distinct featuires in the patient. It talks about the psychological attributions of schizophrenia bipolar sort, change issue, schizoaffective issue, and unknown condition that is pegged on substance misuse. There is the need to comprehend the way that patients with substance withdrawal and psychological instability need to have a reasonable evaluation addressing the self-destructive and forceful conduct in the general framework in one way or the other. This signal must be done, paying little respect to the particular determination done on the patient. It is additionally significant for the assessor to know about the way that the patient may concede encounters from specific indications to help keep up the trust from the customer. At long last, the assessor must make sure to completely archive the perceptions in the wellbeing record so as to make the specialists, medical caretakers, and specialists analyze all the more suitably the particular issue experienced by the patient.

References


Fowler, T., Conner, R., & Smith, W. (2018). Master of Science in Nursing and Doctor of Nursing Practice Clinical Curriculum Map. Journal of Nursing Education, 57(7), 440-445.

Mendes, D., Lopes, M., Romão, A., & Rodrigues, I. P. (2019). Healthcare Computer Reasoning Addressing Chronically Ill Societies Using IoT: Deep Learning AI to the Rescue of Home-Based Healthcare. In Chronic Illness and Long-Term Care: Breakthroughs in Research and Practice (pp. 720-736). IGI Global.

Richard-Eaglin, A., & Johnson, R. (2019). Innovative Strategies for Nurse Practitioner Student Engagement in Alternative Patient Visits. Journal of Nursing Education, 58(4), 249-249.

READ PDF: Episodic SOAP Notes