SOAP NOTE REPLIES
Critique the decision making of two of your peers in your response posts.
1. Do you agree/disagree with their medication choice? Why?
2. Is there anything else you recommend including?
3. Compare peer’s decision making to yours—what are the advantages and disadvantages of each?
Your response should include evidence of review of the course material through proper citations using APA format.
Reply one:
1)Psychosis: Again, the diagnosis of schizophrenia is best made over time because repeated observations increase the reliability of the diagnosis. A diagnosis of schizophrenia is reached through an assessment of patient-specific signs and symptoms, as described in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5). Schizophrenia presents with four symptom clusters: positive, negative, cognitive, and affective disturbances. Positive symptoms can include hallucinations, delusions, thought disorders/behaviors, and movement disorders. Negative symptoms include a flat affect, alogia, anhedonia, lack of self-motivation, social withdrawal. Cognitive symptoms include poor executive function, difficulty focusing, memory deficits. And finally, affective disturbances include odd expressions or actions, poor self-esteem, depression with an increased risk of suicide (Dunphy, Winland-Brown, Porter, & Thomas, 2011).
The diagnostic criteria for schizophrenia include the persistence of two or more of the following active-phase symptoms, each lasting for a significant portion of at least a one-month period: delusions, hallucinations, disorganized speech, grossly disorganized or catatonic behavior, and negative symptoms. At least one of the qualifying symptoms must be delusions, hallucinations, or disorganized speech (DSM-5, 2013). Patient Andy presents with delusions, auditory/cenesthetic hallucinations, and increasing social withdrawal extending upon two months. As well, an estimated 80% of clients affected by a psychotic disorder experience their first episode between the ages of 16-30. In men, the symptoms tend to present between 18 and 25 years of age. In women, the onset of symptoms has two peaks, the first between 25 years of age and the mid-30s, and the second after 40 years of age (Holder & Wayhs, 2014). While continued clinical observation is necessary, this patient is presenting with psychosis along the disorder of schizophrenia.
Any patient presenting with such symptoms must be fully evaluated for underlying medical conditions. Consideration of substance abuse should be one of the primary differentials, and toxicology testing should be performed (Dunphy et al., 2011). Alcohol, opioids, cocaine, amphetamines, barbiturates, and hallucinogens are some of the most common offenders. Commonly prescribed medications such as anticholinergic agents, phenytoin, steroids, and anxiolytics may also produce similar symptoms. Our patient does admit to use of marijuana and speed; therefore, it is imperative to have the patient discontinue these substances. Other differentials to consider include delirium, in which the onset of symptoms occurs more rapidly and in which visual hallucinations are more common, versus schizophrenia in which symptoms occur over a longer time period and auditory hallucinations occur more frequently. Medical illness such as hepatic encephalopathy, hyponatremia, hypoglycemia, hypoxia, intracranial bleed, infection, meningitis, and so forth should be considered. A complete history and physical exam with attention to neurologic and mental status exam are essential. Laboratory evaluation should include CBC with differential, electrolytes, renal function, liver profile, thyroid function, drug and alcohol toxicology, and for woman, pregnancy (Dunphy et al., 2011).
Schizophrenia influences all aspects of life for patients and their families. Treatment goals should address reducing or eliminating symptoms, maximizing quality of life, improving function, and promoting and maintaining recovery. Pharmacologic intervention is the mainstay for treatment of schizophrenia (Patel, Cherian, Gohil, & Atkinson, 2014). Numerous studies have shown there is often a significant delay in initiating treatment for people affected by a psychotic disorder. These delays vary widely but the interval between onset of psychotic symptoms and commencement of appropriate treatment is often more than one year and as a consequence of these delays, significant disruption can occur at a critical developmental stage along with the formation of alarming secondary problems. The longer the period of untreated illness, the greater the risk for psychosocial disruption and secondary morbidity for the person and their family. Some evidence shows that long delays in treatment may cause psychotic symptoms to become less responsive to treatment (“Early Psychosis,” 2000).
Antipsychotic medications are the treatment of choice and patients should be offered such when they are suspected or initially diagnosed. Potential risks, benefits, adverse effects, and alternatives should be discussed with the patient. Antipsychotic medications include the typical or first-generation antipsychotics or the atypical or second-generation antipsychotics. Data suggest similar antipsychotic efficacy for both classes and a tendency for the second generation being better tolerated leading to enhance compliance (Papadakis & McPhee, 2017). It is essential to start any antipsychotic medication at very low doses to minimize side effects as these contribute to poor compliance. The start low and go-slow approach will bring around 60% of patients to full remission responding by 12 weeks and another 25% will respond more slowly (“Early Psychosis,” 2000).
For patient Andy, consideration should be given to the atypical antipsychotic risperidone. Risperidone works by blocking dopamine 2 receptors and can reduce positive symptoms of psychosis, sometimes within one week and then improve negative symptoms (Stahl, 2013). Andy can be started on a 2 mg dose administered as a single daily dose or 1 mg twice a day. If the dose is well tolerated, the dose can be increased to 3 mg on the second day and 4 mg on the third day. Risperidone 4 mg is in the therapeutic range for most patients, and should the patient continue this medication, he can stay at this dose for an additional two weeks before considering an increase. If he shows only minimal or no improvement, the dose can be increased up to 8 mg daily with careful monitoring for response and side effects, as doses of risperidone above 8 mg daily are associated with substantial side effects (Up To Date, 2018). Resolution of symptoms generally occurs over several days and may take as much as four to six weeks.
Side effects of risperidone can include increased heart rate, increased blood pressure, increased body mass index, increase weight gain, increased weight circumference, increased lipid panel, increased glucose level, and signs of movement disorder (i.e. extrapyramidal symptoms of akathisia, parkinsonism, dystonia or tardive dyskinesia of abnormal movements of the face, tongue, extremities, perioral areas) (Papadakis & McPhee, 2017). Prior to medication administration the clinician must obtain a thorough patient history as well as family history to know if it may include hypertension, obesity, diabetes, or dyslipidemia. It would also be feasible to obtain a CBC, electrolytes, fasting glucose, lipid profile, liver, renal, and thyroid function tests. Each visit should include a full set of vital signs and body mass index (Papadakis & McPhee, 2017). It is imperative to make patients aware of the adverse effects and to notify the clinician of any concerns. The patient should follow up in office in one week after starting medication for re-assessment and evaluation of adverse effects and clinical outcomes.
Recovery during the treatment of schizophrenia is defined both objectively and subjectively. Objective dimensions of recovery include the remission of symptoms and the patient’s return to full-time work or enrollment in college (Patel et al., 2014). Several tools are available for rating the progress of patients with schizophrenia. The Brief Psychiatric Rating Scale (BPRS) and the Positive and Negative Syndrome Scale (PANSS), for example, were developed as numerical indicators of improvement. Clinicians can also use quicker four-item instruments such as the Positive Symptom Rating Scale and the Brief Negative Symptom Assessment. Subjective dimensions of recovery are measured by the patient in terms of his or her life satisfaction, hope, knowledge about his or her mental illness, and empowerment (Patel et al., 2014).
2) Substance Use/Abuse: Predictors of a poor prognosis include the illicit use of amphetamines and other central nervous system stimulants, as well as alcohol and drug abuse. Several past studies have found that more frequent use of marijuana is associated with a higher risk of psychosis. In one particular study, researchers compared incidence of psychosis with the availability and use of marijuana in several different cities. The study found that three European cities, London, Paris and Amsterdam, had the highest rates of new diagnoses of psychosis at 45.7 per 100,000 person per year in London, 46.1 in Paris and 37.9 in Amsterdam. These are also cities where high-potency marijuana is most easily available and commonly used (Chatterjee, 2019). Other European cities in Spain, Italy and France were shown to have less marijuana use and also have lower rates of new psychosis diagnosis (Chatterjee, 2019). While it is reasonable to suggest that patient Andy discontinue his use of marijuana and speed as a first line treatment, if there is no immediate improvement in his presentation, the patient will need to start on psychopharmacologic therapy as the patient can end up a danger to self/others and an increased chance of acting out his suicidal or homicidal ideation. However, as previously discussed, given the patient’s current symptoms, medication management is highly recommended as first choice treatment, along with discontinuation of alcohol and drug use.
3)Suicidal/Homicidal Ideation: Despite continued therapeutic advances, the life expectancy of patients with a diagnosis of schizophrenia is reduced by approximately ten to twenty-five years compared with that of healthy individuals. The risk of suicide is thirteen times greater in persons diagnosed with schizophrenia compared with the general public, with a lifetime risk of about five percent (Holder & Wayhs, 2014). At this time, Andy is having passive thoughts of suicidal ideation and denies thoughts of wanting to purposely hurt others, but if necessary, he reports he will use a knife or baseball bat as a means of personal protection. While these are both highly concerning, the patient is able to contract for safety and his plan of care will include to remove these items from his possession along with removing self from his current living situation and stay with his parents for support while undergoing treatment and safety monitoring. Patient and family are aware to notify of any immediate or life-threatening changes as this may require in patient hospitalization for safety of self and others.
4)Individual, Group, Family Therapy: Nonpharmacological treatments should be used as an addition to medications, not as a substitute for them. In addition to positive lifestyle choices, such as healthy diet, increased exercise, social integration, psychotherapy has shown to improve treatment adherence, insight, and quality of life, and decreased hospital admissions (Holder & Wayhs, 2014). Psychotherapeutic approaches may be divided into three categories: individual, group, and cognitive behavioral therapy. I don’t think it’s necessary for the patient to be inpatient at this time given he has family support, a safe place to stay, initiation of psychopharmacological medication, and has contracted for safety. Psychotherapy involves teaching the patient and family about mental illness while imparting a message of hope without downplaying the seriousness of the disease. Three inter-related issues that should be addressed are meaning, mastery, and self-esteem which will help patients to develop coping strategies, recognize warning symptoms, and reduce stressors by adjusting to individual or environmental needs (“Early Psychosis,” 2000).
5)Cognitive Behavioral Therapy: Cognitive behavioral therapy is a structured psychotherapy directed toward solving current problems by modifying distorted thinking and behavior (Holder & Wayhs, 2014). It assumes that thoughts, beliefs, attitudes and perceptual biases influence emotions and behavior. Realistic evaluation and modification of thinking produces improvement in mood and behavior. Cognitive behavioral therapy is the most commonly used adjunctive therapy with a Cochrane review finding it may be helpful in dealing with emotions and distressing feelings (Holder & Wayhs, 2014).
Prognosis:
Andy has a good prognosis if his psychoses are controlled and stabilized and passive suicidality/homicidality are avoided. He has no previous history or personal family history that seems to indicate a need for eminent danger. Also, his support system through his family will be important to his continued health.
REPLY TWO
Referrals: Andy is reporting suicidal ideation with a plan to overdose. Additionally, the patient reports having a knife and a baseball bat for protection from his roommates. Therefore, to ensure safety, the patient will be referred to an acute inpatient mental health hospital where he can be on suicide precautions and he can be further evaluated and assessed for medication effectiveness. Patients that are at risk of harm to themselves or others may need to be hospitalized (UpToDate, 2019). Furthermore, hospitalization will allow Andy an opportunity to avoid the use of substances that may be contributing to the psychosis and therefore will aid in the diagnosis process. In addition, hospitalization will allow the patient to be monitored for amphetamine withdrawal symptoms. The recommendation is a follow-up appointment at this clinic within 24 hours after discharge from the inpatient facility.
Medication:
Aripiprazole (Abilify) 10 mg by mouth daily.
Drug Rationale: Guidelines recommend symptomatic treatment of psychosis, with antipsychotic medication, even if the psychiatric disorder or medical condition underlying the psychosis has not yet been established. Guideline recommendations for a first-episode patient is 1 to 3 mg of risperidone or 10 mg of Abilify daily (UpToDate, 2019). Abilify was chosen because of its partial antagonist action. This will reduce the likelihood of EPS or hyperprolactinemia. Additionally, Abilify is generally not a sedating type of drug due to its lack of M1-muscarinic cholinergic and H1- Histamine antagonist properties, this will allow the patient to feel alert and awake as he finishes his last year of college (Stahl, 2013). Another reason that Abilify is chosen because it is less likely to cause metabolic effects such as insulin resistance, hyperlipidemia or elevated triglycerides and/or weight gain (Stahl, 2013). Lastly, Andy complains of feeling suicidal. Antipsychotics may reduce suicide risk. In addition to being shown as an effective treatment for Schizophrenia, Abilify is an approved medication for depressive disorders. Therefore, it is possible that this drug could improve his depression symptoms and avoid polypharmacy. Most antipsychotic drugs should be titrated slowly from an initial dose until it reaches a therapeutic range. This should be done as quickly as the patient can tolerate but no more than one increase per every two weeks. According to guidelines, Abilify can be increased to a maximum of 30 mg once daily. The patient should have a reduction of psychotic symptoms in the first week and significant improvement after two weeks. If not, the patient will be tapered from Abilify and a different antipsychotic can be considered (UpToDate, 2019). If Ability is not effective, the plan is to prescribe Risperidone (Risperdal) 1 mg by mouth twice daily. This drug was not chosen as the first line of treatment due to the higher risk of raising prolactin levels, dyslipidemia, weight gain and EPS when compared to Abilify.
The largest concern about choosing Abilify is that it does not completely block D 2 receptors, therefore, its ability to produce enough antipsychotic efficacy will need to be assessed regularly for a decrease in positive signs and symptoms. Andy will be hospitalized for the first several days of treatment, if there is no improvement in the expected amount of time, this will be recognized, and Risperidone treatment can be considered. Additionally, while taking Abilify, Andy will be monitored closely for akathisia. If this does occur, a decrease in dose, a beta-blocker or an anticholinergic drug will be considered if the drug is proving to be an effective treatment for the psychosis (Stahl, 2013).
Labs and Monitoring: Serum drug screen, CBC (with differential), CMP, Urinalysis, 9-hour fasting lipid panel, A1C, TSH, Ammonia, Vitamin B-12, fasting-blood glucose. Breathalyzer. *Height and weight (BMI) will be monitored.
Additional tests that may need to be considered: CT scan, hormone levels. EKG. Breathalyzer.
Labs and Monitoring Rationale: It is well established that exposure to antipsychotic medication is linked clinically to cardiovascular and metabolic side effects (Vázquez-Bourgon, Setién-Suero, Pilar-Cuéllar, Romero-Jiménez, Ortiz-Garcia de la Foz, Castro & Crespo-Facorro, 2019) Therefore, a baseline of lipids, blood sugar, and BMI must be obtained. A CMP is ordered because frequent causes of delirium include fluid or electrolyte abnormalities. Psychosis can also be caused by hypoglycemia, hypoxia, hypercapnia, infections, or medications, substance intoxication or withdrawal, therefore, it is necessary to obtain a drug screen and urinalysis and differential CBC (UpToDate, 2019). Neuropsychiatric manifestations may be present in vitamin B12 deficiencies. EKG could be needed as there is a possibility of QT prolongation with some antipsychotics.
Therapy Recommendations: The patient will need further evaluation to determine future outpatient therapy recommendations. This will depend greatly on the patient’s adherence to medication, the effectiveness of medication and response to inpatient treatment. Currently, the therapy recommendation is a referral to an inpatient setting where the patient can benefit from group and individual therapy and a decision about follow up therapy can be determined later, during the inpatient hospitalization stay. It will be imperative to offer substance abuse support groups to Andy. After more evaluation, the patient will be referred to an appropriate outpatient substance abuse program.
Patient and Family Education: The patient and his mother will be educated about possible adverse effects of aripiprazole including headache, body twitching (akathisia), weight gain, metabolic effects(signs of high blood sugar; polydipsia, polyphagia, polyuria), extrapyramidal reactions, drowsiness, dizziness, signs of Neuro Malignant Syndrome(fever, sweats, cramping, change in thinking), constipation, insomnia, nausea and vomiting, muscle cramping (tardive dyskinesia) and increased suicidal thinking(Lexicomp. 2019). Furthermore, Andy’s mother will be educated about psychosis and the risks associated with it such as an increased risk of harm to themselves or others. Additionally, the family will be advised about the importance of decreasing environmental stimulation and the significance of not arguing with delusional ideas (UpToDate, 2019).
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