Comprehensive Focused SOAP Psychiatric Evaluation Essay

Obsessive-Compulsive Disorder (OCD) in a 32 Year-Old African American Male: Comprehensive Focused SOAP Psychiatric Evaluation

There is a diagnostic category of mental disorders in the fifth and latest edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) referred to as the Obsessive-Compulsive and Related Disorders. This diagnostic family of conditions is composed of conditions such as obsessive-compulsive disorder (OCD), body dysmorphic disorder, and trichotillomania amongst others (Sadock et al., 2015; APA, 2013). OCD is characterized by intrusive impulses that the patient cannot get rid of or control. These impulses push the patient to very strongly want to do something or perform a certain act. This uncontrollable urge or obsession is also accompanied by the urge to repeat the obsession over and over again. This makes it a compulsion. The repetitive nature of the compulsion is entirely out of the patient’s control. The diagnosis of OCD requires that there be symptoms of obsession or compulsion or both. The purpose of this paper is to present a comprehensive psychiatric evaluation of a 32 year-old male patient diagnosed with OCD and a differential diagnosis of a psychotic disorder (schizophrenia).

Subjective:

CC (chief complaint): The patient presents to the clinic with a complaint of getting persistent thoughts about getting feco-oral infections. These thoughts and images are repetitive and disturbing but he cannot control them. He finds himself wanting to wash his hands all the time throughout the day and he cannot prevent himself from doing that; even though it seems irrational.  Comprehensive Focused SOAP Psychiatric Evaluation Essay

HPI: The patient is a 32 year-old African American male presenting with an obsession with handwashing through the fear of getting a feco-oral infection. Because of this he is suffering social dysfunction, occupational dysfunction, and interpersonal dysfunction. There is no previous history of the symptoms and their onset was four weeks ago. The driving force of the symptoms is his thoughts so it is all in his mind. The impulses last for about a minute but show very high frequency to the point of making the patient dysfunctional. The impulse is characteristically repetitive and persistent. Aggravating factors are social gatherings and being part of a group such as at work. Relief factors are physical activity like isotonic aerobic exercise or watching the television. These take his mind off the obsession for a while. The obsessive and compulsive impulses are there all day long except when he is asleep. The patient’s historian is able to rate the severity of his symptoms at 6 out of 10. Comprehensive Focused SOAP Psychiatric Evaluation Essay

Past General History

• General Statement: The patient is in good physical shape and has a habit of engaging in physical activity especially walking and jogging. Apart from the current obsessive-compulsive symptoms that he has; he has not suffered any psychiatric symptoms before. The same is the case for his family.
• Caregivers: The patient does not need the services of a caregiver as he can perform his activities of daily living (ADLs) on his own.
• Hospitalizations: He has only one record of previous hospitalization for food poisoning. There is no history of admission to the hospital with a psychiatric condition.
• Medication Trials: Patient BM has not been part of any medication trials of any kind.
• Previous Psychiatric Diagnosis/ psychotherapy: He has no history of psychiatric diagnosis or even psychotherapy. The same is the case for members of his family.

Substance Current Use and History:

Patient BM admits to taking alcohol socially over the weekends, usually alone but at times with friends. He has also been smoking moderately for the last ten years. He however denies ever using any other substances and drugs such as methamphetamine, cannabis, or cocaine.

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Family Psychiatric and Substance Use History

            Both of the patient’s parents are still alive but they do not have any history of psychiatric illness. That is the same case with his grandparents who also have no recollection of mental illness in the family line. He has a younger brother who is still in college but who is doing well. No one in his family either drinks or smokes.

Personal, Lifestyle, and Social History

Patient BM is a smoker and drinks socially over the weekends. He exercises regularly and takes a balanced diet every day with ample servings of fresh fruits and vegetables. He does not abuse any drugs or any other substances aside from smoking. His hobbies include attending sporting activities such as football games and traveling. He works as a forklift operator in one of the warehouses in the city. He lives in a densely populated residential block with limited but sufficient amenities.    

Medical History:

• Current Medications: The patient is currently taking no medications for any condition.
• Allergies: He does not have any allergies to food, drugs, or environmental allergens.

• Reproductive Hx: The patient is heterosexual and has a girlfriend who lives out of state. He has no children of his own.
• Past Medical History and Surgical: He was admitted with a diagnosis of food poisoning in 2015 but has not had any surgery in his life.
• Immunization history: The patient completed his immunization doses as a child as required by the Centers for Disease Control and Prevention (CDC). He got a Tdp booster injection in 2018, a flu vaccine in 2019, and recently two doses of coronavirus vaccine to prevent Covid-19.    

Review of Systems (ROS):

• GENERAL: He denies any recent loss of weight, fatigue, malaise, fever, or chills.
• HEENT: He does not suffer any headaches and denies double vision and photophobia. He is negative for hearing loss, tinnitus, and ear discharge. He denies rhinorrhea, epistaxis, nasal polyps, or sneezing. His sense of smell is unaffected. He does not use eye glasses or hearing aids. His latest eye check-up was in 2019. He denies oral thrush or bleeding gums and had his latest dental check-up in 2020. He denies having a sore throat or difficulty in swallowing (dysphagia).
• SKIN: He denies rashes, dermatitis, or hives.
• CARDIOVASCULAR: He denies having chest pains or tightness of the chest. He also denies having palpitations or calf pain when walking (intermittent claudication).
• RESPIRATORY: He denies dyspnea, chest tightness, wheezing, or coughing.
• GASTROINTESTINAL: He denies having abdominal pain, nausea, diarrhea, or vomiting. He also denies abnormalities in stool such as melena or hematochezia. His bowel movements are regular, with the latest being on the morning of the clinic visit.
• GENITOURINARY: He denies having excessive urination (amount), frequency, hesitancy, or dysuria. He is heterosexual and denies ver contracting sexually transmitted infections or STIs.
• NEUROLOGICAL: Negative for dizziness or syncope (fainting). Denies disturbances in balance and gait as well as seizures. Denies paraesthesia or incontinence of the bowel or bladder.
• MUSCULOSKELETAL: The patient denies having muscle pain or joint pain. Also negative for back pain.
• HEMATOLOGIC: He denies a history of blood or clotting disorders. No hematuria, hematochezia, epistaxis, hemoptysis, or hematemesis.
• LYMPHATICS: Negative for swollen nodes. Denies lymphadenopathy.
• ENDOCRINOLOGIC: he denies polydipsia and polyuria. Also denies cold and heat intolerance, excessive sweating, or use of hormonal therapy. Comprehensive Focused SOAP Psychiatric Evaluation Essay

Objective:

Vital Signs: BP 110/75 mmHg regular cuff and sitting; P 72, regular; T 98.3.0°F; RR 15, non-labored; BMI 22.6 kg/m² (normal body mass index).

General: The patient is alert and oriented in space, place, person, and event. His way of dressing is appropriate for the time of day and the weather. His speech is clear, audible, and goal-oriented. He however appears to want to avoid eye contact most of the time.

Diagnostic results:

• Magnetic resonance imaging (MRI) of the head does not show any organic brain abnormalities to explain the symptoms.
• Hb=11.8 g/dL; C-reactive protein=6 mg/L; WBC=7,300

Assessment:

Mental Status Examination (MSE)

The patient is 32 year-old African American male patient BM. He is alert and oriented in all respects. His speech is clear, audible, coherent, and goal-oriented. Its volume is however loud but content fluent. The speech rhythm is articulated and pressured. He displays no tics but tilts his neck to the left every time he is spoken to. Self-reported mood is “sad” while affect is anxious, stable, and full. There is some degree of congruency between the self-reported mood and the affect. He reports hearing voices sometimes telling him of the dangers of getting infected and dying of diarrhea from the feco-oral infection he fears. There are no delusional thoughts or paranoia. He also does not display suicidal ideation or homicidal tendencies. Insight and judgment are poor. Diagnosis: Obsessive-compulsive disorder (OCD).  Comprehensive Focused SOAP Psychiatric Evaluation Essay

Diagnostic Impression: Obsessive-compulsive disorder (OCD), diagnostic code 300.3 (F42) in the DSM-5 (APA, 2013).

Differential Diagnosis

1. Obsessive-Compulsive Disorder (OCD)

The symptoms of this patient as expressed in the HPI conform to the DSM-5 diagnostic criteria for OCD. These criteria according to the DSM-5 are (APA, 2013):

• The patient must manifest either compulsion or obsession or both. This patient displays exactly that.
• The obsessive and compulsive symptoms impair the patient so much so that they become dysfunctional in all spheres of life. That is true about this patient.
• The symptoms as above manifested by the patient are not due to another medical illness or substance abuse. This is also true about this patient.
• The symptoms are not those of another psychiatric condition. This, too, is true about this patient.

The determination is therefore made that this is the correct primary diagnosis for the patient based on the critical assessment and comparison of presenting symptoms with the DSM-5 diagnostic criteria. The pertinent positives include obsession with getting infected through the feco-oral route, the urge to wash hands all the time (compulsion), and the absence of another mental illness to explain the symptoms. A pertinent negative is inability to carry out activities of daily living due to dysfunction. This is to be expected due to self neglect but this patient did not display it as he was well-groomed.

2. Psychotic disorders (such as schizophrenia)

The poor insight demonstrated by patient BM in this case is similar to that seen in patients diagnosed with psychotic disorders like schizophrenia. There have been reported cases where a patient with OCD has also displayed signs of delusion or delusional behavior. The diagnostic criteria for schizophrenia in the DSM-5 includes hallucinations and delusions lasting for a period not less than six months, abnormal motor behavior, aggressiveness, and loss of insight amongst others (Sadock et al., 2015; APA, 2013). Looking at these criteria, it is obvious that there are similarities between schizophrenia presentation and some of the symptoms of OCD. Schizophrenia is therefore a most likely differential diagnosis, only that the other telltale symptoms such as delusions were not present in this case of patient BM. Therefore, the absence of obsession and compulsion are the factors that rule out schizophrenia as a primary diagnosis.

3. Tic disorder and stereotyped movements

Another likely differential diagnosis for patient BM is this one. The only difference in diagnostic criteria is that tics and stereotyped movements are simple and straightforward without complexity. It is not however easy to distinguish between a tic and a compulsion when making the psychiatric assessment. This is why there is a possibility of clinical comorbidity between OCD and a tic disorder co-occurring in the same patient (Bryan, 2017; Sadock et al., 2015; APA, 2013). According to Stahl (2013), tics may be etiologically linked to neurobiological pathology. Patient BM has shown some mannerisms during the MSE. Tic disorder is however not the primary diagnosis because despite being similar to compulsion, the patient does not confess to having an obsession. This is what would fit the symptomatology to the diagnostic criteria in the DSM-5.  Comprehensive Focused SOAP Psychiatric Evaluation Essay

Reflections

The comprehensive psychiatric assessment done on this patient has been extensive and thorough. I would not do anything differently were I to be given another chance to repeat the assessment. This is because in this case, all history taking and physical examination protocols were observed (Ball et al., 2019; Bickley, 2017; LeBlond et al., 2014). Ethical principles were observed, such as respect for autonomy and informed consent (Haswell, 2019). The patient was given advice to engage more in his hobbies and sporting/ physical activities as these will help distract his mind from the obsessive impulses. He was also advised and referred to a therapist for cognitive restructuring through cognitive behavioral therapy or CBT (Corey, 2017).

Case Formulation and Treatment Plan

This patient has been referred for group cognitive behavioral therapy (CBT) where he is expected to benefit from group curative factors such as catharsis, universality, interpersonal learning, and altruism. Health education was given on avoidance of solitude as this gives room for the obsessive thoughts and impulses to occur. He was also encouraged to increase the involvement in physical exercise as well as his hobbies. This patient as also advised and informed that he may be put on a pharmacotherapeutic agent during the next visit after four weeks if the symptoms will not have shown any signs of remission up to then. The most appropriate agent in this case would be the selective serotonin reuptake inhibitor (SSRI) fluoxetine or Prozac (Stahl, 2017). This medication treatment is to continue concurrently with the therapy. Follow-up of this patient will be after four weeks.

Conclusion

There are many similarities among psychiatric conditions by way of comparable symptoms described in the DSM-5 diagnostic criteria. This is why a very thorough comprehensive psychiatric evaluation must be carried out to arrive at the correct diagnosis. The importance of this is that it will guide the treatment plan. OCD is one such condition that may be especially confused with psychotic disorders such as schizophrenia. This paper has demonstrated what needs to be done in order to arrive at that correct diagnosis for OCD in a 32 year-old AA male.

References

American Psychiatric Association [APA] (2013). Diagnostic and Statistical Manual of Mental Disorders (DSM-5), 5^th ed. Author.

Ball, J., Dains, J.E., Flynn, J.A., Solomon, B.S., & Stewart, R.W. (2019). Seidel’s guide to physical examination: An interprofessional approach, 9^th ed. Elsevier.

Bickley, L.S. (2017). Bates’ guide to physical examination and history taking, 12^th ed. Wolters Kluwer.

Bryan, D. (2017). OCD vs tics – What ‘s the difference? Anxiety House Brisbane. https://anxietyhouse.com.au/ocd-vs-tics-whats-the-difference/#:~:text=Tics%20are%20considered%20involuntary%20compulsions,that%20are%20rooted%20in%20anxiety

Corey, G. (2017). Theory and practice of counselling and psychotherapy, 10^th ed. Cengage Learning.

Haswell, N. (2019). The four ethical principles and their application in aesthetic practice. Journal of Aesthetic Nursing, 8(4), 177-179. https://doi.org/10.12968/joan.2019.8.4.177

LeBlond, R.F., Brown, D.D., & DeGowin, R.L. (2014). DeGowin’s diagnostic examination, 10^th ed. McGraw Hill Medical.

Sadock, B.J., Sadock, V.A., & Ruiz, P. (2015). Synopsis of psychiatry: Behavioral sciences clinical psychiatry, 11^th ed. Wolters Kluwer.

Stahl, S.M. (2017). Stahl’s essential psychopharmacology: Prescriber’s guide, 6^th ed. Cambridge University Press.

Stahl, S. M. (2013). Stahl’s essential psychopharmacology: Neuroscientific basis and practical applications, 4^th ed. Cambridge University Press.  Comprehensive Focused SOAP Psychiatric Evaluation Essay