Focused SOAP Note for Schizophrenia Spectrum, Other Psychotic, and Medication-Induced Movement Disorders Essay

Focused SOAP Note for Schizophrenia Spectrum, Other Psychotic, and Medication-Induced Movement Disorders Essay

Focused SOAP Note for Schizophrenia Spectrum, Other Psychotic, and Medication-Induced Movement Disorders Essay

Subjective:

CC (chief complaint): “My sister said that I should come here. These people won’t leave me alone.”

HPI:

Sherman Tremaine is a 53-year-old female patient who says she came to the psychiatric clinic after her sister forced her to have a psychiatric evaluation. The client reports that she is being watched, and the people watching her do not want to leave her. She reports hearing them and seeing their shadows when they are surveilling her. Sherman states that those surveilling think she does not see them, but she can see them on the contrary. The patient further states that the government sent those people watching her, which is why her taxes have increased. Sherman also mentions that she experiences sleeping disturbances because the voices of the people watching her are loud, making her remain awake for days. Furthermore, Sherman believes that these people enter her house and poison her food. She also mentions that her sister is planning with the government to change her lifestyle, and her phone has been tapped.

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Substance Current Use: The patient states that she smokes tobacco 3PPD and takes alcohol. She previously used marijuana but quit three years ago. However, she denies using other illicit substances.

Medical History:

• Current Medications: Currently on Metformin to manage Diabetes. The patient was previously on Thorazine, Haldol, Risperidone, and Seroquel.
• Allergies: No known allergies.

• Reproductive Hx:  Para 0+0. No history of reproductive health disorders.

Family Psychiatric History: Sherman’s father had paranoid schizophrenia, while the mother had an anxiety disorder. There is no history of suicidal attempts in the family.

Social History: Sherman currently lives alone, which has been the case since her parents’ death three years ago. The patient was raised by her mother and sister. She is single with no children. She studied up to 10th grade and is currently unemployed. The patient has no legal history of arrest or conviction.

ROS:

• GENERAL: Negative for fever, chills, fatigue, or weight changes
• HEENT: Negative for headaches, eye pain, double vision, ear pain/discharge, hearing loss, nasal secretions, or sore throat.
• SKIN: Negative for rashes, discoloration, or bruises.
• CARDIOVASCULAR: Negative for palpitations, SOB, chest pain, or ankle edema.
• RESPIRATORY: Negative for productive/dry cough, chest pain, sputum, or breathing difficulties.
• GASTROINTESTINAL: Negative for nausea, vomiting, abdominal tenderness, flatulence, bowel changes, or rectal bleeding.
• GENITOURINARY: Negative for flank pain, dysuria, urinary frequency/urgency, or abnormal urine color.
• NEUROLOGICAL: Negative for dizziness, headache, muscle weakness, or tingling sensations.
• MUSCULOSKELETAL: Negative for joint pain/stiffness, muscle pain, or back pain.
• HEMATOLOGIC: Negative for anemia or bruising.
• LYMPHATICS: Negative for swollen lymph nodes.
• ENDOCRINOLOGIC: Negative for heat/cold intolerance, excessive thirst or hunger, or increased sweating.

Objective:

General: Female patient in her 50s. She is well-groomed and appropriately dressed. The patient is alert and maintains adequate eye contact. Her speech is clear, but the rate and volume vary. She is oriented to person, place, and date but does not know the day of the week.

Diagnostic results: No lab/imaging tests were ordered.

Assessment:

Mental Status Examination:

The patient is neat and appropriately dressed for the function and weather. Her self-reported mood is anxious, and her affect is blunted. Her speech is clear, but the volume and rate vary. Auditory and visual hallucinations and persecutory delusions are apparent. However, the patient has no obvious suicidal thoughts or ideations. Her short- and long-term memory is intact, and she has good judgment. Insight is absent.

Diagnostic Impression:

Schizophrenia: Schizophrenia presents with psychosis, which is a loss of touch with reality. Psychosis is characterized by hallucinations, delusions, disorganized thinking and speech, and bizarre/inappropriate motor behavior that suggest a loss of contact with reality (APA, 2013). Schizophrenic patients also have a flattened affect, cognitive deficits like impaired problem solving and reasoning, and occupational and social impairment (Stępnicki et al., 2018). Schizophrenia is a differential diagnosis based on the patient’s positive symptoms of persecutory delusions, visual and auditory hallucinations, and blunted affect.

Brief Psychotic Disorder:  According to the DSM-5, a Brief psychotic disorder should be diagnosed if a patent presents with at least one of the following psychotic symptoms for less than one month: Delusions, Hallucinations, Disorganized speech, and Grossly disorganized or catatonic behavior. Patients with Brief psychotic disorder eventually return to their normal premorbid functioning (APA, 2013; Provenzani et al., 2021). Brief psychotic disorder is a differential diagnosis based on positive findings of visual and auditory hallucinations and persecutory delusions. However, if these symptoms have persisted for more than one month, Brief psychotic disorder would be ruled out as a primary diagnosis.

Delusional Disorder: According to the DSM-5, the key feature when diagnosing Delusional disorder is the presence of one or more delusions that persist for at least a month (APA, 2013). The patient in this case likely has the Persecutory delusional type, characterized by strange and unshakable beliefs that one is being spied, conspired against, cheated on, harassed/followed, or poisoned/drugged (González-Rodríguez & Seeman, 2020). Delusion disorder is a differential diagnosis due to the patient’s irrational belief that people are monitoring her and they enter her house to poison her food. She also has an odd belief that her sister is working with the government to alter her lifestyle and that her phone is tapped.

Reflections:

If I were to conduct the assessment again, I would use screening tools to rate the severity of the patient’s schizophrenia symptoms. I would utilize the Brief Psychiatric Rating Scale (BPRS) since it obtains information about the likely presence and severity of psychiatric symptoms in a patient like depression, hallucinations, anxiety, psychosis, and unusual behavior (Tarsitani et al., 2019). Besides, if I were to follow up with the patient, I would use the BPRS to measure the degree to which the patient’s symptoms have alleviated. The results will determine if additional interventions will be needed in the treatment plan. Legal and ethical considerations include nonmaleficence, beneficence, and autonomy. The treatment interventions should aim to improve patient outcomes without causing harm to the patient. In addition, the patient should be informed of the treatment plan, and the clinician should obtain consent from the patient or caregiver before starting treatment. Health promotion for this patient should center on promoting smoking cessation and reducing alcohol consumption.

Case Formulation and Treatment Plan: 

The patient’s presumptive diagnosis is schizophrenia. The plan for psychotherapy is Cognitive behavioral therapy (CBT), which will help change the patient’s irrational thinking and behavioral patterns and ultimately have logical thoughts and behaviors (Stępnicki et al., 2018).

A follow-up visit will be scheduled after four weeks to assess the patient’s response to psychotherapy and identify any challenges that could hinder attaining the desired outcomes.

References

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (DSM-5®). American Psychiatric Pub.

González-Rodríguez, A., & Seeman, M. V. (2020). Addressing Delusions in Women and Men with Delusional Disorder: Key Points for Clinical Management. International journal of environmental research and public health, 17(12), 4583. https://doi.org/10.3390/ijerph17124583

Provenzani, U., Salazar de Pablo, G., Arribas, M., Pillmann, F., & Fusar-Poli, P. (2021). Clinical outcomes in brief psychotic episodes: a systematic review and meta-analysis. Epidemiology and psychiatric sciences, 30, e71. https://doi.org/10.1017/S2045796021000548

Stępnicki, P., Kondej, M., & Kaczor, A. A. (2018). Current Concepts and Treatments of Schizophrenia. Molecules (Basel, Switzerland), 23(8), 2087. https://doi.org/10.3390/molecules23082087

Tarsitani, L., Ferracuti, S., Carabellese, F., Catanesi, R., Biondi, M., Quartesan, R., Pasquini, M., & Mandarelli, G. (2019). Brief Psychiatric Rating Scale-Expanded (BPRS-E) factor analysis in involuntarily hospitalized psychiatric patients. Psychiatry Research, 279, 380–381. https://doi.org/10.1016/j.psychres.2019.02.055

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Assignment: Focused SOAP Note for Schizophrenia Spectrum, Other Psychotic, and Medication-Induced Movement Disorders
Psychotic disorders change one’s sense of reality and cause abnormal thinking and perception. Patients presenting with psychotic disorders may suffer from delusions or hallucinations or may display negative symptoms such as lack of emotion or withdrawal from social situations or relationships. Symptoms of medication-induced movement disorders can be mild or lethal and can include, for example, tremors, dystonic reactions, or serotonin syndrome.

For this Assignment, you will complete a focused SOAP note for a patient in a case study who has either a schizophrenia spectrum, other psychotic, or medication-induced movement disorder.

To Prepare
Review this week’s Learning Resources. Consider the insights they provide about assessing, diagnosing, and treating schizophrenia spectrum, other psychotic, and medication-induced movement disorders.

Photo Credit: Getty Images/Wavebreak Media

Review the Focused SOAP Note template, which you will use to complete this Assignment. There is also a Focused SOAP Note Exemplar provided as a guide for Assignment expectations.
Review the video, Case Study: Sherman Tremaine. You will use this case as the basis of this Assignment. In this video, a Walden faculty member is assessing a mock patient. The patient will be represented onscreen as an avatar.
Consider what history would be necessary to collect from this patient.
Consider what interview questions you would need to ask this patient.
The Assignment
Develop a focused SOAP note, including your differential diagnosis and critical-thinking process to formulate a primary diagnosis. Incorporate the following into your responses in the template:

Subjective: What details did the patient provide regarding their chief complaint and symptomology to derive your differential diagnosis? What is the duration and severity of their symptoms? How are their symptoms impacting their functioning in life?
Objective: What observations did you make during the psychiatric assessment? 
Assessment: Discuss the patient’s mental status examination results. What were your differential diagnoses? Provide a minimum of three possible diagnoses with supporting evidence, and list them in order from highest priority to lowest priority. Compare the DSM-5-TR diagnostic criteria for each differential diagnosis and explain what DSM-5-TR criteria rules out the differential diagnosis to find an accurate diagnosis. Explain the critical-thinking process that led you to the primary diagnosis you selected. Include pertinent positives and pertinent negatives for the specific patient case.
Plan: What is your plan for psychotherapy? What is your plan for treatment and management, including alternative therapies? Include pharmacologic and nonpharmacologic treatments, alternative therapies, and follow-up parameters, as well as a rationale for this treatment and management plan. Also incorporate one health promotion activity and one patient education strategy.
Reflection notes: What would you do differently with this patient if you could conduct the session again? Discuss what your next intervention would be if you were able to follow up with this patient. Also include in your reflection a discussion related to legal/ethical considerations (demonstrate critical thinking beyond confidentiality and consent for treatment!), health promotion, and disease prevention, taking into consideration patient factors (such as age, ethnic group, etc.), PMH, and other risk factors (e.g., socioeconomic, cultural background, etc.).
Provide at least three evidence-based, peer-reviewed journal articles or evidenced-based guidelines that relate to this case to support your diagnostics and differential diagnoses. Be sure they are current (no more than 5 years old).