Focused SOAP Note for Schizophrenia Essay
CC (chief complaint): “The patient has been displaying bizarre behavior over the past month; she ran away from home and spoke to herself most of the time.”
HPI: The female patient, age 41, presents with a one-month history of erratic conduct and cognitive problems. The reports from family members indicate that she has been exhibiting strange and alarming behaviors during this time. Relatives saw minor changes in the patient’s attitude and demeanor as the sickness began manifesting. The patient started expressing strange and nonsensical thoughts as well as isolating themselves. According to family members, the patient started talking to herself, occasionally incoherently and had signs of stress and restlessness.
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The patient’s behavior has worsened over the past month, causing increasingly obvious disturbances in their daily lives. She claims to have been having hallucinations, hearing voices only they can hear, and feeling that someone is watching or following them. The patient has experienced severe worry and suffering due to these events. There have also been instances of unorganized speech and thinking. The patient’s mental processes seem disjointed, making it challenging to carry on rational conversations. Her conversation can go off-topic and change abruptly to other subjects. The patient’s family also claims she has become more secluded, skipping everyday chores and personal hygiene. She has demonstrated a diminished interest in past hobbies and has experienced sleep disturbances due to difficulty falling asleep.
Substance Current Use:
- Cannabis (marijuana): The patient admits to regular use of marijuana.
- Methamphetamine: The patient reports recent use of methamphetamine.
- Hallucinogens: The patient acknowledges using hallucinogenic substances, such as LSD, sporadically over the past three months.
- Alcohol: The patient states occasional alcohol consumption, with episodes of binge drinking occurring.
- Current Medications: No current medications.
- Allergies: The patient is allergic to nuts.
- Reproductive Hx: Menstrual History: The client began menstruating at 12 and reports having regular menstrual cycles with an average duration of 28 days. No significant complaints related to menstruation, such as severe pain or heavy bleeding.
Obstetric History: Gravida: 2 Para: 1 Abortion: 1
- GENERAL: The patient appeared agitated and restless during the examination, with rapid speech and disorganized thought processes. She denied having a fever or chills.
- HEENT: The patient denied any recent head injury, ear infection, throat infection, nose bleeds, or eye pain.
- CARDIOVASCULAR: The patient denied experiencing any chest pain or palpitations.
- RESPIRATORY: No breathing issues or cough were reported by the patient.
- GASTROINTESTINAL: The patient did not report any abdominal hernia, diarrhea, or vomiting.
- GENITOURINARY: There were no complaints of burning sensation or pain during urination.
- NEUROLOGICAL: The patient reported a headache with a pain level of four out of ten, which has persisted for fifteen days.
- MUSCULOSKELETAL: The patient did not report any joint or muscular pain.
- HEMATOLOGIC: No symptoms of anemia or bleeding were reported.
- LYMPHATICS: The patient did not report any previous issues related to the lymphatic system.
- ENDOCRINOLOGIC: The patient denied experiencing excessive sweating, flushing, or intolerance to heat or cold.
- Complete Blood Count (CBC): The CBC indicates no symptoms of infection or anemia since the numbers of red blood cells, white blood cells, and platelets are normal.
- Comprehensive Metabolic Panel (CMP): The CMP shows that the kidneys and liver function normally and that the electrolyte balance is within the acceptable range.
- Thyroid Function Tests: The results of the thyroid function tests indicate that the thyroid hormone levels are normal, ruling out thyroid problems as the cause of the patient’s symptoms.
- Toxicology Screen: In the patient’s system, the toxicology test finds methamphetamine and traces of cannabis, which indicate recent drug use.
- Brain Imaging (MRI): No structural abnormalities or lesions are visible on the brain MRI. Imaging tests come back normal, eliminating any organic brain pathology.
- Urinalysis: The urinalysis indicates normal kidney function and no signs of urinary tract infections or metabolic disorders.
Mental Status Examination:
The patient had a messy, untidy appearance, with mismatched clothes and poor grooming, which suggested a deterioration in self-care. The patient was agitated and restless throughout the examination, frequently talking to themselves and responding to internal cues. The patient struggled to order her thoughts and spoke quickly and incoherently, switching topics repeatedly with no obvious link. During the evaluation, the patient displayed anxiety, agitation, and brief anxiety moments, making mood swings clear. The patient’s affect was labile, with sharp changes in emotional expression. She occasionally laughed inappropriately, and sometimes, her expressions seemed emotionless. It was difficult for the patient to sustain a logical flow of speech because of her chaotic and tangential thought process, which frequently wandered into irrelevant and absurd thoughts.
The patient’s thought content included grandiose and paranoid delusions. She was convinced that she was being watched and pursued by unidentified beings. In addition, the patient stated that she was experiencing auditory hallucinations, hearing voices that others could not hear, and briefly mentioned seeing visual hallucinations. Her unwillingness to seek therapy and partial underestimation of the intensity of their symptoms made it difficult to have insight into her condition. During the evaluation, the patient struggled with simple activities and computations because of low attention and concentration, indicating poor cognition. She was disoriented about time and could not tell what day or time it was. In addition, she had trouble recalling recent events or the information presented during the evaluation due to short-term memory loss. Throughout the evaluation, the patient showed indicators of restlessness and agitation due to poor impulse control.
Differential Diagnosis for the Patient:
The patient fulfills the requirements for a schizophrenia diagnosis according to the DSM-5 TR’s diagnostic guidelines. This judgment is based on the existence of two or more essential symptoms, such as hallucinations and delusions. The patient also demonstrates chaotic speech and confused thought processes, supporting the diagnosis of schizophrenia. Additionally, since the commencement of their symptoms, the patient’s level of functioning has been considerably impacted, including effects on things like work, interpersonal relationships, and self-care. This significant decline in functioning is consistent with the schizophrenia diagnosis criteria. The patient’s symptoms have continued for at least a month, and there is proof that functioning has declined significantly since the disturbance first appeared. As a result, the symptoms’ persistent nature fits the description of schizophrenia. Overall, the patient’s presentation satisfies the essential requirements for schizophrenia, including recognizable symptoms, diminished functioning, chronicity, and excluding other diseases as the main contributor to the patient’s symptoms (American Psychiatric Association, 2022).
- Bipolar Disorder:
Due to the patient’s mood swings, euphoric episodes, and abrupt changes in emotional expression, bipolar disorder with psychotic characteristics should be considered a differential diagnosis. However, the presence of distinct manic or hypomanic episodes together with depressed periods is required for the diagnosis of bipolar disorder (Carvalho et al., 2020). The information from the current patient was insufficient to substantiate the existence of these mood episodes. Therefore, additional analysis of the patient’s past experiences with mood is required to confirm or rule out this diagnosis.
- Substance-Induced Psychosis:
Given the patient’s history of drug usage, a substance-induced psychotic illness should be explored. Methamphetamine usage, in particular, can cause hallucinations, delusions, and erratic behavior (Mizoguchi & Yamada, 2019). Drug intoxication may also be the cause of any agitation, restlessness, or rapid speech that may be present. However, the patient’s symptoms go beyond the direct consequences of substance abuse, suggesting a potential fundamental mental health issue, such as schizophrenia. To rule in or out a substance-induced psychotic condition, a thorough history of substance use and monitoring of symptom persistence following detoxification are helpful.
I would spend more time building a stronger therapeutic rapport with this patient if I could repeat the session with them. Establishing trust and a secure therapeutic partnership is essential, especially when dealing with individuals with complicated mental health issues. I could create a setting where the patient feels more comfortable discussing their thoughts and feelings by spending more time actively listening and affirming their experiences.
I would continue to evaluate the patient’s development during the follow-up sessions, tracking how they responded to the medication and psychotherapy. Additionally, I would incorporate the patient’s family or other support network in the therapeutic process, highlighting the significance of their contribution to creating a positive environment.
Treatment adherence, coping skills, and symptom control would all improve with the help of these interventions. The patient’s ability to cope with the stresses and triggers that contribute to their mental health will likely increase, as will the patient’s general quality of life and social functioning.
But if I could not do a follow-up, my next step would be to work closely with the medical staff to ensure the patient gets ongoing care and support. The psychiatrist and other team members would receive my observations and assessment results, and I would ensure that any necessary changes to the treatment plan are implemented immediately. To continue helping the patient, I would also look into the potential of involving community-based support services, including support groups or outreach initiatives for mental health. The patient’s well-being and progress toward recovery would require constant observation and coordination of care.
Case Formulation and Treatment Plan:
Plan for Psychotherapy
Schizophrenia treatment and management heavily rely on psychotherapy. A licensed psychologist, counselor, or other suitable mental health practitioner will be suggested for the patient’s individual therapy sessions. Cognitive Behavioral Therapy (CBT) will be the main strategy in the psychotherapy sessions. CBT tries to assist the patient in recognizing and disputing unreasonable thoughts, assumptions, and actions connected to their schizophrenia (Guaiana et al., 2022). The patient can develop coping mechanisms to deal with distressing symptoms like hallucinations and delusions with CBT. To help the patient operate better daily and overall, the therapist will work with them to develop problem-solving abilities, strengthen communication, and set attainable goals.
Health Promotion Activity and Patient Education:
The patient will be urged to participate in a health promotion activity as part of the treatment plan to support their general well-being. Regular physical activity, such as jogging, yoga, or walking, might improve mood and cognitive function. A good coping strategy to lower stress and encourage better sleep is participating in a physical activity they like.
Patient education will focus on the following areas:
- Medication Adherence: The patient will receive in-depth instruction about the function of the recommended medications and any possible side effects. To effectively manage their symptoms, they must comprehend the significance of following the drug regimen exactly as directed.
- Stress Management: To lessen anxiety and agitation, the patient will get education on stress management practices such as deep breathing exercises, mindfulness, and relaxation techniques.
- Early Warning Signs: The patient and their family will be taught how to recognize potential relapses or symptoms getting worse at an early stage. To stop further deterioration, prompt medical care is crucial in these situations.
Plan for Treatment and Management
- Pharmacologic Treatments: The psychiatrist may recommend antipsychotic drugs depending on the patient’s medical history and the severity of their symptoms. The ideal drug will depend on how well they responded to past treatments, how well they can handle any side effects, and how healthy they are overall. To lessen the negative effects of these medications, the lowest safe dose should be administered.
- Nonpharmacologic Treatments: The patient will also get psychosocial therapies, such as cognitive rehabilitation, social skills training, and psychotherapy. Such therapies can increase a person’s capacity for daily activity and promote fruitful social relationships.
- Alternative Therapies: Alternative therapies like art therapy or music therapy may be considered in addition to conventional treatments to offer additional opportunities for emotional processing and self-expression.
Frequent follow-up appointments will be made to track the patient’s development and response to treatment. The patient’s stability and needs will determine how frequently the patient will return. The medical staff will review medication adherence, watch out for side effects, and assess how well therapy approaches work throughout these visits.
The Rationale for the Treatment and Management Plan:
The trimodal approach aims to comprehensively address the multifaceted presentation of schizophrenia through psychotherapy, medication, and nonpharmacologic interventions. CBT can assist the patient in recognizing and challenging distorted ideas and actions, improving everyday functioning and better coping skills. Regular exercise is one example of a health promotion activity that might benefit the patient’s mental and physical health.
To control schizophrenia’s positive symptoms, such as hallucinations and delusions, pharmacologic therapies using antipsychotic drugs are necessary. Social skills training is one non-pharmacologic intervention that can help the patient reestablish their social network and improve their quality of life. Alternative therapies may also enhance treatment by offering special channels for emotional and self-expression (McCutcheon et al., 2019).
Assuring that the patient receives prompt attention in the event of a relapse or worsening will help guarantee that periodic follow-up visits and instructions about early warning signals are in place. A collaborative approach incorporating the patient, their family, and a multidisciplinary healthcare team is essential to aid the patient’s rehabilitation and enhance their long-term prognosis.
Lack of stable housing and homelessness are socioeconomic determinants of health that affect this patient’s mental health. Housing instability can make it more challenging to manage the symptoms of schizophrenia and make it harder to access regular mental health care. It is recommended that the patient be directed to a case manager or social worker who focuses on housing aid programs. The referral aims to put the patient in touch with community services, including rental assistance programs or supportive housing initiatives, to help them find stable accommodation. Stable housing can lay the groundwork for better mental health outcomes and continuity of care, allowing patients to concentrate more successfully on their road to recovery (Smit et al., 2022).
- Considering the patient’s history of drug dependency, how would you manage the patient’s schizophrenia? Which interventions would you focus on to address drug usage and mental health conditions?
- What extra diagnostic tests or evaluations would you, in your opinion, consider carrying out for this patient to rule out any other possible medical or psychiatric issues affecting their presentation?
- One social element affecting the patient’s mental health was the lack of permanent housing. How would you approach this problem, ensure the patient has access to secure housing while overseeing their mental health care, and work with social workers or neighborhood resources?
Carvalho, A. F., Firth, J., & Vieta, E. (2020). Bipolar disorder. New England Journal of Medicine, 383(1), 58–66. https://doi.org/10.1056/nejmra1906193
Guaiana, G., Abbatecola, M., Aali, G., Tarantino, F., Ebuenyi, I. D., Lucarini, V., Li, W., Zhang, C., & Pinto, A. (2022). Cognitive behavioral therapy (group) for schizophrenia. The Cochrane Database of Systematic Reviews, 7, CD009608. https://doi.org/10.1002/14651858.CD009608.pub2
McCutcheon, R. A., Reis Marques, T., & Howes, O. D. (2019). Schizophrenia—An overview. JAMA Psychiatry, 77(2), 1. https://doi.org/10.1001/jamapsychiatry.2019.3360
Mizoguchi, H., & Yamada, K. (2019). Methamphetamine use causes cognitive impairment and altered decision-making. Neurochemistry International, 124, 106–113. https://doi.org/10.1016/j.neuint.2018.12.019
Smit, M. M. C., Waal, E. de, Tenback, D. E., & Deenik, J. (2022). Evaluating the implementation of a multidisciplinary lifestyle intervention for people with severe mental illness in sheltered housing: Effectiveness-implementation hybrid randomised controlled trial. BJPsych Open, 8(6). https://doi.org/10.1192/bjo.2022.600
American Psychiatric Association. (2022). Diagnostic and statistical manual of mental disorders (5th ed., text rev.). https://doi.org/10.1176/appi.books.9780890425787
Review this week’s Learning Resources and consider the insights they provide. Also review the Kaltura Media Uploader resource in the left-hand navigation of the classroom for help creating your self-recorded Kaltura video.
Select an older adult patient from your clinical experience that presents with a significant concern. Create a focused SOAP note for this patient using the template in the Resources. All SOAP notes must be signed by your Preceptor. When you submit your SOAP note, you should include the complete SOAP note as a Word document and PDF/images of the completed assignment signed by your Preceptor. You must submit your SOAP note using Turnitin.
Please Note: Electronic signatures are not accepted. If both files are not received by the due date, Faculty will deduct points per the Walden Late Policies.
Then, based on your SOAP note of this patient, develop a video case study presentation. Set aside time to practice what you will say beforehand and ensure that you have the appropriate lighting and equipment to record the presentation.
Your presentation should include objectives for your audience, at least 3 possible discussion questions/prompts for your classmates to respond to, and at least 5 scholarly resources to support your diagnostic reasoning and treatment plan.
Video assignment for this week’s presenters:
Record yourself presenting the complex case study for your clinical patient. In your presentation:
Dress professionally and present yourself in a professional manner.
Display your photo ID at the start of the video when you introduce yourself.
Ensure that you do not include any information that violates the principles of HIPAA (i.e., don’t use the patient’s name or any other identifying information).
State 3–4 objectives for the presentation that are targeted, clear, use appropriate verbs from Bloom’s taxonomy, and address what the audience will know or be able to do after viewing.
Present the full complex case study. Include chief complaint; history of present illness; any pertinent past psychiatric, substance use, medical, social, family history; most recent mental status exam; current psychiatric diagnosis including differentials that were ruled out; and plan for treatment and management.
Report normal diagnostic results as the name of the test and “normal” (rather than specific value). Abnormal results should be reported as a specific value.
Pose three questions or discussion prompts, based on your presentation, that your colleagues can respond to after viewing your video.
Be succinct in your presentation, and do not exceed 8 minutes. Specifically address the following for the patient, using your SOAP note as a guide.
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 their mental status examination results. What were your differential diagnoses? Provide a minimum of three possible diagnoses and why you chose them. List them from highest priority to lowest priority. What was your primary diagnosis, and why? Describe how your primary diagnosis aligns with DSM-5-TR diagnostic criteria and is supported by the patient’s symptoms.
Plan: What was your plan for psychotherapy (include one health promotion activity and patient education)? What was 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. Discuss an identified social determinate of health impacting this patient’s mental health status and provide your recommendation for a referral to assist this patient in meeting this identified need (students will need to conduct research on this topic both in the literature and for community resources).
Reflection notes: What would you do differently with this patient if you could conduct the session again? If you are able to follow up with your patient, explain whether these interventions were successful and why or why not. If you were not able to conduct a follow-up, discuss what your next intervention would be.
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Focused SOAP Note for Schizophrenia Essay
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