CC (chief complaint): “I was living, and not bothering anyone, and those people—those people, they just won’t leave me alone.” “There are some people who do not leave me alone and with this, my sister made me come in today.” The patient also expressed concern about being observed by people outside his window. He asserts that he is able to see and hear shadows of people.

HPI: ST is a 53-year-old male patient who has come to the clinic saying that people are disturbing him and that they are observing him.

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His sister coerced him to come for an evaluation. ST reports that he can hear and see individuals troubling him, despite their unawareness. He says that he has not troubled anyone and has been living quietly. He does not understand why some individuals do not want to leave him alone. During the session, he reports that he can hear heavy metal music and that he sees a bird in the surrounding. He reveals that he could put up with his mother, but she died three years ago, so he is living alone. He fears that the government and his sister are planning to meddle with his personal life. He reports that loud voices prevent him from enjoying a good night’s sleep, forcing him to be awake most of the time.

He admits that he abuses alcohol and smokes 3 packs of cigarettes daily. He also used to smoke marijuana but stopped after his mother passed away three years ago. He says that he does not abuse cocaine or any other narcotics and has not had any seizures or experienced any blackouts. He had been prescribed risperidone, haloperidol, Seroquel, and Thorazine. However, he resisted taking these drugs, terming them as poisonous. He reports that his mother had suffered anxiety and a history of paranoid schizophrenia on his father’s side. He has never had suicidal thoughts, and no one has ever committed suicide in his family. He has diabetes and is managing it using metformin.

Substance Current Use:

The patient had previously abused marijuana but stopped using it three years ago. He currently abuses alcohol and takes 3 packs of cigarettes daily. He consumed alcohol the previous night before coming to the hospital. The length of his smoking period cannot be established.

Medical History:


  • Current Medications: ST is treated for his mental disorder with four different drugs. These drugs include Risperidone, Thorazine, Haldol, and Seroquel. ST, however, is not following this recommendation because he believes they are poison and partially because of their adverse effects, like gynecomastia. He is also using metformin to control his diabetes.
  • Allergies: No known drug for food allergies.
  • Social history: TS is the family’s second child. He has one older sister. He formerly resided with his mother, who raised him and his sister together. His mother and father have both died. TS presently lives alone. He thinks his sister conspired with the authorities to meddle in his life. He enjoys drinking alcohol and smoking cigarettes. When he has trouble going to sleep, he watches television.
  • Reproductive Hx: He has never been married and has no children.


  • GENERAL: ST has not reported weight loss, fever, or weariness. He has denied feeling cold, distressed, or hotness in the body.
  • HEENT: ST exhibits none of the following symptoms: no visual impairment, no sneezing, no ear discharge or pain, no hearing loss or impairment, no congestion, no running nose, and no sore throat. The patient does not have any nasal blockage or swallowing issues.
  • SKIN: There was no mention of any skin rashes or itching. He has not displayed any apparent injuries, scars, or bruises.
  • CARDIOVASCULAR: ST shows regular heart activity. No palpitations, chest discomfort, or fatigue-related conditions exist.
  • RESPIRATORY: ST did not experience any breathing difficulties, chest discomfort, chest pain, coughing, or tachypnea. Additionally, there is no sputum production, cough, or shortness of breath.
  • GASTROINTESTINAL: No reports of vomiting, diarrhea, or anorexia were made, nor were any reports of abdominal pain or blood.
  • GENITOURINARY: there are no reports of hematuria, abdominal pains, discomfort or pain with urination, or urethral discharge.
  • NEUROLOGICAL: No reports of paralysis, limb tingling, blurred vision, vertigo, or photophobia. No reports of ataxia, changes in bladder control, headache syncope, or bowel problems.
  • MUSCULOSKELETAL: He has not mentioned any joint pain, joint stiffness, back pain, or deformity. He has also not mentioned any muscle pain or stiffness.
  • HEMATOLOGIC: ST has not had any hematologic conditions. He did not mention anemia or easy bleeding, or bruising.
  • LYMPHATICS: ST has no splenectomy history, no leg edema, no lymphadenopathy, and no discomfort.
  • ENDOCRINOLOGIC: There was no excessive palmar sweating, polyuria, cold, or heat intolerance. He has not reported any sweating or polydipsia.



Diagnostic results:

The patient actively participated in the assessment and responded to the evaluation questions. Although no laboratory testing was performed, it was required to carry out based tests, such as endocrine function tests, to see if they fall within the normal ranges.


Mental Status Examination:

ST, a 53-year-old man, was compelled to visit the clinic by his sister for a psychiatric evaluation. ST appears to be his purported age. He also displays a cooperative, alert, and calm demeanor throughout the assessment. He looks well-groomed and kept and is appropriately attired for the situation. He is oriented to location and person. His time orientation is poor. His speech has a constricted effect, and the tone of voice varies. He has recurrent visual and auditory hallucinations. His insight is poor. Despite exhibiting a calm demeanor, he is still paranoid. He does not have suicidal ideations.

Diagnostic Impression:


The presence of two or more symptoms, such as delusions, hallucinations, incoherent speech, severely disorganized or catatonic conduct, or negative symptoms, is required to diagnose schizophrenia (American Psychiatric Association, 2022). People should be less functional in their jobs, relationships, or self-care. Active-phase symptoms must be evident for at least one month within the first six months of the disturbance’s occurrence (McCutcheon et al., 2019). It is essential to rule out medical diseases, substance-induced effects, schizoaffective disorder, depression or bipolar disorder with psychotic characteristics, and other possible diagnoses.

According to DSM-5 TR criteria, ST exhibits anhedonia, hallucinations, blunted expression, disorganized speech, and disorderly conduct as the primary symptoms of schizophrenia. These symptoms have been present for more than six months. The presence of hallucinations has disturbed his daily routines and functioning.

Schizophreniform disorder and brief psychotic disorder

Compared to schizophrenia, which requires six months of symptoms according to Criterion C, the disorders in this diagnosis have shorter symptom durations. If it is a psychotic disorder, symptoms last less than one month (Stephen & Lui, 2022). On the other hand, in schizophreniform, the symptoms should last for less than six months. The duration of the symptoms rules out the possible diagnosis of these conditions.

Schizoaffective disorder

Schizoaffective disorder is distinguished by a continuous period of illness during which a significant mood episode (depressive or manic) occurs together with symptoms that fulfill the criteria for schizophrenia (American Psychiatric Association, 2022). A depressed mood must be present during the major depressive episode. Furthermore, delusions or hallucinations must be evident for at least two weeks apart from a major mood episode throughout the illness. Most disease duration should be characterized by symptoms consistent with a severe mood episode. Substance misuse, medicine, or another medical issue should not be the source of the disruption. This diagnosis has been ruled out because the symptoms occur in less than six months, unlike in the case of ST.

Delusional disorder

This disorder is characterized by two or more episodes of delusions for more than one month. The themes of the hallucinations, if present, should be related to the delusions (American Psychiatric Association, 2022). However, in this case, the themes of the delusions and hallucinations are not related, rendering it not a probable diagnosis.


I would have a more comprehensive plan for the next session. My initial intervention would concentrate on developing rapport and gaining trust because the patient was willing to talk. I would take more time to empathize with the patient’s worries, validate their experiences, and acknowledge their medication worries.

I would work with a multidisciplinary team, including a psychiatrist and a pharmacist, to investigate other treatment options in light of the patient’s noncompliance and mistrust of medications. We would review several drugs’ advantages and disadvantages to address the individual’s concerns about poisoning. I would also involve the patient’s family or support network to provide information and support for promoting medication adherence.

Ethically, I would respect the patient’s autonomy while guaranteeing their safety. It would be imperative to inform the patient about the possible effects of untreated schizophrenia, such as symptom aggravation and potential injury to oneself or others. If the patient’s condition deteriorates noticeably, discussions about potential legal repercussions, such as forced hospitalization or court-ordered therapy, may arise.

I would work with the patient to create a comprehensive care plan while considering illness prevention and health promotion. This strategy would include coping mechanisms, stress reduction approaches, and psychoeducation regarding schizophrenia. In addition, I would investigate socioeconomic and cultural aspects that can affect the patient’s treatment compliance and modify interventions as necessary.

Case Formulation and Treatment Plan: 

The primary diagnosis for ST is paranoid schizophrenia. Pharmaceutical and psychotherapy interventions will be included in the plan of care. The patient will be administered Clozapine 25 mg and Amisulpride 200 mg. Amisulpride will help to resolve hallucinations (Hadryś & Rymaszewska, 2020). Clozapine helps to enhance emotional, behavioral, and mental issues by rebalancing serotonin and dopamine in the brain (Krakowski et al., 2021). The client will also be educated on the essence of medication adherence to resolve his symptoms.

Individual cognitive behavioral treatment is the third strategy. Notably, the client will be subjected to individual cognitive behavioral therapy. The therapy aims to support the client’s ability to work independently while resolving his symptoms. Additionally, cognitive behavioral therapy will decrease the stress in his everyday life. Training in coping mechanisms, self-monitoring, and cognitive restructuring are all part of the CBT therapies.

Health education will follow, and the client will be educated on quitting or reducing smoking. He will also learn the importance of forming social connections with other people. Additionally, the patient must be active and practice physical activity. After a month, the follow-up will begin to see if the symptoms have resolved and if the medication needs to be changed or referred for further treatment.


American Psychiatric Association. (2022). Diagnostic and statistical manual of mental disorders. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision (DSM-5-TR), 5(5).

Hadryś, T., & Rymaszewska, J. (2020). Amisulpride – is it as all other medicines or is it different? An update. Psychiatria Polska, 54(5), 977–989.

Krakowski, M., Tural, U., & Czobor, P. (2021). The importance of conduct disorder in the treatment of violence in schizophrenia: efficacy of clozapine compared with olanzapine and haloperidol. American Journal of Psychiatry, 178(3), 266–274.

McCutcheon, R. A., Reis Marques, T., & Howes, O. D. (2019). Schizophrenia—An overview. JAMA Psychiatry, 77(2), 1.

Stephen, A., & Lui, F. (2022). Brief psychotic disorder. In StatPearls. StatPearls Publishing.



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.


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).


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