NRNP 6675 Focused SOAP Note for Schizophrenia Spectrum
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 withdraw 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.
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).
Sample Focused SOAP Note for Schizophrenia Spectrum
Patient particular’s
Name: Sherman Tremaine
Age: 54 years
Gender: male
Ethnicity: American
Subjective Data
Chief complaint: hallucinations
History of presenting illness: Sherman Tremaine is a 54years old male who is not self-aware of having a mental illness. The patient has hallucinations both visual and auditory because he says some people cannot leave him to enjoy his time. He explains that he cannot sleep at night because of the loud metal music in his house. The patient has episodes of delirium and paranoia because he states that people watching him on the television are contemplating poisoning him. He has withdrawn social behavior because he wants to stay alone and has disorganized speech. He denies suicidal ideation, self-harm, and hopelessness.
Substance use history: he smokes cigarettes and drinks pop. He admits to having ever taken marijuana but stopped three years ago. He denies the use of cocaine and other illegal drugs
Current medication: metformin
Psychiatric medication trial: the patient was on haldol and Thorazine but stopped because of the side effects. He was put on risperidone but stopped after putting on weight. He states that Seroquel is better though he is not compliant with medication.
Allergies: he denies food, drug, latex, and environmental allergies.
Past medical history: the patient has diabetes mellitus, fatty liver disease, and schizophrenia.
Family history: the patient is the last born in a family of three. His mother passed three years ago and had an anxiety disorder. His father passed on a while ago and has paranoid schizophrenia. He denies a family history of suicidal events.
Social history: the patient is single and has no children. He has been living with his mother and sister until his mother’s demise. He has studied up to 10th grade. He does not work. He enjoys smoking and drinking pops. He recalls his childhood traumas because his father was rough.
Review of systems
General: the patient denies fever, fatigue, sweating, chills, rigors, and weight loss.
Heent: the patient denies headache, dizziness, eye pain, blurring of vision,
Skin: the patient denies skin rash and itchiness.
Cardiovascular: he denies chest pain, palpitations, syncope, claudication, edema, orthopnea, dyspnea, and tachycardia.
Respiratory: he denies cough, sputum, wheezing, shortness of breath, and difficulties in breathing.
Gastrointestinal: he denies nausea, vomiting, abdominal pain, diarrhea, reflux, and reduced appetite.
Genitourinary: he denies dysuria, hematuria, polyuria, oliguria, urethral discharge, and lower abdominal pain.
Neurological: the patient denies dizziness, numbness of extremities, paralysis, facial droop, and tremors.
Musculoskeletal: he denies muscle pain, joint pain, and muscle stiffness.
Hematologic: he denies bleeding tendencies and easy bruising.
Lymphatics: he denies lower limb swelling, fever, and recurrent infections.
Endocrinologic: he denies heat and or cold intolerance, unintentional weight loss or weight gain, polyuria, polyphagia, and polydipsia.
Objective Data
General: the patient is in fair general condition and calm. He has no pallor, jaundice, cyanosis, edema, dehydration, or lymphadenopathy.
Vitals: his blood pressure is 115/88mmhg, the temperature at 36.6 degrees Celsius, weight is 66kgs, height is 161cm, oxygen circulation is at 95% room air, and respiratory rate at 16breaths per cycle.
Heent: the head is round with no mass, swelling, or scar. The eyes are clear and moist. The nose is intact without scars and erythema and the mucus membrane is moist. The ears have no scars, swelling, wax impaction, and discharge, the mouth is pink and moist with no swollen tonsil gland.
Respiratory system: the chest expands symmetrically when breathing. There is no mass or scar on the chest wall. There is a resonant percussion note and vesicular breath sounds on auscultation. There are no rhonchi, stridor, or crackles.
Cardiovascular system: the heart is at 5th ics mcl. The peripheral pulses are present with normal volume, regular rhythm, and rate without bruits. The heart sounds s1 s2 are present without murmurs, parasternal heaves, and thrills.
Abdominal examination: the abdomen is round with a normal contour. The bowel sounds are present in the four quadrants and there is a tympanic percussion note. There is no shifting dullness or organ enlargement.
Diagnostic investigations: there are no specific tests for making a diagnosis of schizophrenia. However, one should rule out other diseases that may cause schizophrenia. A thyroid function test rules out hypothyroidism and hyperthyroidism. A complete blood count rules out sepsis, thrombocytopenia, and anemia. Renal function tests rule out kidney injury and electrolyte disturbance. Liver function test rules out chronic liver diseases like encephalopathy.
Assessment
Mental State Examination
Sherman Tremaine is neat and well-groomed for the time and occasion. He is oriented in person and place but disoriented to time. He seems agitated, does not maintain eye contact, and fidgets during the interview. He has coherent speech and language but goes off-topic occasionally. He seems to introduce new vocabulary during the interview. The patient has thought of insertions of people harming him and loosening of association when he states that the police officers want to arrest him for calling 911. The patient has evident delirium and hallucinations in the interview. He has no emotional expression, has poor judgment and insight regarding his illness, and his cognitive abilities are intact.
Differential diagnoses
Schizophrenia is a chronic and severe mental disorder that affects how a person thinks, feels, and behaves. It is characterized by a combination of symptoms, including hallucinations, delusions, disorganized thinking and speech, lack of motivation, and difficulties in social interaction (Keepers et al., 2020). Positive symptoms of schizophrenia perceiving things that are not there and/or hearing voices, having false beliefs, disorganized thinking and speech, and abnormal motor behavior. The negative symptoms are reduced emotional expression, social withdrawal, diminished motivation, and difficulties with speech and communication. Schizophrenia usually develops in late adolescence or early adulthood, although it can occur at any age. The exact cause of schizophrenia is unknown, but it is believed to result from a combination of genetic, environmental, and neurochemical factors (Keepers et al., 2020). The patient has schizophrenia because of the presenting signs and symptoms. The onset of these symptoms was in his early adulthood. Additionally, he had a traumatic environment when growing up and has a positive family history of schizophrenia.
Delusional disorder is a mental disorder characterized by the presence of persistent delusions without the presence of other prominent psychotic symptoms, such as hallucinations or significant disorganized thinking (González-Rodríguez et al., 2022). Delusions are fixed, false beliefs that are not based on reality and are not typically accepted by others within the person’s culture or background. Delusional disorder can manifest in different types such as persecutory delusions where one is being harassed, harmed, or targeted in some way. Grandiose delusions are beliefs of having exceptional abilities, wealth, or fame that are not grounded in reality. Erotomanic delusions are beliefs that someone, usually of higher status, is in love with the individual, despite lack of evidence. Patients with delusional disorder often have a strong conviction in the truth of their delusions and may have limited insight into their condition. The delusional disorder does not typically cause significant impairment in cognitive functioning or daily functioning outside of the specific area affected by the delusion (González-Rodríguez et al., 2022). However, the impact on relationships, social interactions, and overall well-being can vary depending on the content and severity of the delusion.
Substance-induced psychotic disorder is a mental disorder characterized by the presence of psychotic symptoms, including hallucinations, delusions, or disorganized thinking, that are directly caused by the use of or withdrawal from substances such as drugs or medications. These substances can include alcohol, hallucinogens, amphetamines, cocaine, cannabis, sedatives, and others (Tandon & Shariff, 2019). The psychotic symptoms of substance-induced psychotic disorder are directly linked to substance use. The symptoms emerge during intoxication or withdrawal from the substance and are not better explained by another primary mental disorder. The duration of substance-induced psychotic symptoms can be brief and resolved within a few hours or days after substance use has ceased, or they can last for an extended period if substance use continues. This is not the patient’s diagnosis because these symptoms are not associated with substance use.
Plan
Pharmacologic Treatment
Seroquel-initiate at 50mg once daily and gradually increase the dosage by 50mg weekly while monitoring for tolerance, therapeutic efficiency, and side effects (Maan et al., 2017).
Non-Pharmacological Treatment:
- Psychoeducation: educating individuals with schizophrenia and their families about the illness, its symptoms, treatment options, and coping strategies is crucial (Škodlar & Henriksen, 2019). It helps improve understanding, adherence to medication, and relapse prevention.
- Individual therapy: cognitive-behavioral therapy helps individuals identify and change negative thought patterns and develop coping skills.
- Family therapy: involving family members in therapy can provide support, improve communication, and enhance understanding of the illness (Škodlar & Henriksen, 2019). It can also help in addressing family dynamics and promoting a supportive environment.
Reflection Note
The assessment aimed to gather information about the patient’s current mental state, symptomatology, functioning, and treatment history. During the assessment, I observed several key findings indicative of schizophrenia presented with positive symptoms, including auditory hallucinations and persecutory delusions. The content of the delusions revolved around an external entity thus leading to significant distress and impaired functioning. The patient also exhibited disorganized thinking and speech, with tangentiality and difficulty maintaining a coherent conversation. The primary focus will be on addressing symptom management, improving insight, and enhancing overall functioning and quality of life. I will collaborate with the multidisciplinary team to ensure a comprehensive approach to care. Patients with schizophrenia provided valuable insights into their symptom profiles and functioning. By tailoring a comprehensive treatment plan that combines pharmacological and non-pharmacological interventions, we aim to alleviate symptoms, enhance insight, and improve the overall quality of life.
References
González-Rodríguez, A., Seeman, M. V., Izquierdo, E., Natividad, M., Guàrdia, A., Román, E., & Monreal, J. A. (2022). Delusional disorder in old age: A hypothesis-driven review of recent work focusing on epidemiology, clinical aspects, and outcomes. International Journal of Environmental Research and Public Health, 19(13), 7911. https://doi.org/10.3390/ijerph19137911
Keepers, G. A., Fochtmann, L. J., Anzia, J. M., Benjamin, S., Lyness, J. M., Mojtabai, R., … & (Systematic Review). (2020). The American Psychiatric Association practice guideline for the treatment of patients with schizophrenia. American Journal of Psychiatry, 177(9), 868-872. https://doi.org/10.1176/appi.ajp.2020.177901
Maan, J. S., Ershadi, M., Khan, I., & Saadabadi, A. (2017). Quetiapine. https://www.ncbi.nlm.nih.gov/books/NBK459145/
Škodlar, B., & Henriksen, M. G. (2019). Toward a phenomenological psychotherapy for schizophrenia. Psychopathology, 52(2), 117-125. https://doi.org/10.1159/000500163
Tandon, R., & Shariff, S. M. (2019). Substance-induced psychotic disorders and schizophrenia: pathophysiological insights and clinical implications. American Journal of Psychiatry, 176(9), 683-684. https://doi.org/10.1176/appi.ajp.2019.19070734