Assignment: Focused SOAP Note for Schizophrenia Spectrum, Other Psychotic, and Medication-Induced Movement Disorders
Case Study: Sherman Tremaine
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.
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.
- 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.
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 diagnostic criteria for each differential diagnosis and explain what DSM-5 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).
SOAP Note for Schizophrenia
Patient Initials: Sherman Tremaine Age: 53 years Gender: Male
Chief Complaint (CC): “He was made to come in by his sister.”
History of Present Illness (HPI): Sherman Tremaine is a 53-years-old African American male who visited my office saying that he was made to come in by his sister. Sherman notes that people have been watching him for weeks and his taxes have raised. He says that the government sent these people to watch him. The patient’s symptoms alleviate when he listens to music.
Medical trials and Current Medications:
No medical trials but reports using Haldol, Thorazine, and Seroquel previously. Takes metformin for diabetes.
Allergies: Denies food, environmental, or drug allergies.
Past Medical History: The patient was diagnosed with diabetes and fatty liver.
Past Psychiatric/Physical History (PMH): Have been in the hospital three times though when he was 20.
Past Surgical History (PSH): No past surgeries.
Personal/Social History: The patient smokes three packets a day, drunks 12 packets of alcohol a week, and used marijuana last three years ago. Denies substance abuse.
History of Violence: His dad was abusive.
Immunization History: The patient does not remember immunization dates.
Significant Family History: The patient is single, never married, and has no children. The patient’s mother had anxiety and father had paranoid schizophrenia.
Lifestyle: The patient has his sister has his main social support.
Review of Systems:
General: Denies fatigue, fever, weight changes, or weakness.
Respiratory: No shortness of breath, sputum, or cough.
Cardiovascular/Peripheral Vascular: No chest pain or chest discomfort.
Psychiatric: Positive for sleeping problems.
Neurological: No headache or other neurological problems.
Skin: No sores, dryness, or rashes.
Vital signs: Wt. 180lbs, Ht. 5’8’’, T 36.4, HR 76, HH 18, BP 134/98
General: Sherman is oriented to place, date, and people. However, the patient does not know whether today is Wednesday or Thursday. The patient is well groomed and wears clothes that conforms to weather of the day and climate of the year. The patient answers most questions correctly.
Chest/Lungs: Regular heart rhythm and rate. No murmurs.
Heart/Peripheral Vascular: Lungs clear. No wheezes, chest cracks, or rhonchi.
Psychiatric: The patient experiences hallucinations and delusions. He says that there are people outside his window watching him. He notes that these people were sent by the government. He says that he hears loud voices and also notes that people from his TV want to poison him but he tricks them.
PSYRATS – Hallucinations Subscale-Positive for hallucinations.
PSYRATS – Delusions Subscale-Positive for delusions
- Schizophrenia-Primary disorder for this case.
- Brief Psychotic Disorder
- Schizoaffective Disorder
- Delusional Disorders
The primary diagnosis for this case is schizophrenia. According to Ng et al. (2019), symptoms of schizophrenia include disorganized speech, delusions, catatonic behavior, negative symptoms, and hallucinations. According to DSM-5, one must experience at least two of the five symptoms for them to be said to have schizophrenia (American Psychiatric Association, 2013). The patient has hallucinations and delusions, making the disorder a primary diagnosis. The diagnosis has also been supported by PSYRATS, a mental health tool used to assess patients’ mental status (Chong et al., 2020).
Treatment Plan: I would recommend that the patient be prescribed Invega Sustenna 234 mg intramuscular X1. The medication can improve the patient’s heath by improving his judgment, thinking, and mood (Pesa et al., 2017). Apart from medication, the patient will also be advised to go for talk therapy once a week. Galbusera et al. (2018) note that a combination of talk therapy and medication can highly improve the mental health of schizophrenic patients.
Health Promotion: The patient should avoid smoking and alcohol.
Follow-Up: The patient should come for re-evaluation and check-up after four weeks.
If I was given another chance to work on the case, I would have recommended that the patient be taken to a psychologist for counseling. A combination of medication and therapy can improve the health of the patient.
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed). Arlington, VA: American Psychiatric Publishing.
Chong, B., Wahab, S., Muthukrishnan, A., Tan, K. L., Ch’ng, M. L., & Yoong, M. T. (2020). Prevalence and Factors Associated with Suicidal Ideation in Institutionalized Patients with Schizophrenia. Psychology research and behavior management, 13, 949–962. https://doi.org/10.2147/PRBM.S266976
Galbusera, L., Finn, M. T., & Fuchs, T. (2018). Interactional synchrony and negative symptoms: An outcome study of body-oriented psychotherapy for schizophrenia. Psychotherapy Research, 28(3), 457-469. https://doi.org/10.1080/10503307.2016.1216624
Ng, Q. X., Soh, A. Y. S., Venkatanarayanan, N., Ho, C. Y. X., Lim, D. Y., & Yeo, W. S. (2019). A systematic review of the effect of probiotic supplementation on schizophrenia symptoms. Neuropsychobiology, 78(1), 1-6. https://www.karger.com/Article/Abstract/498862
Pesa, J. A., Doshi, D., Wang, L., Yuce, H., & Baser, O. (2017). Health care resource utilization and costs of California Medicaid patients with schizophrenia treated with paliperidone palmitate once monthly or atypical oral antipsychotic treatment. Current Medical Research and Opinion, 33(4), 723-731. https://doi.org/10.1080/03007995.2016.1278202
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