Assignment: Focused SOAP Note for Schizophrenia Spectrum, Other Psychotic, and Medication-Induced Movement Disorders
NRNP 6675 Assignment: Focused SOAP Note for Schizophrenia Spectrum, Other Psychotic, and Medication-Induced Movement Disorders
Focused SOAP Note for Schizophrenia Spectrum, Other Psychotic, and Medication-Induced Movement Disorders
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 male patient who says he came to the psychiatric clinic after his sister forced him to have a psychiatric evaluation. The client reports that he is being watched, and the people watching him do not want to leave him. He reports hearing them and seeing their shadows when they are surveilling him. Sherman states that those surveilling think he does not see them, but he can see them on the contrary. The patient further states that the government sent those people watching him, which is why his taxes have increased. Sherman also mentions that he experiences sleeping disturbance
Assignment Focused SOAP Note for Schizophrenia Spectrum Other Psychotic and Medication Induced Movement Disorders
s because the voices of the people watching him are loud, making him remain awake for days. Furthermore, Sherman believes that these people enter his house and poison his food. He also mentions that his sister is planning with the government to change his lifestyle, and his phone has been tapped.
Substance Current Use: The patient states that he smokes tobacco 3PPD and takes alcohol. He previously used marijuana but quit three years ago. However, he 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 his parents’ death three years ago.
Assignment Focused SOAP Note for Schizophrenia Spectrum, Other Psychotic, and Medication-Induced Movement Disorders
The patient was raised by his mother and sister. He is single with no children. He 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: Male patient in his 50s. He is well-groomed and appropriately dressed. The patient is alert and maintains adequate eye contact. His speech is clear, but the rate and volume vary. He 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. His self-reported mood is anxious, and his affect is blunted. His 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. His short- and long-term memory is intact, and judgment is poor. 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). Invega Sustenna might be an appropriate pharmacological intervention for this patient for as he keeps on talking about not wanting to take several oral medications in the past, as this is a monthly injection.
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