FOCUSED SOAP NOTE FOR SCHIZOPHRENIA SPECTRUM, OTHER PSYCHOTICDERS
FOCUSED SOAP NOTE FOR SCHIZOPHRENIA SPECTRUM, OTHER PSYCHOTIC, AND MEDICATION-INDUCED MOVEMENT DISORDERS
Subjective: The patient is a 32-year-old male with a diagnosis of schizophrenia spectrum disorder. He reports experiencing auditory hallucinations, disorganized thinking, and delusions for the past several years. He has a history of non-adherence to medication and has recently been experiencing involuntary movements and tremors.
Objective: Upon assessment, the patient appears disheveled and anxious. He is unable to maintain eye contact and is fidgeting with his hands. He reports hearing voices that tell him to do things and expresses belief in a conspiracy against him. He reports experiencing tremors in his hands and arms, as well as involuntary movements of his head and face. He is currently taking risperidone and lorazepam for his schizophrenia and has been experiencing these movement disorders since starting the medications.
Assessment: The patient’s symptoms and history suggest a diagnosis of schizophrenia spectrum disorder with medication-induced movement disorders.
Plan: The patient will be referred to a psychiatrist for further evaluation and management of his schizophrenia and movement disorders. The possibility of switching to a different medication or adjusting the dosage of his current medication will be discussed. The patient will also be encouraged to adhere to his treatment plan and to attend follow-up appointments.
Follow-up: The patient will follow up with the psychiatrist in one week for further management of his schizophrenia and movement disorders. He will be monitored for any changes in his symptoms and for any adverse effects of his medication. The patient will also be encouraged to continue participating in individual therapy and to engage in self-help strategies such as practicing relaxation techniques and maintaining a healthy lifestyle.
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 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)
Create documentation in the Focused SOAP Note Template about your assigned patient. In the Subjective section, provide: • Chief complaint• History of present illness (HPI)• Past psychiatric history• Medication trials and current medications• Psychotherapy or previous psychiatric diagnosis• Pertinent substance use, family psychiatric/substance use, social, and medical history• Allergies• ROS
The response thoroughly and accurately describes the patient’s subjective complaint, history of present illness, past psychiatric history, medication trials and current medications, psychotherapy or previous psychiatric diagnosis, pertinent histories, allergies, and review of all systems that would inform a differential diagnosis.
In the Objective section, provide:• Physical exam documentation of systems pertinent to the chief complaint, HPI, and history• Diagnostic results, including any labs, imaging, or other assessments needed to develop the differential diagnoses
The response thoroughly and accurately documents the patient’s physical exam for pertinent systems. Diagnostic tests and their results are thoroughly and accurately documented.
In the Assessment section, provide:• Results of the mental status examination, presented in paragraph form• At least three differentials with supporting evidence. List them from top priority to least 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.
The response thoroughly and accurately documents the results of the mental status exam…. Response lists at least three distinctly different and detailed possible disorders in order of priority for a differential diagnosis of the patient in the assigned case study, and it provides a thorough, accurate, and detailed justification for each of the disorders selected.
In the Plan section, provide:• Your plan for psychotherapy• 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. • Incorporate one health promotion activity and one patient education strategy.
The response provides an evidence-based, detailed, and appropriate plan for psychotherapy for the patient…. The response provides an evidence-based, detailed, and appropriate plan for treatment and management, including pharmacologic and nonpharmacologic treatments, alternative therapies, and follow-up parameters. A strong rationale for the plan is provided that demonstrates critical thinking and content understanding…. The response includes at least one evidence-based health promotion activity and one evidence-based patient education strategy.
• Discussion include what may be done differently with this patient if student conducted the session again. Discussed the next intervention if you could follow up with this patient. The discussion was related to legal/ethical considerations (demonstrated critical thinking beyond confidentiality and consent for treatment!), social determinates of health, health promotion, and disease prevention that take into consideration patient factors (such as age, ethnic group, etc.), PMH, and other risk factors (e.g., socioeconomic, cultural background, etc.).
Reflections are thorough, thoughtful, and demonstrate critical thinking. Reflections contain a discussion of all elements described within assignment directions.
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).
The response provides at least three current, evidence-based resources from the literature to support the assessment and diagnosis of the patient in the assigned case study. The resources reflect the latest clinical guidelines and provide strong justification for decision making.
Written Expression and Formatting – The paper follows correct APA format for parenthetical/in-text citations and reference list.
Uses correct APA format with no errors
Written Expression and Formatting – English Writing Standards: Correct grammar, mechanics, and punctuation
DR. MOORE: Good afternoon. I’m Dr. Moore. Want to thank you for coming in for your appointment today. I’m going to be asking you some questions about your history and some symptoms. And to get started, I just want to ensure I have the right patient and chart. So can you tell me your name and your date of birth?
SHERMAN TREMAINE: I’m Sherman Tremaine, and Tremaine is my game. My birthday is November 3, 1968.
DR. MOORE: Great. And can you tell me today’s date? Like the day of the week, and where we are today?
SHERMAN TREMAINE: Use any recent date, and any location is OK.
DR. MOORE: OK, Sherman. What about do you know what month this is?
SHERMAN TREMAINE: It’s March 18. DR. MOORE: And the day of the week?
SHERMAN TREMAINE: Oh, it’s a Wednesday or maybe a Thursday.
DR. MOORE: OK. And where are we today?
SHERMAN TREMAINE: I believe we’re in your office, Dr. Moore.
DR. MOORE: OK, great. So tell me a little bit about what brings you in today. What brings you here? SHERMAN TREMAINE: Well, my sister made me come in. I was living with my
mom, and she died. I was living, and not bothering anyone, and those people– those people, they just
won’t leave me alone. DR. MOORE: What people?
SHERMAN TREMAINE: The ones outside my window watching. They watch me. I can hear them, and
I see their shadows. They think I don’t see them, but I do. The government sent
them to watch me, so my taxes are high,so high in the sky. Do you see that bird? DR. MOORE: Sherman,
how long have you saw or heard these people?
SHERMAN TREMAINE: Oh, for weeks, weeks and weeks and weeks. Hear that– hear that heavy metal music? They want you to think it’s weak, but it’s heavy.
DR. MOORE: No, Sherman. I don’t see any birds or hear any music. Do you sleep well, Sherman?
SHERMAN TREMAINE: I try to but the voices are loud. They keep me up for days and days. I try to watch TV, but they watch me through the screen, and they come in and poison my food. I tricked them though. I tricked them. I locked everything smoking here. How much do you usually smoke?
SHERMAN TREMAINE: Well, I smoke all day, all day. Three packs a day. .
DR. MOORE: Three packs a day. OK. What about alcohol? When was your last drink?
SHERMAN TREMAINE: Oh, yesterday. My sister buys me a 12-pack, and tells me to make it last until next week’s grocery run. I don’t go to the grocery store. They play too loud of the heavy metal music. They also follow me there.
DR. MOORE: What about marijuana?
SHERMAN TREMAINE: Yes, but not since my mom died three years ago. DR. MOORE: Use any cocaine? SHERMAN TREMAINE: No, no, no, no, no, no, no. No drugs ever, clever, ever. DR. MOORE: What about
any blackouts or seizures or see or hear things from drugs or alcohol?
SHERMAN TREMAINE: No, no, never a clever [INAUDIBLE] ever.
DR. MOORE: What about any DUIs or legal issues from drugs or alcohol?
SHERMAN TREMAINE: Never clever’s ever.
DR. MOORE: OK. What about any medication for your mental health? Have you tried those before, and
what was your reaction to them?
SHERMAN TREMAINE: I hate Haldol and Thorazine. No, no, I’m not going to take it. Risperidone gave me boobs. No, I’m not going to take it. Seroquel, that is OK. But they’re all poison, nope, not going to take it. DR. MOORE: OK. So tell me, any
blood relatives have any mental health or substance abuse issues? .
SHERMAN TREMAINE: They say that my dad was crazy withparanoid schizophrenia. He did in the old
state hospital. They gave him his beer there. Can you believe that? Not like them today. My mom had anxiety.
DR. MOORE: Did any blood relatives commit suicide? SHERMAN TREMAINE:
Oh, no demons there. No, no. DR. MOORE: What about you? Have you ever done anything like cut yourself, or had any thoughts about killing yourself or anyone else? SHERMAN TREMAINE:
I already told you. No demons there. Have been in the hospital three times though when I was 20. DR. MOORE: OK. What about any medical issues? Do you have any medical problems? SHERMAN TREMAINE: Ooh, Itake metformin for diabetes. Had or I have a fatty
liver, they say, but they never saw it. So I don’t know unless
the aliens told them. DR. MOORE: OK. So who raised you? SHERMAN TREMAINE: My
mom and my sister. DR. MOORE: And who
do you live with now? SHERMAN TREMAINE: Myself, but my sister’s plotting with the
government to change that. They tapped my phone. DR. MOORE: OK. Have you ever been married? Are you single, widowed, or divorced? SHERMAN TREMAINE: I’ve never been married.
DR. MOORE: Do you have any children?
SHERMAN TREMAINE: No.
DR. MOORE: OK. What is your highest level of education?
SHERMAN TREMAINE: I went to the 10th grade. DR. MOORE: And what do you like to do for fun? SHERMAN TREMAINE: I don’t work, so smoking and drinking pop.
DR. MOORE: OK. Have you ever been arrested or convicted for anything legally?
SHERMAN TREMAINE: No, but they have told me they would. They have told me they would
if I didn’t stop calling 911 about the people outside.
DR. MOORE: OK. What about any kind of trauma as a child or an adult? Like physical, sexual,
emotional abuse. SHERMAN TREMAINE: My dad was rough on us until he died.
DR. MOORE: OK. [MUSIC PLAYING] So thank you for answering those questions for me. Now, let’s talk about how I can best help you. [MUSIC PLAYING]