NRNP 6675 Week 5 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.
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.
To Prepare
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.
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. Assessment: Talk about the results of the patient’s mental status exam. What different diagnoses did you make? Give at least three possible diagnoses with evidence to back them up, and list them from most important to least important. 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 the correct diagnosis. Explain how you used critical thinking to come up with the main diagnosis you chose. Include both the positive and negative things that are important to the patient’s 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: Schizophrenia Spectrum Example Approach
Subjective:
CC (chief complaint):
Delusions and hallucinations.
HPI:
C.M, a 27-year-old female Hispanic patient comes for a psychiatric Assessment. She was last well about two months ago when she started experiencing delusions and hallucinations. The patient was constantly on the lookout believing that someone was spying on her with the motive of harming her. The patient also started experiencing auditory hallucinations. She claims that she often hears voices of several men and women talking and laughing at her constantly. The delusions and hallucinations have been there for the past two months with no recollection of similar symptoms previously. Over the last month, the patient has reported low energy levels on several occasions and often withdrawing herself from close family members and friends.
Substance Current Use:
The patient denies any alcohol, tobacco, or drug use.
Medical History:
The patient has no known chronic illnesses. No previous surgeries. No prior hospital admissions.
Current Medications:
The patient is currently not on any medication.
Allergies
NKDFA.
Reproductive Hx:
LMP 04/06/2022. The cycle is 30 days lasting 5 days. Regular flow. G0T0P0A0L0. No contraceptive. Currently single. The patient is a victim of both physical and sexual assault from a previous relationship.
Family Hx:
Family history of schizophrenia. No other known chronic illnesses among close family members.
ROS:
GENERAL: No reports of fever, body aches, or any other concerns.
HEENT: No history of trauma, headache, or falls. No complications related to the throat, nose, and ears.
SKIN: No history of rash, lesions, or concerns with eczema.
CARDIOVASCULAR: No complains of chest pain, no palpitations, no orthopnea.
RESPIRATORY: No chest pain, no cough, no difficulty in breathing.
GASTROINTESTINAL: No change in appetite. No history of abnormal bowel movements.
GENITOURINARY: No hematuria, no dysuria, no urgency, no frequency.
NEUROLOGICAL: No syncope, no dizziness, no blurry vision, no tinnitus.
MUSCULOSKELETAL: No pain in the muscles or joints.
HEMATOLOGIC: No history of easy bruising or bleeding.
LYMPHATICS: Denies any lymph node swelling.
ENDOCRINOLOGIC: Denies increased thirst or urination.
Objective:
VS: Temp: 98.0 F, BP: 99/69, HR: 96, RR: 17, 100% on RA, Height: 5ft, 3in Wt.: 139 lbs.
BMI: 24.6. Lies within the normal range.
General: The patient is not sick looking and is in fair general condition with no signs of respiratory distress.
Skin: No abnormal lesions were observed on the skin.
Head: Normal shape and size.
Eyes: No abnormalities detected. The pupils respond appropriately to stimulation by light.
ENT: No abnormalities were observed on the ears and nose. The tympanic membrane is intact. Hearing is unaffected. The throat looks normal with no signs of inflammation.
Neck: No abnormalities on the neck.
CVS: Apex beat is not displaced. There is a normal heart rate and rhythm. Auscultation reveals normal S1 and S2 sounds with no murmurs.
RS: Trachea is central. Vesicular and bronchial breath sounds were heard. No additional sounds.
Abdomen: No visible scars. No distention. No tenderness or masses were elicited.
Musculoskeletal: Muscle tone and strength intact. Normal range of movement observed.
Assessment:
MSE:
C.M is a 27-year-old Hispanic female patient who comes in for the Assessment. Her appearance and stated age are appropriate. The patient is well responsive throughout the session. Her blouse is buttoned inappropriately. Her hair is quite unkempt. The patient displays no tics or any other abnormal movements. The patient communicates incoherently, responding to questions asked with unrelated responses and at times moving away from the issue at hand to discuss unrelated matters. The patient often repeats what she had said earlier. Her thought is impaired. There is evidence of looseness of association and flight of ideas. Her mood is euthymic, but she demonstrates a blunt affect. Incongruency is noted. Auditory and visual hallucinations are present in this patient. Delusions are present with the patient constantly worried that someone wants to harm her. There are no thoughts of inflicting harm to self or others. Cognitively, she is alert. C.M is appropriately oriented. Her memory is not impaired. Concentration is impaired. Insight is lacking in her current condition. NRNP 6675 Week 5 Focused SOAP Note for Schizophrenia Spectrum
Diagnostic Impression:
The primary diagnosis is schizophreniform disorder.
Differential diagnoses are substance-induced schizophrenia and delusional disorder.
Schizophreniform disorder is a psychotic disorder lasting between one to six months. The condition greatly affects an individual’s level of cognition, emotions, and actions. The condition affects both genders, with a peak incidence among women being reported between the ages of 24 to 35 years (Kahn et al., 2018). Patients often present with delusions, hallucinations, disorganized speech, and diminished energy levels. In most instances, patients are often untidy and unkempt, often withdrawing from close family members and friends. These symptoms align with the patient’s presenting complaints and findings on examination, making this the most probable diagnosis.
The substance-induced psychotic disorder is often associated with the start or cessation of the use of alcohol or other drugs. Patients often present with delusions, hallucinations, impaired speech, impaired mood, and poor general hygiene (Wilson et al., 2018). These findings are similar to the patient’s presenting complaint. She, however, denies any alcohol or drug use. Further laboratory investigations are required to rule out any substance use and confirm what she said. Delusional disorders are mental health conditions where patients experience various delusions of different kinds. In most instances, there is little to no impact on an individual’s well-being, and one may continue functioning normally. In severe instances, psychotic symptoms may ensue. Pertinent positives, in this case, include the history of delusions and hallucinations, disorganized speech, social withdrawal, and a family history of schizophrenia. In addition, mood and affect incongruency and lack of insight are other pertinent positives. Pertinent negatives include no alcohol or drug use, the patient being well oriented and memory being intact.
Case Formulation and Treatment Plan:
Pharmacological Interventions
Atypical antipsychotics are often used in the management of schizophreniform disorder. These include risperidone, olanzapine, and quetiapine (Alphs et al., 2022 NRNP 6675 Week 5 Focused SOAP Note for Schizophrenia Spectrum).
Nonpharmacologic Interventions
Cognitive-behavioral therapy (CBT), psychoeducation, cognitive remediation, social and coping skills, and family interventions are proven nonpharmacologic interventions for the condition (Ganguly et al., 2018).
Alternative Therapies
Alternative therapies that can prove helpful include talk therapy, family therapy, career coaching, and communication and social skills.
Follow-up Parameters
Assessment of the patient should be done monthly. Symptoms should have completely subsided by 6 months.
Rationale For Management
The management plan is to ensure the protection and stabilization of the patient. Minimizing psychosocial complications and enabling the patient to lead a normal life with minimal adverse effects is another critical goal of management.
Health Promotion Activity
Educating the patient on coping with life’s stresses is a critical component of health promotion.
Patient Education Strategy
The best education strategy is dependent on the patient’s literacy level and ability to embrace the use of technology in healthcare.
Reflection
If I were to conduct the session again, I would inquire further into the family history of schizophrenia. Probing further into the drug and substance use history to know if the patient is lying is another thing I would do. In follow-up meetings, I would work on the patient’s communication and social skills. It is essential to take into account confidentiality, conflict of interest, operational challenges, placebo related, exploitation, informed consent, vulnerability, exploitation, and therapeutic misconception (Brown et al., 2020) as key legal/ethical considerations.
NRNP 6675 Week 5 Focused SOAP Note for Schizophrenia Spectrum References
Alphs, L., Brown, B., Turkoz, I., Baker, P., Fu, D. J., & Nuechterlein, K. H. (2022). The Disease Recovery Assessment and Modification (DREaM) study: Effectiveness of paliperidone palmitate versus oral antipsychotics in patients with recent-onset schizophrenia or schizophreniform disorder. Schizophrenia Research, 243, 86–97. https://doi.org/10.1016/j.schres.2022.02.019
Brown, C., Ruck Keene, A., Hooper, C. R., & O’Brien, A. (2020). Isolation of patients in psychiatric hospitals in the context of the COVID-19 pandemic: An ethical, legal, and practical challenge. International Journal Of Law And Psychiatry, 71, 101572. https://doi.org/10.1016/j.ijlp.2020.101572
Ganguly, P., Soliman, A., & Moustafa, A. A. (2018). Holistic Management of Schizophrenia Symptoms Using Pharmacological and Non-pharmacological Treatment. Frontiers in Public Health, 6, 166. https://doi.org/10.3389/fpubh.2018.00166
Kahn, R. S., Winter van Rossum, I., Leucht, S., McGuire, P., Lewis, S. W., Leboyer, M., Arango, C., Dazzan, P., Drake, R., Heres, S., Díaz-Caneja, C. M., Rujescu, D., Weiser, M., Galderisi, S., Glenthøj, B., Eijkemans, M., Fleischhacker, W. W., Kapur, S., Sommer, I. E., & OPTiMiSE study group (2018). Amisulpride and olanzapine followed by open-label treatment with clozapine in first-episode schizophrenia and schizophreniform disorder (OPTiMiSE): a three-phase switching study. The lancet. Psychiatry, 5(10), 797–807. https://doi.org/10.1016/S2215-0366(18)30252-9
Wilson, L., Szigeti, A., Kearney, A., & Clarke, M. (2018). Clinical characteristics of primary psychotic disorders with concurrent substance abuse and substance-induced psychotic disorders: A systematic review. Schizophrenia Research, 197, 78–86. https://doi.org/10.1016/j.schres.2017.11.001
By Day 7 of Week 5
Submit your Focused SOAP Note.
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Sample Answer Guide:
SOAP Note for Sherman Tremaine, a Patient with Schizophrenia Spectrum Disorder
Subjective:
Chief Complaint (CC): “I have been hearing voices and seeing things that other people cannot see.”
History of Present Illness (HPI): Sherman Tremaine is a 32-year-old African American male who presents with a history of auditory hallucinations and delusions for the past six months. The patient reported that he hears voices telling him to harm himself and others. The voices are more frequent at night and are often accompanied by visual hallucinations of people watching him. The patient also reported experiencing paranoid delusions, believing that people are conspiring against him. He stated that he has been feeling anxious and depressed since the onset of his symptoms and has been experiencing difficulty with sleep. The patient denied any history of substance use, head injury, or neurological symptoms.
Subjective:
General: The patient was alert and oriented to person, place, and time. He appeared anxious, with psychomotor agitation, fidgeting in his seat and tapping his foot.
Mood and affect: The patient appeared depressed and reported feeling hopeless and helpless. His affect was constricted, with minimal eye contact and flat affect.
Thought process: The patient’s thought process was disorganized, with a flight of ideas and tangentiality. He reported paranoid delusions and auditory hallucinations.
Speech: The patient’s speech was coherent, with no abnormalities in rhythm or rate. There were no indications of thought blocking or loosening of associations.
Perception: The patient reported auditory hallucinations and visual hallucinations. He appeared fearful and anxious during the interview.
Assessment:
The patient’s mental status examination suggested the presence of a psychotic disorder, specifically a schizophrenia spectrum disorder. The differential diagnoses include brief psychotic disorder, schizophreniform disorder, and schizophrenia.
The DSM-5-TR diagnostic criteria for schizophrenia spectrum disorders include the presence of two or more of the following symptoms for a significant portion of time during a one-month period: delusions, hallucinations, disorganized speech, grossly disorganized or catatonic behavior, and negative symptoms. In addition, social or occupational functioning must be impaired, and the symptoms must persist for at least six months. Sherman Tremaine presents with symptoms of auditory hallucinations, paranoid delusions, disorganized speech, and social impairment, which support the diagnosis of schizophrenia spectrum disorder.
Plan:
The patient will be started on a second-generation antipsychotic medication, risperidone, at 1 mg/day, with a gradual increase to 4 mg/day as tolerated. The patient will be closely monitored for side effects, including extrapyramidal symptoms and metabolic changes. The patient will be referred to a therapist for psychotherapy, including cognitive-behavioral therapy (CBT) and family therapy. CBT will focus on symptom management and coping skills, while family therapy will address communication and support. Additionally, the patient will be advised to maintain a regular sleep schedule and avoid alcohol and drugs. The patient will be scheduled for follow-up in one week to monitor medication response and side effects.
Health promotion activity: The patient will be encouraged to engage in regular physical activity, such as walking, to improve overall health and well-being.
Patient education: The patient will be educated about schizophrenia spectrum disorders and their treatment options, including the importance of medication adherence and regular follow-up appointments. The patient will be encouraged to ask questions and express any concerns or side effects related to the medication.
Reflection notes:
If I were to conduct the session again, I would focus on building a therapeutic alliance with the patient before discussing the diagnosis and treatment options. Additionally, I would explore the patient’s cultural and religious beliefs about mental illness and medication to address any potential barriers to treatment.
For follow-up, I would evaluate the patient’s response to the medication and therapy, as well as any side effects or adverse reactions. I would also continue to monitor the patient’s mood, affect, and thought processes, as well as his compliance with medication and therapy. It is important to maintain open communication with the patient and his family throughout the treatment process to ensure the best possible outcomes.
