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[ANSWERED OCTOBER 2022] Assignment: Focused SOAP Note for Schizophrenia Spectrum, Other Psychotic, and Medication-Induced Movement Disorders

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.

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.
  • 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 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).
By Day 7 of Week 5

Submit your Focused SOAP Note.

Submission and Grading Information

To submit your completed Assignment for review and grading, do the following:

  • Please save your Assignment using the naming convention “WK5Assgn+last name+first initial.(extension)” as the name.
  • Click the Week 5 Assignment Rubric to review the Grading Criteria for the Assignment.
  • Click the Week 5 Assignment link. You will also be able to “View Rubric” for grading criteria from this area.
  • Next, from the Attach File area, click on the Browse My Computer button. Find the document you saved as “WK5Assgn+last name+first initial.(extension)” and click Open.
  • If applicable: From the Plagiarism Tools area, click the checkbox for I agree to submit my paper(s) to the Global Reference Database.
  • Click on the Submit button to complete your submission.

Rubric Detail

Select Grid View or List View to change the rubric’s layout.

Name: NRNP_6675_Week5_Assignment_Rubric

  Excellent

90%–100%

Good

80%–89%

Fair

70%–79%

Poor

0%–69%

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

14 (14%) – 15 (15%)

The response throughly 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.

12 (12%) – 13 (13%)

The response 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.

11 (11%) – 11 (11%)

The response 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 but is somewhat vague or contains minor innacuracies.

0 (0%) – 10 (10%)

The response provides an incomplete or inaccurate description of 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. Or the subjective documentation is missing.

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

14 (14%) – 15 (15%)

The response thoroughly and accurately documents the patient’s physical exam for pertinent systems. Diagnostic tests and their results are thoroughly and accurately documented.

12 (12%) – 13 (13%)

The response accurately documents the patient’s physical exam for pertinent systems. Diagnostic tests and their results are accurately documented.

11 (11%) – 11 (11%)

Documentation of the patient’s physical exam is somewhat vague or contains minor innacuracies. Diagnostic tests and their results are documented but contain minor innacuracies.

0 (0%) – 10 (10%)

The response provides incomplete or inaccurate documentation of the patient’s physical exam. Systems may have been unnecessarily reviewed. Or the objective documentation is missing.

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.

18 (18%) – 20 (20%)

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.

16 (16%) – 17 (17%)

The response 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 an accurate justification for each of the disorders selected.

14 (14%) – 15 (15%)

The response documents the results of the mental status exam with some vagueness or innacuracy.

Response lists at least three different possible disorders for a differential diagnosis of the patient and provides a justification for each, but may contain some vagueness or innacuracy.

0 (0%) – 13 (13%)

The response provides an incomplete or inaccurate description of the results of the mental status exam and explanation of the differential diagnoses. Or the assessment documentation is missing.

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.

23 (23%) – 25 (25%)

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.

20 (20%) – 22 (22%)

The response provides an evidence-based and appropriate plan for psychotherapy for the patient.

The response provides an evidence-based and appropriate plan for treatment and management, including pharmacologic and nonpharmacologic treatments, alternative therapies, and follow-up parameters. An adequate rationale for the plan is provided.

The response includes at least one health promotion activity and one patient education strategy.

18 (18%) – 19 (19%)

The response provides a somewhat vague or inaccurate plan for psychotherapy for the patient.

The response provides a somewhat vague or inaccurate plan for treatment and management, including pharmacologic and nonpharmacologic treatments, alternative therapies, and follow-up parameters. The rationale for the plan is weak or general.

The response includes one health promotion activity and one patient education strategy, but it may contain some vagueness or innacuracy.

0 (0%) – 17 (17%)

The response provides an incomplete or inaccurate plan for psychotherapy for the patient.

The response provides an incomplete or inaccurate plan for treatment and management, including pharmacologic and nonpharmacologic treatments, alternative therapies, and follow-up parameters. The rationale for the plan is inaccurate or missing.

The health promotion and patient education strategies are incomplete or missing.

• Reflect on this case. Discuss what you learned and what you might do differently. 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 that takes into consideration patient factors (such as age, ethnic group, etc.), PMH, and other risk factors (e.g., socioeconomic, cultural background, etc.). 5 (5%) – 5 (5%)

Reflections are thorough, thoughtful, and demonstrate critical thinking.

4 (4%) – 4 (4%)

Reflections demonstrate critical thinking.

3.5 (3.5%) – 3.5 (3.5%)

Reflections are somewhat general or do not demonstrate critical thinking.

0 (0%) – 3 (3%)

Reflections are incomplete, inaccurate, or missing.

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). 9 (9%) – 10 (10%)

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.

8 (8%) – 8 (8%)

The response provides at least three current, evidence-based resources from the literature that appropriately support the assessment and diagnosis of the patient in the assigned case study.

7 (7%) – 7 (7%)

Three evidence-based resources are provided to support the assessment and diagnosis of the patient in the assigned case study, but they may only provide vague or weak justification.

0 (0%) – 6 (6%)

Two or fewer resources are provided to support the assessment and diagnosis decisions. The resources may not be current or evidence based.

Written Expression and Formatting – The paper follows correct APA format for parenthetical/in-text citations and reference list. 5 (5%) – 5 (5%)

Uses correct APA format with no errors

4 (4%) – 4 (4%)

Contains 1-2 grammar, spelling, and punctuation errors

3.5 (3.5%) – 3.5 (3.5%)

Contains 3-4 grammar, spelling, and punctuation errors

0 (0%) – 3 (3%)

Contains five or more grammar, spelling, and punctuation errors that interfere with the reader’s understanding

Written Expression and Formatting – English Writing Standards:

 

Correct grammar, mechanics, and punctuation

5 (5%) – 5 (5%)

Uses correct grammar, spelling, and punctuation with no errors

4 (4%) – 4 (4%)

Contains 1-2 APA format errors

3.5 (3.5%) – 3.5 (3.5%)

Contains 3-4 APA format errors

0 (0%) – 3 (3%)

Contains five or more APA format errors

Total Points: 100

Expert Answer and Explanation

Subjective:

CC (chief complaint): “I do not bother anyone and people outside my window do not leave alone.”

HPI: Sherman Tremaine is a 53-years-old African American male who was asked to come for mental health assessment by his sister. The patient complains that he does not bother anybody but people outside his window to not leave him alone. he says that the people outside his window watch him. He says that he can hear these people and see their shadow. He also says that these people were sent to watch him by the government. He also complains of sleeping problems and people follow him everywhere.

Substance Current Use: He smokes cigarette (12 packets of cigarettes weekly) and a bit of marijuana.

Medical History:

  • Current Medications: Used Haldol, Thorazine, and Seroquel. Takes metformin currently for diabetes.
  • Allergies: No allergies.
  • Reproductive Hx: No problems with reproductive system.

ROS:

  • GENERAL: No fever, weakness, fatigue, chills, or weight loss/gain.
  • HEENT: Eyes: No visual problem. Ears, Nose, Throat: No hearing pain, loss, sneezing, runny nose, congestion, or sore throat.
  • SKIN: No itching or rash.
  • CARDIOVASCULAR: No chest pain, edema, no chest pressure palpitations, or chest discomfort.
  • RESPIRATORY: No cough or shortness of breath.
  • GASTROINTESTINAL: No abdominal pain, nausea, or vomiting.
  • GENITOURINARY: No urination problems.
  • NEUROLOGICAL: No headaches or any other neurological problems.
  • MUSCULOSKELETAL: No joint pain or muscle pain.
  • HEMATOLOGIC: No anemia.
  • LYMPHATICS: No enlarged nodes
  • ENDOCRINOLOGIC: No sweating, heat, or cold problems.

Objective:

Vital signs: T 35.7, Ht. 5’9, Wt. 159lbs, HR 80, RR 20, BP 130/95

Chest/Lungs: Regular heart rhythm and rate. No murmurs.

Heart/Peripheral Vascular: No wheezes. Lungs clear.

Diagnostic results:

  • CT-Scan-pending. The test will be used to rule out any physical symptoms that might cause hallucinations and delusions.
  • Positive and Negative Syndrome Scale (PANSS): Baandrup et al. (2022) noted that PANSS is a valid, scalable, and reliable tool for screening for people with schizophrenia. The authors found that the tool is 98% effective. The patient scored 19.9 on positive scale and 22.3 on negative scale meaning that he has schizophrenia (Baandrup et al., 2022).

Assessment:

Mental Status Examination: He is well-dressed and alert. He answers questions properly. The patient does not know the days of the week. He has hallucinations. He says that he sees people watching him from his window. He even sees a bird during assessment which the interviewer cannot see. He also says that he can hear them. He has delusions. He ways that the people watching him were sent by the government. He also says that these people want to poison his food and that they are plotting with his sister to arrest him. He is forgetful. No homicidal or suicidal thoughts.

Diagnostic Impression:

  1. Schizophrenia
  2. Persecutory Delusion Disorder
  3. Schizoaffective Disorder

The primary diagnosis for the case Sherman’s case is schizophrenia. Ng et al. (2019) noted that symptoms of schizophrenia include catatonic behavior, hallucinations, and disorganized speech. DSM-5 also notes that a person with schizophrenia must have experienced at least two of these symptoms for at least a month. The symptoms include delusions, disorganized speech, hallucinations, negative symptoms, and catatonic behavior (American Psychiatry Association, 2013). One of the symptoms must be either hallucinations, delusions, or disorganized speech. The patient has both delusions and hallucinations making the disorder the primary diagnosis. The second diagnosis is persecutory delusion disorder.  A person with persecutory delusion disorder often believe that people are spying on them, what to poison them, harassed, or conspired against (González-Rodríguez et al., 2019). This disorder is part of the diagnosis because the patient believes that the government is conspiring with his sister to arrest him. However, it is a secondary disorder because the delusions as a result of schizophrenia (American Psychiatry Association, 2013). The last diagnosis is schizoaffective disorder. Schizoaffective disorder causes schizophrenia symptoms and depression (Chandran et al., 2019). The disorder is part of the diagnosis because the patient has schizophrenia symptoms. However, it is a secondary diagnosis because the patient does not show symptoms of depression (American Psychiatry Association, 2013).

Reflections:

I would order for MRI if I was given the patient again. MRI can help identify physical problems impacting the patient’s brain function. An ethical consideration in this case is to do no harm. The medications or treatments I will prescribe for the patient should be in his best interest and do better than harm. I would educate the patient to avoid smoking and taking marijuana because they are not good for this health. Another ethical practice is improving the patient’s knowledge about the medication to ensure that he knows its side effects and benefits to help him make proper decisions regarding his treatment.

Case Formulation and Treatment Plan:

The patient is said to have schizophrenia based on PANSS results and DSM-5 criteria for diagnosing patients with schizophrenia. MRI and CT-scan will provide more information about the patient’s physical brain health. I would recommend that the patient be prescribed Invega Sustenna 234 mg intramuscular X1 for treatment of schizophrenia. The drug has proven effective in improving the symptoms of schizophrenia. Chang et al. (2021) noted that Invega improved social and cognitive functions of people with schizophrenia. The authors recommended the medication as the best drug for people with schizophrenia. The authors found that patients with schizophrenia and had taken Invega had less delusions and hallucinations. They were also more social.

References

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed). Arlington, VA: American Psychiatric Publishing.

Baandrup, L., Allerup, P., Nielsen, M. Ø., Düring, S. W., Bojesen, K. B., Leucht, S., & Glenthøj, B. Y. (2022). Scalability of the Positive and Negative Syndrome Scale in first‐episode schizophrenia assessed by Rasch models. Acta Psychiatrica Scandinavica. https://doi.org/10.1111/acps.13434

Chandran, D., Robbins, D. A., Chang, C. K., Shetty, H., Sanyal, J., Downs, J., & Hayes, R. (2019). Use of natural language processing to identify obsessive compulsive symptoms in patients with schizophrenia, schizoaffective disorder or bipolar disorder. Scientific Reports, 9(1), 1-7. https://www.nature.com/articles/s41598-019-49165-2

Chang, C. L., Huang, Y. C., & Yang, P. (2021). Improving of cognition and quality of life in schizophrenia with one-month and three-month paliperidone palmitate treatment. https://assets.researchsquare.com/files/rs-483945/v1/82e1e8cf-b059-4835-a1f9-79e12decda47.pdf?c=1632299363

González-Rodríguez, A., Esteve, M., Álvarez, A., Guardia, A., Monreal, J. A., Palao, D., & Labad, J. (2019). What we know and still need to know about gender aspects of delusional disorder: a narrative review of recent work. Journal of Psychiatry and Brain Science, 4(3). https://jpbs.hapres.com/UpLoad/PdfFile/jpbs_1023.pdf

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. Neuropsychobiology78(1), 1-6. https://www.karger.com/Article/Abstract/498862

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