Week 5- Focused Soap Note for Schizophrenia Spectrumother Psychotic, and Medication-Induced Movement Disorders

Week 5- Focused Soap Note for Schizophrenia Spectrumother Psychotic, and Medication-Induced Movement Disorders

PATIENT INFORMATION

Name: Sherman Tremaine

Age: 35 years

Gender: Male

Ethnicity: Caucasian

Occupation: Unemployed

Subjective:

CC (chief complaint):

The patient has delusions, hallucinations, and difficulty with movements. He says, “Those people, they just won’t leave me alone. The ones outside my window watching. They watch me. I can hear them and see their shadows. They think I don’t. Do you see that bird?”

HPI:

Mr. Tremaine reports experiencing delusions and hallucinations for the past six months, feeling paranoid and believing that there are people watching him. He describes auditory hallucinations commenting negatively about his deeds. Furthermore, he has been experiencing tremors and muscle stiffness that have been at their peak over the past few weeks, affecting his ability to function. These symptoms are distressing and alter with their routine schedule.

Substance Current Use:

Mr. Tremaine reports cigarette smoking, where he states that he uses three packs of cigarettes daily along with alcohol consumption of an estimated amount of twelve packs weekly. He declines recent use of hard substances such as marijuana, cocaine, or opioids. He reports no history of blackouts, seizures, or hallucinations attributed to substance use.

Medical History: 

• Current Medications: The patient is currently on Haldol, Thorazine, and risperidone. However, he reports non-compliance to the therapeutic medications due to the perceived adverse drug side effects. The patient says that he uses metformin for diabetes.
• Allergies:  Mr. Tremaine has no known history of any food or drug allergy.
• Reproductive Hx:  Mr. Tremaine has no significant reproductive history since he has never been married and has no children.

ROS:

• GENERAL: Mr. Tremaine appeared tousled and agitated during the assessment. The patient stated age corresponds to their look, and they have no scars or bruising on their body.
• HEENT: No specific complaints were reported, both eyes were present with no discharge, and the patient reported no visual loss. The sclerae are normal, with no paleness or jaundice. The ears present have normal symmetry and no rings or piercings. No discharge or reported hearing loss. The nose is present, a normal nasal septum is situated correctly, and no running nose or congestion was observed. No horseness was observed in the throat, and a sore throat was reported.
• SKIN: The skin has normal compression with no paintings or tattoos on it. No scars, bruising, or open wounds were observed. No skin rash or itching from the patient. There is no paleness observed.
• CARDIOVASCULAR: The patient reports no pain, pressure, tightness, or any chest discomfort. The are normal chest movements observed and no palpitations or edema. Their normal respiratory rate was observed.
• RESPIRATORY: No difficulty in breathing was reported. There is no shortness of breath, dyspnea, or labored breathing. No coughing or sputum was produced during the assessment. No abnormal chest sounds were produced during the auscultation of the chest.
• GASTROINTESTINAL: Normal eating habits were evidenced by the normal weight of the patient observed. No anorexia, nausea, vomiting, or diarrhea. No abdominal pain or passing of bloody stool. There is no change in bowel habits.
• GENITOURINARY: The patient reports no burning sensation during urination, no urgency to micturate, no significant change in the color of urine, and no hematuria reported. No incontinence evident.
• NEUROLOGICAL:  The patient reports no headache, dizziness, syncope paralysis, ataxia, numbness, or tingling in the extremities. There is normal bowel and bladder control.
• MUSCULOSKELETAL: No back pain or joint pain was reported. However, tremors and muscle rigidity were observed during the examination.
• HEMATOLOGIC:  The patient reports no signs related to the hematological system. No anemia, bleeding, or bruising was observed.
• LYMPHATICS: No enlarged lymph nodes. No history of splenectomy.
• ENDOCRINOLOGIC: No reports of sweating, cold, or heat intolerance. No polyuria or polydipsia.

Objective:

Diagnostic results:

The toxicology test was done to help rule out the possibility of having a drug-induced psychosis.

Assessment:

Mental Status Examination:

The 35-year-old American male appears to be the stated age and groomed appropriately for the weather. He displays psychomotor agitation by frequently fidgeting and shifting in his seat during the assessment. His attitude towards the examiner is initially cooperative but later displays a sign of agitation. The speech is goal-oriented and coherent. Mr. Tremaine’s rate of speech is increased, suggesting underlying anxiety or agitation. He occasionally becomes tangential, particularly when discussing his delusional beliefs.

Mr. Tremaine’s mood appears anxious and apprehensive, with affect labile, shifting between periods of guardedness and moments of intensity when discussing his paranoid delusions. Further, his thought process is predominantly linear, but he frequently exhibits tangentiality when discussing his delusional beliefs about being watched by unspecified individuals outside his window. He displays circumstantiality, providing excessive detail when describing his experiences.

Regarding the thought content, Mr. Tremaine presents with paranoid delusions, believing that people are watching him and plotting against him. He reports auditory hallucinations, commenting negatively about his actions, indicating the presence of persecutory delusions. Additionally, he expresses concerns about government surveillance and conspiracy theories. Regarding perception, Mr. Tremaine reports auditory hallucinations and hearing voices commenting negatively about his actions. He also reports visual hallucinations, describing shadows and movements outside his window that he interprets as people watching him.

Regarding cognition, Mr. Tremaine is oriented to person, place, and time, correctly identifying himself, the location, and the approximate date. His attention appears intact, as evidenced by his ability to engage in conversation and follow instructions during the assessment. Mr. Tremaine’s immediate and recent memory appears intact as he accurately recalls personal details and recent events. In addition, Mr. Tremaine demonstrates poor insight into the nature of his symptoms, attributing them to external factors such as government surveillance rather than recognizing them as manifestations of his mental illness. Judgment appears impaired, as evidenced by his refusal to engage in recommended treatment and his belief in conspiracy theories. Nonetheless, Mr. Tremaine denies current suicidal or homicidal ideation during the assessment. He reports no history of self-harm or harming others.

Noting the overall impression, Mr. Tremaine presents with symptoms consistent with a psychotic disorder characterized by paranoid delusions, auditory and visual hallucinations, and impaired insight. His thought content is dominated by persecutory on addressing his psychotic symptoms while addressing his reluctance to engage in the treatment, collaboration with family members, and consideration of involuntary hospitalization may be necessary to ensure his safety and well-being.

Differential Diagnoses

The results of the mental status examination of Mr. Tremaine reveal findings that justify a discussion on possible consideration of multiple differential diagnoses as outlined below in order of their priority.

• Paranoid Schizophrenia

Paranoid schizophrenia is characterized by the presence of pertinent positive symptoms such as paranoid delusions (Mr. Tremaine believes that people are watching him), auditory and visual hallucinations (Mr. Tremaine hears voices commenting negatively about him and sees shadows and movements), impaired insight, and poor judgment (attributing the symptoms to external factors). The pertinent negative is that the patient has no current suicidal or homicidal ideation and has intact orientation, attention, and memory. These presentations align with the DSM-5 criteria on paranoid schizophrenia, which stipulates that symptoms include delusions or auditory hallucinations, along with disorganized thinking and negative symptoms.

• Delusional Disorder

Delusional disorder is characterized by the pertinent positive of delusions with intact memory, attention, and orientation. The pertinent negatives are auditory and visual hallucinations, impaired insight, and poor judgment. The DSM-5 criteria for delusional disorder states that for a person to make a diagnosis of delusional disorder, there has to be one or more delusions for at least one month without other prominent psychotic symptoms. This is contrary to Mr. Tremaine’s case, who has hallucinations, consequently making delusional disorder to be ruled out.

• Schizoaffective Disorder

The pertinent positives include paranoid delusions and auditory and visual hallucinations. The pertinent negative is that the patient has no mood symptoms observed during the assessment. These findings are contrary to the DSM-5 criteria that suggest that there have to be psychotic symptoms together with mood episodes such as manic, depressive, or mixed episodes. The absence of this makes schizoaffective disorder less likely to be the diagnosis.

Diagnostic Impression:

Mr. Tremaine reports symptoms most consistent with psychotic disorder, most consistent with schizophrenia spectrum disorder, and paranoid type, which includes delusions. He believes that he is being watched by and monitored by unspecified individuals. He expresses the fixed false belief of others conspiring against him; these are paranoid delusions commonly seen in schizophrenia. He also reports auditory hallucinations, hearing voices commenting negatively about him, as well as visual hallucinations, perceiving shadows and movements outside his window. He also portrays disorganized thinking as well as impaired insight concerning his disease, where he attributes his symptoms to external factors such as government surveillance rather than recognizing them as manifestations of a mental disorder.

Reflections:

Given the duration of these symptoms, severity, and impact of his symptoms on functioning, a diagnosis of schizophrenia spectrum disorder, the paranoid type, is most appropriate. It is important to consider features of other psychotic disorders and mood disorders with psychotic features and rule out substance-induced psychosis. Collaborative treatment involving pharmacotherapy, psychoeducation, and psychosocial interventions is effective in Mr. Tremaine’s case to improve his overall functioning and quality of life. In the next session, I would make the assessment flow like a story to allow the patient to express himself without being limited by the questions that might irritate him or lower his concentration levels. Lastly, I would also ask the patient if he would wish to stop smoking and taking alcohol; this would give an indication to take him through a rehabilitation program.

Case Formulation and Treatment Plan:

Mr. Tremaine, a 35-year-old caucasian male, presents with symptoms of schizophrenia spectrum disorder. He has a clinical presentation of paranoid delusions, auditory and visual hallucinations, disorganized thinking, and impaired insight. He has distress and functional impairment due to his psychotic symptoms, including social withdrawal and difficulty maintaining daily activities.

Treatment Plan:

• Pharmacotherapy: Due to the experience of Mr. Tremaine with the current medication, a second-line antipsychotic agent such as risperidone and olanzapine should be considered to manage the symptoms and stabilize the patient. Close monitoring of the patient should be present to ensure compliance and adverse side effects (Grover & Avasthi, 2019).
• Psychoeducation: It is important to do psychotherapeutic education to the patient to improve the patient’s insight into the condition, improve his coping mechanisms, and alleviate his anxiety and depressive symptoms (Prusiński, 2022).
• Individual and family therapy: For individual therapy, cognitive-behavioral therapy will be used to help the patient reframe and challenge his delusional beliefs, reduce distress related to hallucinations, and improve insight into his disorder (Karukivi et al., 2021). On the other hand, the patient’s family will be involved in the treatment to help provide support, improve understanding of the illness, and improve communication. Family therapy will focus on communication skills, psychoeducation, and problem-solving strategies (Varghese et al., 2020).
• Alternative therapy: Alternative therapies can be used to help Mr. Tremaine manage stress, reduce anxiety, and increase awareness of his thoughts and emotions. These therapies may include the use of art therapy as a complementary approach to express emotions, reduce distress, and enhance self-expression.
• Follow-up parameters: The reason for follow-up is to conduct regular psychiatric evaluations to assess medication efficacy, side effects, and symptom severity. It also helps evaluate adherence to medication and engagement in psychotherapy, assess the overall functioning, as well as identify areas that need further intervention.

Rationale for the treatment plan and management

The combination of pharmacological and non-pharmacological therapies intends to address the reduction of symptoms of paranoid schizophrenia as well as improve functionality. The use of antipsychotics aims to alleviate positive symptoms, while the non-pharmacologic aims to improve insight, coping skills, and underlying cognitive distortions. Involving family members promotes a supportive environment. Lastly, alternative therapies are rationalized by offering complementary ways for symptom management and self-expression.

References

Grover, S., & Avasthi, A. (2019). Clinical practice guidelines for the management of schizophrenia in children and adolescents. Indian Journal of Psychiatry, 61(8), 277. https://doi.org/10.4103/psychiatry.indianjpsychiatry_556_18

Karukivi, J., Herrala, O., Säteri, E., Tornivuori, A., Salanterä, S., Aromaa, M., Kronström, K., & Karukivi, M. (2021). The effectiveness of individual mental health interventions for depressive, anxiety and conduct disorder symptoms in school environment for adolescents aged 12–18—A systematic review. Frontiers in Psychiatry, 12. https://doi.org/10.3389/fpsyt.2021.779933

Prusiński, T. (2022). The strength of alliance in individual psychotherapy and patient’s wellbeing: The relationships of the therapeutic alliance to psychological wellbeing, satisfaction with life, and flourishing in adult patients attending individual psychotherapy. Frontiers in Psychiatry, 13. https://doi.org/10.3389/fpsyt.2022.827321

Varghese, M., Kirpekar, V., & Loganathan, S. (2020). Family interventions: Basic principles and techniques. Indian Journal of Psychiatry, 62(2), 192–200. https://doi.org/10.4103/_770_19

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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 rule 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).