Week (enter week #): Focused SOAP Note for Schizophrenia Spectrum, Other Psychotic, and Medication-Induced Movement Disorders

Subjective

CC (chief complaint): “My sister made me come in. People will not leave me alone. They are watching me.”

HPI

Mr. Sherman Tremaine is a 56-year-old white male who has been presented for psychological assessment at the request of his sister. He describes continuing distressing experiences, such as thoughts that people are observing him along the window and TV and hearing voices and heavy metal music. He reports delusions involving government monitoring and food poisoning. These symptoms have lasted several weeks since they were not known to have started, but it was reported that it has gotten worse since his mother died: Week (enter week #): Focused SOAP Note for Schizophrenia Spectrum, Other Psychotic, and Medication-Induced Movement Disorders.

He experiences insomnia due to the voices and expresses strong distrust of medications, reporting that risperidone caused breast development and that haloperidol and chlorpromazine are “poison.” He notes tolerating quetiapine in the past but remains reluctant to take medications. These symptoms are causing functional impairment, including social withdrawal and difficulty managing daily activities such as grocery shopping.

Substance Current Use

Mr. Tremaine smokes three packs a day of cigarettes and a 12-pack of beer every week, supplied by his sister. He documents the termination of marijuana smoking three years back and denies using cocaine or other illegal drugs. He does not experience withdrawal effects, lapses, or legal charges of substances.

Medical History

Has type 2 diabetes mellitus, controlled using metformin. Report fatty liver non-confirmed diagnosis. No known operations.

• Current Medications: Metformin (dose unspecified); refuses antipsychotics due to perceived side effects and distrust.
• Allergies: No known drug, food, or environmental allergies reported.

• Reproductive Hx: Never married, no children, not sexually active. Reproductive health not applicable.

ROS

• GENERAL: No fever, chills, or fatigue.
• HEENT: No vision or hearing loss reported; acknowledges auditory hallucinations.
• SKIN: No rash or itching.

• CARDIOVASCULAR: No chest pain or palpitations.

• RESPIRATORY: No cough or shortness of breath.
• GASTROINTESTINAL: No nausea, vomiting, or abdominal pain.
• GENITOURINARY: No urinary symptoms.
• NEUROLOGICAL: Denies headaches, seizures, or weakness.
• MUSCULOSKELETAL: No joint or muscle pain.
• HEMATOLOGIC: Denies bruising or bleeding.
• LYMPHATICS: No known lymphadenopathy.
• ENDOCRINOLOGIC: History of diabetes mellitus, denies polydipsia or weight changes.

Objective

Diagnostic Results

There are no laboratory results, imaging, or other diagnostic tests available for review at this visit. All clinical impressions are based on the psychiatric interview and mental status examination.

Assessment

Mental Status Examination

Mr. Tremaine appears the stated age, is casually dressed, and displays poor eye contact. He is alert and cooperative but displays circumstantial and tangential speech. His mood is anxious, and his affect is blunted but congruent. He demonstrates paranoid delusions (e.g., being surveilled, poisoned) and auditory hallucinations (voices, music) and reports visual misperceptions (shadows).

Thought processes are disorganized. Insight and judgment are impaired. He is oriented to person and place but not fully to time. No suicidal or homicidal ideation is present. Cognition and memory appear grossly intact, though clouded by psychotic symptoms.

Diagnostic Impression

Primary Diagnosis: Schizophrenia, Paranoid Type – ICD-10 Code: F20.0

Mr. Tremaine meets DSM-5-TR criteria for schizophrenia, with prominent delusions and hallucinations persisting over a significant duration, coupled with disorganized speech and social/occupational dysfunction (Hany et al., 2024). His functional decline, family history (father with schizophrenia), and early hospitalization history further support this diagnosis.

Differential Diagnoses

• Schizoaffective Disorder – ICD-10 Code: F25.0: Ruled out due to lack of mood episodes meeting criteria for major depression or mania concurrent with psychotic symptoms (Wy & Saadabadi, 2023).
• Delusional Disorder, Persecutory Type – ICD-10 Code: F22: Considered due to the intensity of paranoid ideation, but the presence of auditory hallucinations and disorganized thinking exceeds the DSM-5-TR criteria for this diagnosis (Joseph & Siddiqui, 2023).
• Substance/Medication-Induced Psychotic Disorder – ICD-10: F11.959 (Alcohol-related): Considered due to alcohol use. However, psychotic symptoms predate use and persist beyond intoxication. DSM-5-TR excludes diagnosis if psychosis is independent of substance (Fiorentini et al., 2021).

Critical Thinking Summary

Schizophrenia is the most fitting diagnosis due to the full spectrum of positive symptoms and social dysfunction. Alternative diagnoses were excluded based on the absence of mood episodes or limited scope of psychosis. The chronicity and genetic predisposition lend additional support.

Reflections

If I were to conduct this session again, I would incorporate structured symptom rating tools such as the PANSS to better assess severity and track progress. I would emphasize motivational interviewing to address the patient’s medication resistance. My next steps would include evaluating him for Assisted Outpatient Treatment if he continues to deny care despite the risk.

Legal and Ethical Considerations

Given the extent of the patient’s impaired insight and psychosis, issues of capacity and treatment adherence must be addressed. If Mr. Tremaine becomes a danger to himself or others, involuntary commitment or guardianship may be necessary. Monitoring for medication compliance without coercion remains ethically challenging.

Health Promotion and Disease Prevention Considerations:

His age, history of trauma, substance use, socioeconomic constraints, and chronic illness (diabetes) require a comprehensive and culturally sensitive approach. Consistent monitoring and interprofessional collaboration are crucial to preventing relapse and hospitalization.

Case Formulation and Treatment Plan

Psychotherapy Plan

Mr. Tremaine will begin Cognitive Behavioral Therapy for Psychosis (CBTp), which is effective in addressing delusional thinking and promoting insight. This therapy will help him challenge hallucinations and reduce distressing symptoms (Chand et al., 2023). Given his distrust of the system, building rapport early is essential to engagement.

Pharmacologic Treatment

Quetiapine (Seroquel) will be started at 50 mg twice daily. It was previously tolerated and is associated with a lower risk of extrapyramidal symptoms (Maan et al., 2024). The patient will be monitored for side effects, including sedation, weight gain, and glucose elevation.

Nonpharmacologic Treatment

The patient will be referred for smoking cessation support due to his three-pack-per-day use. Community mental health services will assist in managing daily functioning and compliance. Nutritional counseling will also support his diabetic care.

Follow-Up Parameters

Weekly follow-ups will monitor treatment response. Labs for glucose, liver, and lipids will be drawn. A social worker will assess his living and support needs.

Health Promotion Activity

The patient will receive education on smoking and alcohol risks. These substances worsen psychosis and diabetes. Thus, reducing use will enhance outcomes.

Patient Education Strategy

Education will use clear, simple language. His sister will be involved, with consent, to enhance understanding. Visual aids will reinforce concepts and improve compliance.

References

Chand, S. P., Kuckel, D. P., Huecker, M. R. (2023, May 23). Cognitive behavior therapy. PubMed. https://pubmed.ncbi.nlm.nih.gov/29261869/

Fiorentini, A., Cantù, F., Crisanti, C., Cereda, G., Oldani, L., & Brambilla, P. (2021). Substance-induced psychoses: An updated literature review. Frontiers in Psychiatry, 12(12). https://doi.org/10.3389/fpsyt.2021.69486

Hany, M., Rehman, B., Azhar, Y., & Chapman, J. (2024, February 23). Schizophrenia. NIH.gov; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK539864/

Joseph, S. M., & Siddiqui, W. (2023). Delusional disorder. National Library of Medicine; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK539855/

Maan, J. S., Ershadi, M., Khan, I., & Saadabadi, A. (2024). Quetiapine. PubMed; StatPearls Publishing. https://pubmed.ncbi.nlm.nih.gov/29083706/

Wy, T. J. P., & Saadabadi, A. (2023, March 27). Schizoaffective disorder. Nih.gov; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK541012/

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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.

Resources

• Be sure to review the Learning Resources before completing this activity.
• Click the weekly resources link to access the resources.

To Prepare

• 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.
  

  Week (enter week #): Focused SOAP Note for Schizophrenia Spectrum, Other Psychotic, and Medication-Induced Movement Disorders

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.
• 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).