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

Eunice

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

Subjective:

CC (chief complaint): “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”: Week (enter week #): Focused Soap Note for Schizophrenia Spectrum, Other Psychotic, and Medication-Induced Movement Disorders.

HPI: Sherman Termaine is aged fifty-six. He is an African American male presenting for psychiatric examination at his sister’s request following strange behaviors and paranoid thoughts. He claims to have had sleeplessness for “weeks and weeks,” persecutory delusions, and ongoing visual and auditory hallucinations.

He believes government agents are surveilling him and manipulating his environment, including his food, television, and tapping his phone. He describes elaborate delusional beliefs involving birds, heavy metal music, and poison. At the age of 20, he experienced three hospitalizations due to mental health issues.

Although he denies having suicidal or homicidal thoughts, he displays disordered thinking and impaired reality testing. The symptoms have significantly affected his social life and daily living.

Substance Current Use: Every day, the patient consumes three packs of cigarettes. Every week, he consumes about a dozen packs of beer. He claims to have used marijuana three years ago, but he denies using cocaine or any other illegal drugs recently.

There have been no reports of seizures, blackouts, or withdrawal symptoms. No prior history of substance-related legal issues or driving under the influence (DUI).

Medical History: The patient has a history of diabetes mellitus, currently managed using metformin. He reports being told he has a fatty liver, though he doubts the accuracy of this diagnosis, and he has no known surgeries.

ROS:

Objective:

Diagnostic Results:

During the current session, no laboratory or imaging tests were reviewed. Nonetheless, further tests may be recommended to provide a thorough diagnostic assessment. Some required tests are a complete blood count, a comprehensive metabolic panel, thyroid-stimulating hormone levels, and a urine drug screen.

It is necessary to perform these investigations to make sure that any medical, endocrine, or drug-related factors are not adding to the psychotic symptoms. When such factors are accounted for, treatment decisions can be made correctly, and diagnostic accuracy can be improved.

Assessment:

Mental Status Examination:

The patient is a middle-aged African American man who presents with just mediocre personal grooming and looks to be his stated age. Although he can be easily distracted and is unaware of the time or date, he is oriented to person and place. He tends to talk quickly, shift from subject to subject and repeats words that sound alike, such as “Clever Sever,” which suggests disorganized thought patterns (Calabrese & Al Khalili, 2023).

His affect is labile and inconsistent with the pervasive paranoid mood already present in the session. The patient displays unorganized and random thinking and is strongly affected by paranoid delusions along with experiencing persecutory feelings.

He explains that he has disturbing experiences of hearing heavy metal music and many voices that wake him for several days and seeing birds and shadows outside his window, which he thinks are spies sent by the government. Insight and judgment are markedly impaired; however, he disputes having thoughts of suicide or homicide. Memory is grossly intact, though his concentration remains poor.

Diagnostic Impression:

Primary Diagnosis

The primary diagnosis is Paranoid Schizophrenia (F20.0). The patient satisfies the DSM-5-TR criteria for schizophrenia, which include hallucinations, delusions, disordered thought patterns, and negative symptoms of social withdrawal, persisting for over one month with impaired functioning (Kakar et al., 2023).

Auditory hallucinations, paranoid delusions, and flat affect support this. Rule-outs for other psychotic disorders were considered based on timeline, content, and severity. The duration, severity, and significant impact on functioning, in addition to the patient’s father’s family history of paranoid schizophrenia, support a primary diagnosis of schizophrenia.

Differential Diagnoses

One of the differential diagnoses is substance/medication-induced psychotic disorder (F19.959). While he reports regular alcohol and tobacco use, there is no clear temporal connection between substance use and the start of psychotic symptoms. He denies recent use of illicit drugs such as marijuana or cocaine and does not present with signs of intoxication or withdrawal symptoms.

Additionally, the persistence and chronic nature of presenting with hallucinations, delusions, and disorganized thought processes occur independently of any substance influence (Fiorentini et al., 2021). This diagnosis is disregarded because of the lack of direct substance-related symptom causation.

The other differential diagnosis is delusional disorder (F22). The patient presents with persistent, fixed paranoid delusions involving government surveillance and poisoning. However, he also exhibits multiple hallmark features that exceed the diagnostic boundaries of delusional disorder, including auditory hallucinations, visual illusions, severely disorganized thought processes, and markedly impaired functioning.

Based on DSM-5-TR criteria, delusional disorder excludes the existence of notable hallucinations and significant functional decline, which are both evident in this case (Joseph & Siddiqui, 2023). Therefore, this diagnosis is also ruled out.

A third differential diagnosis is schizoaffective disorder (F25.0). This condition involves psychotic symptoms concurrent with mood episodes (Wy & Saadabadi, 2023). Although the patient displays clear evidence of psychosis, including hallucinations and delusions, a substantial amount of the illness duration is spent in a major mood episode that does not meet the DSM-5-TR criteria.

He shows no clinical indication of sustained depressive or manic symptoms, either as reported or observed. Considering that psychotic symptoms predominate and mood disturbances are absent, this diagnosis is unlikely and is ruled out in favor of a primary psychotic disorder.

Reflections:

Given that another session was to be held again, I would prioritize building a stronger therapeutic alliance before addressing the patient’s delusional content, as this approach could help minimize resistance and promote trust. Additionally, getting collateral information from the patient’s sister would be essential to assess his capacity to perform activities of daily living and evaluate safety concerns more comprehensively.

From an ethical standpoint, it is essential to consider the potential need for involuntary treatment, given the patient’s impaired insight, presence of hallucinations, and high risk of self-neglect. Cultural sensitivity should be exercised by acknowledging the patient’s unique communication style and underlying distrust, which may reflect a more profound sense of vulnerability.

Given his limited educational attainment and socioeconomic challenges, all health education should be delivered using clear, straightforward language to ensure understanding. Legal issues could require establishing guardianship or recommending help from community-based mental health organizations. To achieve a full recovery, health promotion activities should look after his mental health and manage his diabetes at the same time.

Case Formulation and Treatment Plan:

The treatment plan recommends individual cognitive behavioral therapy for psychosis as well as psychosocial education to help the patient understand his condition, challenge his beliefs, and take his medication regularly. A low dose of quetiapine needs to be given at the start, gradually increased according to the patient’s response, and monitored for signs of side effects (Maan & Saadabadi, 2023).

Considering the previous adverse reactions to haloperidol and risperidone, they should be avoided. For non-pharmacologic care, the patient could be allowed to join a smoking cessation program and follow an alcohol harm-reduction strategy. Mindfulness-based stress reduction activities will be shared with the patient to help manage paranoia and improve sleep routines.

After one week, the response to symptoms will be reassessed and metabolic tests revisited. At the same time, diabetes and liver monitoring and health promotion will be coordinated with the primary provider, focusing on making healthy choices, changing diet, exercising, and arranging for resource crisis management support.

References

Calabrese, J., & Al Khalili, Y. (2023, May 1). Psychosis. Nih.gov; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK546579/

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.2021.694863

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

Kakar, G., Mehendale, A. M., Sadh, K., Bakshi, S. S., Bodke, H., & Krishnani, H. (2023). A phenomenal depiction of paranoid schizophrenia with auditory hallucinations: A case report. Cureus, 15(9). https://doi.org/10.7759/cureus.46092

Maan, J. S., & Saadabadi, A. (2023). Quetiapine. PubMed; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK459145/

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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Question 

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.
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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.

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

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).

Resources:

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