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.(Focused SOAP Note for Schizophrenia Spectrum Comprehensive Essay)

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. (Focused SOAP Note for Schizophrenia Spectrum Comprehensive Essay)

RESOURCES

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

WEEKLY 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.(Focused SOAP Note for Schizophrenia Spectrum Comprehensive Essay)
• 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?(Focused SOAP Note for Schizophrenia Spectrum Comprehensive Essay)
• 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.(Focused SOAP Note for Schizophrenia Spectrum Comprehensive Essay)
• 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.).(Focused SOAP Note for Schizophrenia Spectrum Comprehensive Essay)
• 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 INFORMATION

Before submitting your final assignment, you can check your draft for authenticity. To check your draft, access the Turnitin Drafts from the Start Here area. 

1. To submit your completed assignment, save your Assignment as WK5Assgn_LastName_Firstinitial
2. Then, click on Start Assignment near the top of the page.
3. Next, click on Upload File and select Submit Assignment for review.

Rubric

NRNP_6675_Week5_Assignment_Rubric

NRNP_6675_Week5_Assignment_Rubric

CriteriaRatingsPts

This criterion is linked to a Learning OutcomeCreate 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(Focused SOAP Note for Schizophrenia Spectrum Comprehensive Essay)

15 to >13.0 pts

Excellent 90%–100%

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.(Focused SOAP Note for Schizophrenia Spectrum Comprehensive Essay)

13 to >11.0 pts

Good 80%–89%

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.(Focused SOAP Note for Schizophrenia Spectrum Comprehensive Essay)

11 to >10.0 pts

Fair 70%–79%

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.(Focused SOAP Note for Schizophrenia Spectrum Comprehensive Essay)

10 to >0 pts

Poor 0%–69%

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.(Focused SOAP Note for Schizophrenia Spectrum Comprehensive Essay)

15 pts

This criterion is linked to a Learning OutcomeIn 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(Focused SOAP Note for Schizophrenia Spectrum Comprehensive Essay)

15 to >13.0 pts

Excellent 90%–100%

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

13 to >11.0 pts

Good 80%–89%

The response accurately documents the patient’s physical exam for pertinent systems. Diagnostic tests and their results are accurately documented.(Focused SOAP Note for Schizophrenia Spectrum Comprehensive Essay)

11 to >10.0 pts

Fair 70%–79%

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.(Focused SOAP Note for Schizophrenia Spectrum Comprehensive Essay)

10 to >0 pts

Poor 0%–69%

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.(Focused SOAP Note for Schizophrenia Spectrum Comprehensive Essay)

15 pts

This criterion is linked to a Learning OutcomeIn 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.(Focused SOAP Note for Schizophrenia Spectrum Comprehensive Essay)

20 to >17.0 pts

Excellent 90%–100%

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.(Focused SOAP Note for Schizophrenia Spectrum Comprehensive Essay)

17 to >15.0 pts

Good 80%–89%

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.

15 to >13.0 pts

Fair 70%–79%

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.(Focused SOAP Note for Schizophrenia Spectrum Comprehensive Essay)

13 to >0 pts

Poor 0%–69%

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.(Focused SOAP Note for Schizophrenia Spectrum Comprehensive Essay)

20 pts

This criterion is linked to a Learning OutcomeIn 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.(Focused SOAP Note for Schizophrenia Spectrum Comprehensive Essay)

25 to >22.0 pts

Excellent 90%–100%

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.(Focused SOAP Note for Schizophrenia Spectrum Comprehensive Essay)

22 to >19.0 pts

Good 80%–89%

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.

19 to >17.0 pts

Fair 70%–79%

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.(Focused SOAP Note for Schizophrenia Spectrum Comprehensive Essay)

17 to >0 pts

Poor 0%–69%

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.(Focused SOAP Note for Schizophrenia Spectrum Comprehensive Essay)

25 pts

This criterion is linked to a Learning Outcome• Discussion include what may be done differently with this patient if student conducted the session again. Discussed the next intervention if you could follow up with this patient. The discussion was related to legal/ethical considerations (demonstrated critical thinking beyond confidentiality and consent for treatment!), social determinates of health, health promotion, and disease prevention that take into consideration patient factors (such as age, ethnic group, etc.), PMH, and other risk factors (e.g., socioeconomic, cultural background, etc.).(Focused SOAP Note for Schizophrenia Spectrum Comprehensive Essay)

5 to >4.0 pts

Excellent 90%–100%

Reflections are thorough, thoughtful, and demonstrate critical thinking. Reflections contain a discussion of all elements described within assignment directions.

4 to >3.5 pts

Good 80%–89%

Reflections demonstrate critical thinking. Reflections contain 2 out of 3 (legal/ethical considerations, social determinate of health, health promotion) with consideration of patient factors and risk factors.

3.5 to >3.0 pts

Fair 70%–79%

Reflections are somewhat general or do not demonstrate critical thinking. Reflections contain 2 out of 3 (legal/ethical considerations, social determinate of health, health promotion) without consideration of patient factors and risk factors.

3 to >0 pts

Poor 0%–69%

Reflections are incomplete, inaccurate, or missing.

5 pts

This criterion is linked to a Learning OutcomeProvide 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).

10 to >8.0 pts

Excellent 90%–100%

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 to >7.0 pts

Good 80%–89%

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 to >6.0 pts

Fair 70%–79%

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.(Focused SOAP Note for Schizophrenia Spectrum Comprehensive Essay)

6 to >0 pts

Poor 0%–69%

Two or fewer resources are provided to support the assessment and diagnosis decisions. The resources may not be current or evidence based.(Focused SOAP Note for Schizophrenia Spectrum Comprehensive Essay)

10 pts

This criterion is linked to a Learning OutcomeWritten Expression and Formatting – The paper follows correct APA format for parenthetical/in-text citations and reference list.(Focused SOAP Note for Schizophrenia Spectrum Comprehensive Essay)

5 to >4.0 pts

Excellent 90%–100%

Uses correct APA format with no errors

4 to >3.5 pts

Good 80%–89%

Contains 1-2 APA format for parenthetical/in-text citations and reference list errors

3.5 to >3.0 pts

Fair 70%–79%

Contains 3-4 APA format for parenthetical/in-text citations and reference list errors

3 to >0 pts

Poor 0%–69%

Contains five or more APA format for parenthetical/in-text citations and reference list errors

5 pts

This criterion is linked to a Learning OutcomeWritten Expression and Formatting – English Writing Standards: Correct grammar, mechanics, and punctuation(Focused SOAP Note for Schizophrenia Spectrum Comprehensive Essay)

5 to >4.0 pts

Excellent 90%–100%

Uses correct grammar, spelling, and punctuation with no errors

4 to >3.5 pts

Good 80%–89%

Contains 1-2 grammar, spelling, and punctuation format errors

3.5 to >3.0 pts

Fair 70%–79%

Contains 3-4 grammar, spelling, and punctuation format errors

3 to >0 pts

Poor 0%–69%

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

5 pts

Total Points: 100

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Focused SOAP Note for Schizophrenia Spectrum Comprehensive Essay

Focused SOAP Note for Schizophrenia Spectrum, Other Psychotic, And Medication-Induced Movement Disorders

Schizophrenia is a severe mental condition that impacts a person’s thoughts, feelings, and actions. Individuals with schizophrenia may appear to have lost all sense of reality, which can upset them and their loved ones (NIMH, 2023). Participating in regular, everyday activities may be challenging for someone with schizophrenia, but effective therapies are available. Many persons who receive treatment can participate in school or the workforce, become independent, and value their connections with others. Even though the disease’s prevalence varies worldwide, estimates suggest that schizophrenia affects about 1% of adults worldwide, compared to 0.6 to 1.9% in the U.S. (Hany et al., 2023). African-Caribbean migrants and their descendants have a higher incidence, and men are marginally inclined to be diagnosed and experience an earlier onset than women. This paper intends to offer a comprehensive patient assessment per the case video.(Focused SOAP Note for Schizophrenia Spectrum Comprehensive Essay)

Identifying Data:

Name: Sherman Tremaine (S.T.)  DOB: November 3, 1968, Minor: No Age: 55 Years Gender: Male

Accompanied by: None

SUBJECTIVE:

HPI: S.T., a 55-year-old male, presents at the clinic complaining that people outside will not leave him alone. The patient believes people are watching him outside his window. The patient also reports hearing and seeing their shadows and that those people think he cannot see them. He believes the government sent them to watch him because his taxes are high. The patient reports seeing and hearing those people for weeks. At the office, the patient insinuates the presence of heavy metal music, which he believes those watching him want him to think is weak, but it is heavy. S.T. struggles to fall or stay asleep because he hears loud voices, which keep him up for days. He also believes those people are watching him through the T.V. screen and come in to poison his food. He thinks he tricked them by locking everything in the fridge where they cannot reach. S.T. does not go to the grocery store as he claims they play heavy metal music, and the people he sees and hears follow him there. The patient reports being prescribed Haldol, Thorazine, Risperidone, and Seroquel but will not take them because he believes they are poison. The patient reports positive for diabetes and takes metformin to manage it. The patient reports having a fatty liver, as per the doctors, but he has never seen it and thinks the aliens told the doctors so. The patient believes that his sister and the government are collaborating to ensure he does not live alone, and they have tapped his phone for the same reason.(Focused SOAP Note for Schizophrenia Spectrum Comprehensive Essay)

CC: “My sister told me to come, and those people won’t leave me alone.”

Past Psychiatric History:

General statement: The patient appears to have received a schizophrenia psychiatric evaluation and diagnosis per the prescribed medications.(Focused SOAP Note for Schizophrenia Spectrum Comprehensive Essay)

Caregiver: The sister is the caregiver.

            Hospitalization: Patient was hospitalized three times when he was 20.

Medication trials: No previous medical trails

Psychotherapy or Previous Psychiatric Diagnosis: Previous psychiatric diagnosis for schizophrenia.

Substance Current Use: Patient reports smoking all day, three packs daily. He also drinks 12 packs a week. The last time drinking was yesterday. The last time he used marijuana was three years ago when his mom died. Patient denies using cocaine and other drugs.(Focused SOAP Note for Schizophrenia Spectrum Comprehensive Essay)

Medical History: Reports positive for diabetes.

• Current Medications: The patient takes metformin for diabetes.
• Allergies:
• Reproductive Hx:

Development Milestones: Not reported.

Health Promotion: Not reported.

Legal History: The patient denies any legal issues or DUIs from drugs and alcohol. He denies any conviction, but reports he would be convicted if he did not stop calling 911 about the people he believes are watching him outside.

Family Psychiatric/Substance Use History: Patient reports father had paranoid schizophrenia and was hospitalized. His mom had anxiety. Patient denies suicide by blood relatives.(Focused SOAP Note for Schizophrenia Spectrum Comprehensive Essay)

Psychosocial History: The patient was raised by his mother and sister. Currently, the patient lives alone. The patient denies ever being married or having any children. He reached 10th grade and reported not working. He smokes and drinks pop for fun. The patient reports that the dad was rough on them before he died.(Focused SOAP Note for Schizophrenia Spectrum Comprehensive Essay)

ROS:  

General: Denies weight loss, 3 pounds in the last three weeks. Denies fever, chills, weakness, or fatigue.

HEENT: Eyes: Denies visual loss, blurred vision, double vision, or yellow sclerae. Ears, Nose, Throat: No hearing loss, sneezing, congestion, runny nose, or sore throat.

Skin: No rash or itching.

Cardiovascular: Denies chest pain, chest pressure, or chest discomfort. No palpitations or edema.

Respiratory: Denies wheezes, shortness of breath, consistent coughs, and breathing difficulties while resting.

Gastrointestinal: No anorexia, nausea, vomiting, or diarrhea. No abdominal pain or blood.

Genitourinary: Denies burning on urination, urgency, hesitancy, odor, and odd color.(Focused SOAP Note for Schizophrenia Spectrum Comprehensive Essay)

Neurological: Denies headache, dizziness, syncope, paralysis, ataxia, numbness, or tingling in the extremities. No change in bowel or bladder control.

Musculoskeletal: Denies muscle, back pain, joint pain, or stiffness.

Hematologic: Denies anemia, bleeding, or bruising.

Lymphatics: Denies enlarged nodes. No history of splenectomy.

Endocrinologic: Denies Sweating, No reports of cold or heat intolerance. No polyuria or polydipsia.

Psychiatric: The patient reports seeing and hearing people, whom he believes are watching him from the window and the T.V. screen. S.T. struggles to fall or stay asleep because he hears loud voices, which keep him up for days. Denies self-harm. Patient denies suicidal ideation.

OBJECTIVE:

Vital signs: Stable

Temp: 98.4F

            B.P.: 120/80

            P: 84

             R.R.: 18

             O2: Room air

             Pain: 0/10

             Ht: 5’10 feet

             Wt: 267 lbs

             BMI: 38.3

             BMI Range: Obese

Physical Exam:

General appearance: Patient is alert and oriented to self but not to time, date, and place. The patient is modestly dressed, but the hair is untidy. The patient appears overweight, supported by the BMI, which indicates the patient is obese. His conversation and engagement with the interviewer are regular, and he responds well to the questions, requiring no intervention. The patient was fully attentive during the interview.(Focused SOAP Note for Schizophrenia Spectrum Comprehensive Essay)

HEENT: Normocephalic and atraumatic. Sclera anicteric, No conjunctival erythema, PERRLA, oropharynx red, moist mucous membranes.

Neck: Supple. No JVD. Trachea midline. No pain, swelling, or palpable nodules.

Heart/Peripheral Vascular: Regular rate and rhythm noted. No murmurs. No palpitation. No peripheral edema to palpation bilaterally.(Focused SOAP Note for Schizophrenia Spectrum Comprehensive Essay)

Cardiovascular: Although the patient’s heartbeat and rhythm are regular, murmurs and other sounds are coming from his chest. The patient’s heart rate is constant, and capillaries refill in two seconds.

Musculoskeletal: Normal range of motion. Regular muscle mass for age. No signs of swelling or joint deformities.

Respiratory: No wheezes, and respirations are easy and regular.(Focused SOAP Note for Schizophrenia Spectrum Comprehensive Essay)

Neurological: Balance is stable, gait is normal, posture is erect, tone is good, and speech is regular and constant.  

Psychiatric: The patient indicates an illogical, grandiose, and delusional thought process. The patient indicates auditory and visual hallucinations, and memory is fair.   

Neuropsychological testing: The patient has difficulties executing schoolwork. (Focused SOAP Note for Schizophrenia Spectrum Comprehensive Essay)

Labs: Neutrophils 66%, Lymphocytes 24%, Monocytes 8%, GGT 38, Total cholesterol 208, Phosphate 5.1.

Diagnostic Results:

Positive and Negative Syndrome Scale (PANSS)

This scale includes DMS-5 diagnostic criteria items for schizophrenia and schizoaffective disorder. The patient assessed delusions, disorganized thought, hallucinations, mania, hostility, blunted affect, alogia, anxiety, disorganized behavior/catatonia, depression, poor attention, and lack of insight. The patient scored 95 across these items, indicating markedly ill.(Focused SOAP Note for Schizophrenia Spectrum Comprehensive Essay)

ASSESSMENT:

Mental Status Examination:

The patient is a 55-year-old male presenting complaints that people are watching him through the window, and he can see and hear them. The patient was cooperative during the interview, answering questions appropriately. The patient was alert and oriented to self but not to time, date, and place. He was modestly dressed with some disarray, but the hair was unkempt. The speech was clear, constant, pressured, rambling, flight of ideas, and hyperverbal. Noted grandiosity and mood was congruent. The thought process was illogical, delusional, and grandiose. Noted auditory/visual hallucinations, no suicidal/homicidal ideation, marked delusions with paranoid ideation prominent. The immediate, recent, and remote memory are fair. Concentration was adequate. The intellectual function was average. Judgment was markedly impaired. Insight was markedly impaired.(Focused SOAP Note for Schizophrenia Spectrum Comprehensive Essay)

Diagnostic Impression:

1. 0 Schizophrenia, paranoid type (Confirmed Diagnosis)
2. F22 Delusional disorder
3. F251 Schizoaffective disorder(Focused SOAP Note for Schizophrenia Spectrum Comprehensive Essay)
4. F20. 0 Schizophrenia, paranoid type (Confirmed Diagnosis): The patient exhibits at least three of the five hallmark symptoms of schizophrenia (criterion A from the DSM-IV-TR), such as delusions, verbally disorderly conduct, and disorganized speech. It is difficult to tell if the patient has any negative symptoms (affective flattening, avolition, and anhedonia) based on the information presented in the HPI and the MSE. The patient’s unkempt hair and general disorder suggested he may struggle to take care of himself. It is hard to tell if he has shown difficulties in other domains of functioning, like interpersonal interactions. The information given is inconclusive regarding the length of this patient’s symptoms because the patient reports experiencing these symptoms for weeks and weeks. The patient must exhibit consistent evidence of disturbance for at least six months and at least one month of symptoms (less if the patient is under treatment) in order to support a diagnosis of schizophrenia (Hany et al., 2023). The patient exhibits typical symptoms of schizophrenia, which would support a diagnosis of schizophrenia even though there is no convincing information regarding the length of symptoms. The patient would also be labeled as having paranoid type schizophrenia because of his significant delusions, notably persecutory ones, that he is being watched, followed, poisoned, and plotted against. (Focused SOAP Note for Schizophrenia Spectrum Comprehensive Essay)
5. F22 Delusional disorder: The patient also indicates signs of delusional disorder due to significant instances and reports of delusional thoughts. A delusion is a persistent mistaken belief founded on an incorrect perception of objective reality in the face of contradictory information. One’s society or subculture does not support the belief, and practically everyone knows it is untrue (Joseph & Siddiqui, 2023). When a person experiences one or more non-bizarre (situations that are possible but not likely to occur in real life) delusional thoughts for a month or longer without any other physiological, drug-related, medical, or mental health conditions to account for them, a delusional disorder is diagnosed. Beliefs held by a person’s culture should be taken into account when making a diagnosis. The nature of delusions is also influenced by cultural beliefs (Joseph & Siddiqui, 2023). The fact that the person frequently lacks self-awareness and their illusions are troublesome is another feature of this disease. Even though they are aware that other people would describe their delusions in this way, they cannot accept that they are unreasonable or wrong. If someone suffers from persecutory, jealousy, or erotomanic delusions, anger, and violent conduct may be present. As a result of their delusions, individuals suffering from delusional disorder may also experience anxiety and/or depression. This diagnosis was refuted because the patient presented other symptoms indicating schizophrenia and has a history of schizophrenia.
6. F251 Schizoaffective disorder: The patient also shows signs and symptoms of schizoaffective disorder, including delusions and hallucinations. The following are the precise DSM-5 criteria for schizoaffective disorder:(Focused SOAP Note for Schizophrenia Spectrum Comprehensive Essay)

A: In addition to meeting criterion A for schizophrenia, a major mood episode (either manic or depressive) must occur for an uninterrupted period of time during the illness; the major depressive episode must also contain a depressed mood (Wy & Saadabadi, 2023). The following is criterion A for schizophrenia: One month (or less if the condition is properly treated) of significant duration for two or more of the aforementioned appearances. These must be from the first three listed below, at least one of them.(Focused SOAP Note for Schizophrenia Spectrum Comprehensive Essay)

1. Delusions
2. Hallucinations
3. Disorganized speech, like frequent derailment or incoherence speech
4. Grossly disorganized or catatonic behavior
5. Negative symptoms like diminished emotional expression or avolition

1. Hallucinations and delusions lasting two weeks or longer without a significant mood episode (manic or depressed) throughout the illness’ lifetime.
2. Most of the time during both the active and residual phases of the illness, symptoms consistent with a major mood episode are present.
3. Neither a substance, such as a drug being abused or a medication, nor an underlying medical condition is to blame for the disturbance.(Focused SOAP Note for Schizophrenia Spectrum Comprehensive Essay)

This diagnosis was refuted because the patient did not meet the DMS-5 criteria for schizoaffective disorder due to the lack of major mood episodes.

Reflection:

Lessons Learned and What I would do Differently

This case is among several encounters with patients experiencing schizophrenia and other psychotic disorders. Interviewing such patients presents multiple challenges because of impaired thought patterns and irregular speech. In some cases, the practitioner might require the presence of a surrogate, caregiver, or any adult related to the patient. Schizophrenia of any type is problematic, although most patients lack awareness of their problematic thinking and behavior. This case presents a unique opportunity to learn more about the impact of schizophrenia, particularly the paranoid type. In the first case, the patient, although displaying delusional thought patterns and lacking orientation and alertness to date and time, answered all questions and cooperated throughout the interview, not necessitating a third party. Given another chance with the patient, I would inquire from the sister or previous practitioner to gather comprehensive information about the patient’s daily life and functioning for an in-depth analysis of the impact of schizophrenia.  (Focused SOAP Note for Schizophrenia Spectrum Comprehensive Essay)

Ethical/Legal Considerations

Working with schizophrenic adults presents unique ethical challenges because practitioners cannot rely entirely on them for information. Another consenting adult is a consideration to gather the relevant data to develop a robust care plan. Additionally, the practitioner must obtain informed consent for any treatment regimen, promote patient autonomy, ensure no harm, maintain veracity, and treat the patient with dignity and respect. Even though the truth can cause the patient to feel distressed, maintaining honesty and objectivity is essential to building patient trust (Varkey, 2021). When discussing the patient’s medical information, the practitioner should maintain privacy and confidentiality and acquire permission. (Focused SOAP Note for Schizophrenia Spectrum Comprehensive Essay) 

Health Promotion and Disease Prevention

           The patient’s current medications indicate a previous schizophrenia diagnosis, implying ineffective disease management interventions. The patient needs reminders and medication plans to promote medication adherence. The patient also has diabetes and is on current medication. Therefore, meal plans, physical exercises, and dieting are necessary to address diabetes, which is linked to poor mental health (Akhaury & Chaware, 2022). It is also considerate to promote a healthy relationship between the patient and the sister, which the patient thinks is plotting against him. A supportive environment would help promote a quality life, enhance medication adherence, and improve overall mental and physical health. (Focused SOAP Note for Schizophrenia Spectrum Comprehensive Essay)    

 Case Formulation and Treatment Plan:

S.T. believes he is being watched, followed, poisoned, and plotted against. The patient believes he can hear and see the people watching him outside through the window. He states hearing “loud metal music” played by those people. This symptomology indicates potential schizophrenia, paranoid type. The patient would benefit from combining pharmacological interventions, psychotherapy, and patient education. The plan aims at alleviating the targeted symptoms. The ultimate goal is to remove symptoms, minimize adverse drug side effects, and improve quality of life.(Focused SOAP Note for Schizophrenia Spectrum Comprehensive Essay)

Pharmacological Intervention

The patient can benefit from any prescription below:

1. Risperidone 1 mg BID
2. Aripiprazole 10 mg qAM
3. Quetiapine 25 mg BID x 1 day
4. Olanzapine 10 mg qday (preferentially H.S.
5. Ziprasidone 20 mg BID with food (full meal)
6. Paliperidone 6 mg qday

Psychotherapy

Non-pharmacological treatments aim to increase a person’s potential in all areas of daily life, including social and professional activities. These treatments might be crucial in lowering the chance of a relapse in schizophrenia. Specifically, psychosocial interventions (P.I.s) have three categories: (1) those that emphasize education and support, (2) those that also include training in life and social skills, and (3) interventions that are problem- or symptom-focused (Stevović et al., 2022). cognitive-behavioral therapy (CBT), cognitive remediation, psychoeducation, social and coping skills, family interventions, and assertive community treatment (ACT) will be adopted for this patient to address all areas of functioning, thinking, and behavior. Stevović et al. (2022) indicate that combining these non-pharmacological approaches is effective in alleviating schizophrenia symptoms and promoting quality of life.(Focused SOAP Note for Schizophrenia Spectrum Comprehensive Essay)

Patient Education

• Educate the patient about schizophrenia and medications.
• Stress the need to adhere to the medication regimen.
• Review medication effect onset because efficacy is not identified for many weeks, and the patient might discontinue medication believing it is ineffective.(Focused SOAP Note for Schizophrenia Spectrum Comprehensive Essay)

Follow-up: The patient should follow up after one week. 

References

Akhaury, K., & Chaware, S. (2022). Relation Between Diabetes and Psychiatric Disorders. Cureus, 14(10), e30733. https://doi.org/10.7759/cureus.30733(Focused SOAP Note for Schizophrenia Spectrum Comprehensive Essay)

Hany, M., Rehman, B., & Azhar, Y. (2023, March 20). Schizophrenia. In: StatPearls [Internet]. Treasure Island (F.L.): StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK539864/

Joseph, S. M., & Siddiqui, W. (2023, March 27). Delusional Disorder. In: StatPearls [Internet]. Treasure Island (F.L.): StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK539855/

National Institute of Mental Health (NIMH). (2023, May). Schizophrenia. https://www.nimh.nih.gov/health/topics/schizophrenia

Stevović, L. I., Repišti, S., Radojičić, T., Sartorius, N., Tomori, S., Kulenović, A. D., Popova, A., Kuzman, M. R., Vlachos, I. I., Statovci, S., Bandati, A., Novotni, A., Bajraktarov, S., Panfil, A. L., Maric, N., Delić, M., & Jovanović, N. (2022). Non-pharmacological interventions for schizophrenia-analysis of treatment guidelines and implementation in 12 Southeast European countries. Schizophrenia (Heidelberg, Germany), 8(1), 10. https://doi.org/10.1038/s41537-022-00226-y(Focused SOAP Note for Schizophrenia Spectrum Comprehensive Essay)

Varkey B. (2021). Principles of Clinical Ethics and Their Application to Practice. Medical Principles and Practice: international journal of the Kuwait University, Health Science Centre, 30(1), 17–28. https://doi.org/10.1159/000509119

Wy, T. J. P., & Saadabadi, A. (2023, March 27). Schizoaffective Disorder. In: StatPearls [Internet]. Treasure Island (F.L.): StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK541012/(Focused SOAP Note for Schizophrenia Spectrum Comprehensive Essay)