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.(SOAP Note Essay for Schizophrenia other Psychotic and Medication Induced Movement Disorders)
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. (SOAP Note Essay for Schizophrenia other Psychotic and Medication Induced Movement Disorders)
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.(SOAP Note Essay for Schizophrenia 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:(SOAP Note Essay for Schizophrenia other Psychotic and Medication Induced Movement Disorders)
- 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?(SOAP Note Essay for Schizophrenia other Psychotic and Medication Induced Movement Disorders)
- 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.(SOAP Note Essay for Schizophrenia other Psychotic and Medication Induced Movement Disorders)
- 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 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. (SOAP Note Essay for Schizophrenia other Psychotic and Medication Induced Movement Disorders)
- To submit your completed assignment, save your Assignment as WK5Assgn_LastName_Firstinitial
- Then, click on Start Assignment near the top of the page.
- 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(SOAP Note Essay for Schizophrenia other Psychotic and Medication Induced Movement Disorders)
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.(SOAP Note Essay for Schizophrenia other Psychotic and Medication Induced Movement Disorders)
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.(SOAP Note Essay for Schizophrenia other Psychotic and Medication Induced Movement Disorders)
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.(SOAP Note Essay for Schizophrenia other Psychotic and Medication Induced Movement Disorders)
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.
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(SOAP Note Essay for Schizophrenia other Psychotic and Medication Induced Movement Disorders)
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.
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.(SOAP Note Essay for Schizophrenia other Psychotic and Medication Induced Movement Disorders)
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.(SOAP Note Essay for Schizophrenia other Psychotic and Medication Induced Movement Disorders)
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.(SOAP Note Essay for Schizophrenia other Psychotic and Medication Induced Movement Disorders)
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.
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.(SOAP Note Essay for Schizophrenia other Psychotic and Medication Induced Movement Disorders)
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.(SOAP Note Essay for Schizophrenia other Psychotic and Medication Induced Movement Disorders)
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.
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.
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.(SOAP Note Essay for Schizophrenia other Psychotic and Medication Induced Movement Disorders)
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.(SOAP Note Essay for Schizophrenia other Psychotic and Medication Induced Movement Disorders)
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.
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.(SOAP Note Essay for Schizophrenia other Psychotic and Medication Induced Movement Disorders)
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.).(SOAP Note Essay for Schizophrenia other Psychotic and Medication Induced Movement Disorders)
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.(SOAP Note Essay for Schizophrenia other Psychotic and Medication Induced Movement Disorders)
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.(SOAP Note Essay for Schizophrenia other Psychotic and Medication Induced Movement Disorders)
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).(SOAP Note Essay for Schizophrenia other Psychotic and Medication Induced Movement Disorders)
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.(SOAP Note Essay for Schizophrenia other Psychotic and Medication Induced Movement Disorders)
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.
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.
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.(SOAP Note Essay for Schizophrenia other Psychotic and Medication Induced Movement Disorders)
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
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
SOAP Note Essay for Schizophrenia other Psychotic and Medication Induced Movement Disorders
Subjective:
CC: “I was living and not bothering anyone, and those people, those people, those people won’t just leave me alone.”
HPI: Sherman is a 54-year-old Caucasian male made to come for a psychiatric evaluation by the sister. Sherman lived with his mother, who passed away. Sherman reports people outside his window watching him and cannot just leave him alone. Sherman reports, “I can hear them. I can see their shadows. They think I cannot see them, but I do. The government sent them to watch me, so my taxes are high, so high in the sky.” The client reports having heard and seen “these people” for weeks. The client does not sleep well because of the “voices” that keep him up for days. Reposted attempting suicide three times when he was 20.(SOAP Note Essay for Schizophrenia other Psychotic and Medication Induced Movement Disorders)
Psychotherapy or previous psychiatric diagnosis: None Reported.
Current Medications: Metformin for diabetes.
Medication trials: Prescribed and had a bad experience with Haldol, Risperidone, and Thorazine. Prescribed Seroquel with a positive experience. (SOAP Note Essay for Schizophrenia other Psychotic and Medication Induced Movement Disorders)
Substance Use History: Smoke all day, three packs a day. Drinks occasionally. The client reports smoking marijuana before her mother passed away three years ago. Denies taking cocaine. Blackouts, seizures, or hallucinations from drugs or alcohol.
Family psychiatric/substance use: Father labeled crazy and paranoid. Mother had anxiety. No family history of suicide.
Social: Raised by mother and sister. Never married with no children. Mother died three years ago. Currently lives alone and is supported by the sister. The dad was rough on them before he passed away. Like playing heavy metal music. No legal issues from alcohol. Does not work. Dropped from tenth grade.(SOAP Note Essay for Schizophrenia other Psychotic and Medication Induced Movement Disorders)
Allergies: None reported.
Review of systems (ROS):
GENERAL: No fever or chills.
HEENT: No headache. No visual or hearing changes. No nasal congestion or sore throat.
SKIN: Normal skin turgor. No itchiness or rushes.
CARDIOVASCULAR: No chest discomfort, pressure, or pain.
RESPIRATORY: No dyspnea, wheeze, or cough.
GASTROINTESTINAL: Denies anorexia, or diarrhea.
GENITOURINARY: No abdominal discomfort.
MUSCULOSKELETAL: No joint pain or swelling.
NEUROLOGICAL: Denies seizures, dizziness, or blackout.
HEMATOLOGIC: No hematuria or dysuria.
LYMPHATICS: No enlarged nodes. No history of splenectomy.
ENDOCRINOLOGIC: No polydipsia or polyuria.
ALLERGY: None reported.(SOAP Note Essay for Schizophrenia other Psychotic and Medication Induced Movement Disorders)
Objective:
Vital Signs: Stable
Temp: 96.7 F, BP: 114/77, HR: 77, R: 17, O2: 97, Ht: 5’8’’, Wt: 150lbs, BMI: 22.8 kg/m2
Diagnostic results:
Lab findings: WNL
Tox screen: Positive for nicotine
Alcohol: Positive
PANS: 75
Assessment:
Mental Status Examination: Sherman is a 54-year-old Caucasian male who looks his age. He is cooperative and unconversant. He appears to be in acute distress and disoriented. The client is well-groomed for age and season. Psychomotor activity is not within normal limits. The client is delusional and has auditory and visual hallucinations. Eye contact is inappropriate. Affect dysphoric congruent with delusional mood. The client’s speech is spontaneous, normal rate, appropriate volume, with difficulty expressing himself. Abnormal though content, denies SI/HI. The client’s thought process appears tangential, incoherent, and preoccupied. Cognition is below average with a limited attention span and concentration. Difficulty with abstract thought and average fund of knowledge. Judgment and insight impaired.(SOAP Note Essay for Schizophrenia other Psychotic and Medication Induced Movement Disorders)
Diagnostic Impression: The client is disillusioned. The client believes that all antipsychotic drugs are poisonous, which could be a somatic delusion focusing on preoccupations regarding his health. The client experiences auditory and visual hallucinations. During the psychiatric evaluation, the client sees imaginary birds and birds in the room and hears perceived heavy metal music. The client reports seeing imaginary “people” watch him through the window and TV screen, eventually coming in to poison his food. So, he checks them out and sometimes calls 911 on them. Moreover, the client presents negative symptoms of diminished emotional expression and avolition.(SOAP Note Essay for Schizophrenia other Psychotic and Medication Induced Movement Disorders)
The client does not know what brings him for psychiatric assessment. He says, “I was living with my mom, and she died. I was living a not bothering anyone.” These symptoms meet the primary criterion for Schizophrenia disorder (American Psychiatric Association [APA], 2019). Delusions, abnormal motor activity, negative symptoms, disorganized thinking, and hallucinations characterize Schizophrenia (Ganguly et al., 2018). Probable differential diagnoses include Schizophreniform and Delusional disorders. Like Schizophrenia, Schizophreniform and Delusional disorders are characterized by psychosis, i.e., the inability to differentiate between real from what is imagined (APA, 2019). However, Schizophreniform lasts less than six months, while delusional disorder does not markedly impair an individual’s function or behavior, which is not obviously odd or bizarre. However, Schizophreniform and Delusional disorders are refuted. (SOAP Note Essay for Schizophrenia other Psychotic and Medication Induced Movement Disorders)
Reflection: I agree with the preceptor’s assessment. The client’s past medical history, social history, and illness perception provide the baseline for primary and differential diagnoses. Psychiatric evaluation is critical for ascertaining the presence of a diagnosis and aids clinical data collection (Subjective and objective) to support diagnosis and guide intervention frameworks (Abd El-Hay, 2018). The information from psychiatric assessment is used to evaluate the need for instantaneous intervention formulate a treatment plan. Moreover, I would carry out additional diagnostic tests, including tox screen, alcohol, and PNSS tests, to ascertain the client’s diagnosis.(SOAP Note Essay for Schizophrenia other Psychotic and Medication Induced Movement Disorders)
Case Formulation and Treatment Plan
Start Aripiprazole 20mg Orally daily. Aripiprazole significantly reduces positive and negative syndrome scale (PANSS) symptoms (Ribeiro et al., 2018). Its efficacy is similar to other antipsychotic drugs. It is effective, safe, and well-tolerated. However, Aripiprazole induces weight gain, and the patient should be monitored for adverse side effects. Moreover, mixing Aripiprazole with other antipsychotic medications can worsen the psychosis and should be avoided.(SOAP Note Essay for Schizophrenia other Psychotic and Medication Induced Movement Disorders)
Start cognitive-behavioral therapy (CBT). CBT modifies unwanted though processing, emotions, and behavior. CBT involves using practical self-induced strategies to reduce Schizophrenic symptoms (Ganguly, Soliman, & Moustafa, 2018). CBT addresses the primary symptoms, including cognitive deficits and social impairments. Combining medical intervention and CBT is more effective and crucial in mitigating potential Schizophrenic resistance to pharmacological intervention.(SOAP Note Essay for Schizophrenia other Psychotic and Medication Induced Movement Disorders)
Refer the client to a psychiatrist for further psychiatric assessment and recommendation. Refer the client to a dietician for advice on an appropriate diet. Diet is a modifiable risk factor for psychosis (Aucoin et al., 2020). The need to avoid food with high-fat content and consume foods with more fiber, vitamin C, fruits, and vegetables is critical for the holistic management of Schizophrenia. The client and the caregiver (mother) were implored to adhere to the case management and interventions.(SOAP Note Essay for Schizophrenia other Psychotic and Medication Induced Movement Disorders)
Time allowed for questions and answers provided. Provided supportive listening. The client appeared to understand the discussion. The client is amenable to this plan and agrees to follow the treatment regimen discussed. (this relates to informed consent; you will need to assess their understanding and agreement)
The client cannot articulate his needs. He exudes limited motivation for adherence and compliance to the medication regimen. However, there is a will to be involved in treatment. The patient’s sister to provide additional information for assessment and maintaining adherence to medication and treatment plans.(SOAP Note Essay for Schizophrenia other Psychotic and Medication Induced Movement Disorders)
Return to the clinic: After two weeks.
References
Abd El-Hay, M. A. (2018). Essentials of Psychiatric Assessment. Routledge. http://dx.doi.org/10.4324/9781315148137
Aucoin, M., LaChance, L., Cooley, K., & Kidd, S. (2020). Diet and psychosis: a scoping review. Neuropsychobiology, 79(1-2), 20-42. https://doi.org/10.1159/000493399
Ganguly, P., Soliman, A., & Moustafa, A. A. (2018). Holistic management of schizophrenia symptoms using pharmacological and non-pharmacological treatment. Frontiers in Public Health, 6, 166. https://doi.org/10.3389/fpubh.2018.00166 American Psychiatric Association. (2019). Diagnostic and statistical manual of mental disorders (7th ed.). American Psychiatric Publishing, Inc.
Ribeiro, E. L. A., de Mendonça Lima, T., Vieira, M. E. B., Storpirtis, S., & Aguiar, P. M. (2018). Efficacy and safety of Aripiprazole for the treatment of Schizophrenia: an overview of systematic reviews. European Journal of Clinical Pharmacology, 74(10), 1215-1233. https://doi.org/10.1007/s00228-018-2498-1
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