Schizophrenia Spectrum SoapNote Essay

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.

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.

·. In this video, a Walden faculty member is assessing a mock patient. The patient will be represented onscreen as an avatar.

·!– /wp:paragraph –>

· substance abuse issues? SHERMAN TREMAINE:

· They say that my dad was crazy with

· paranoid schizophrenia. He did in the old

· state hospital. They gave him his beer there. Can you believe that? Not like them today. My mom had anxiety. DR. MOORE: Did any blood

· relatives commit suicide? SHERMAN TREMAINE:

· Oh, no demons there. No, no. DR. MOORE: What about you? Have you ever done anything

· like cut yourself, or had any thoughts about killing(Schizophrenia Spectrum SoapNote Essay)

· yourself or anyone else? SHERMAN TREMAINE:

· I already told you. No demons there. Have been in the hospital three

· times though when I was 20. DR. MOORE: OK. What about any medical issues? Do you have any

· medical problems? SHERMAN TREMAINE: Ooh, I

· take metformin for diabetes. Had or I have a fatty

· liver, they say, but they never saw it. So I don’t know unless

· the aliens told them. DR. MOORE: OK. So who raised you? SHERMAN TREMAINE: My

· mom and my sister. DR. MOORE: And who(Schizophrenia Spectrum SoapNote Essay)

· do you live with now? SHERMAN TREMAINE:

· Myself, but my sister’s plotting with the

· government to change that. They tapped my phone. DR. MOORE: OK. Have you ever been married? Are you single,

· widowed, or divorced? SHERMAN TREMAINE: I’ve

· never been married. DR. MOORE: Do you(Schizophrenia Spectrum SoapNote Essay)

· have any children? SHERMAN TREMAINE: No. DR. MOORE: OK. What is your highest

· level of education? SHERMAN TREMAINE: I

· went to the 10th grade. DR. MOORE: And what do

· you like to do for fun? SHERMAN TREMAINE: I don’t work,

· so smoking and drinking pop. DR. MOORE: OK. Have you ever been arrested or

· convicted for anything legally? SHERMAN TREMAINE: No, but

· they have told me they would. They have told me they would

· if I didn’t stop calling 911 about the people outside. DR. MOORE: OK. What about any kind of trauma

· as a child or an adult? Like physical, sexual,

· emotional abuse. SHERMAN TREMAINE: My dad was

· rough on us until he died. DR. MOORE: OK. [MUSIC PLAYING] So thank you for answering

· those questions for me. Now, let’s talk about

· how I can best help you. [MUSIC PLAYING]

· NRNP_6675_Week5_Assignment_Rubric

NRNP_6675_Week5_Assignment_Rubric

Criteria

Ratings

Pts

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

15to >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.(Schizophrenia Spectrum SoapNote Essay)

13to >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.(Schizophrenia Spectrum SoapNote Essay)

11to >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.

10to >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.(Schizophrenia Spectrum SoapNote 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(Schizophrenia Spectrum SoapNote Essay)

15to >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.(Schizophrenia Spectrum SoapNote Essay)

13to >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.

11to >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.(Schizophrenia Spectrum SoapNote Essay)

10to >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.

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.(Schizophrenia Spectrum SoapNote Essay)

20to >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.(Schizophrenia Spectrum SoapNote Essay)

17to >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.

15to >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.

13to >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.(Schizophrenia Spectrum SoapNote 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.(Schizophrenia Spectrum SoapNote Essay)

25to >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.(Schizophrenia Spectrum SoapNote Essay)

22to >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.(Schizophrenia Spectrum SoapNote Essay)

19to >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.(Schizophrenia Spectrum SoapNote Essay)

17to >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.

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.).

5to >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.

4to >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.(Schizophrenia Spectrum SoapNote Essay)

3.5to >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.

3to >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).

10to >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.(Schizophrenia Spectrum SoapNote Essay)

8to >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.

7to >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.(Schizophrenia Spectrum SoapNote Essay)

6to >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.

5to >4.0 pts

Excellent 90%–100%

Uses correct APA format with no errors

4to >3.5 pts

Good 80%–89%

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

3.5to >3.0 pts

Fair 70%–79%

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

3to >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

5to >4.0 pts

Excellent 90%–100%

Uses correct grammar, spelling, and punctuation with no errors

4to >3.5 pts

Good 80%–89%

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

3.5to >3.0 pts

Fair 70%–79%

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

3to >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

Schizophrenia Spectrum SoapNote Essay-Solution

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.(Schizophrenia Spectrum SoapNote Essay)

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. (Schizophrenia Spectrum SoapNote Essay)

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.(Schizophrenia Spectrum SoapNote Essay)

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.(Schizophrenia Spectrum SoapNote Essay)

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.(Schizophrenia Spectrum SoapNote Essay)

CARDIOVASCULAR: No chest discomfort, pressure, or pain.

RESPIRATORY: No dyspnea, wheeze, or cough.(Schizophrenia Spectrum SoapNote Essay)

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.(Schizophrenia Spectrum SoapNote Essay)

ALLERGY: None reported.

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(Schizophrenia Spectrum SoapNote Essay)

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.(Schizophrenia Spectrum SoapNote Essay)

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.(Schizophrenia Spectrum SoapNote Essay)

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.(Schizophrenia Spectrum SoapNote Essay)

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.(Schizophrenia Spectrum SoapNote Essay)

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.(Schizophrenia Spectrum SoapNote Essay)

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.(Schizophrenia Spectrum SoapNote Essay)

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.

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.(Schizophrenia Spectrum SoapNote Essay)

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 (7^th ed.). American Psychiatric Publishing, Inc.   (Schizophrenia Spectrum SoapNote Essay)

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

·!– /wp:paragraph –>

· what was your reaction to them? SHERMAN TREMAINE: I hate

· Haldol and Thorazine. No, no, I’m not(Schizophrenia Spectrum SoapNote Essay)

· going to take it. Risperidone gave me boobs. No, I’m not going to take it. Seroquel, that is OK. But they’re all poison,

· nope, not going to take it. DR. MOORE: OK. So tell me, any

·!– /wp:paragraph –>

· substance abuse issues? SHERMAN TREMAINE:

· They say that my dad was crazy with

· paranoid schizophrenia. He did in the old

· state hospital. They gave him his beer there. Can you believe that? Not like them today. My mom had anxiety. DR. MOORE: Did any blood

· relatives commit suicide? SHERMAN TREMAINE:

· Oh, no demons there. No, no. DR. MOORE: What about you? Have you ever done anything

· like cut yourself, or had any thoughts about killing(Schizophrenia Spectrum SoapNote Essay)

· yourself or anyone else? SHERMAN TREMAINE:

· I already told you. No demons there. Have been in the hospital three

· times though when I was 20. DR. MOORE: OK. What about any medical issues? Do you have any

· medical problems? SHERMAN TREMAINE: Ooh, I

· take metformin for diabetes. Had or I have a fatty

· liver, they say, but they never saw it. So I don’t know unless

· the aliens told them. DR. MOORE: OK. So who raised you? SHERMAN TREMAINE: My

· mom and my sister. DR. MOORE: And who(Schizophrenia Spectrum SoapNote Essay)

· do you live with now? SHERMAN TREMAINE:

· Myself, but my sister’s plotting with the

· government to change that. They tapped my phone. DR. MOORE: OK. Have you ever been married? Are you single,

· widowed, or divorced? SHERMAN TREMAINE: I’ve

· never been married. DR. MOORE: Do you(Schizophrenia Spectrum SoapNote Essay)

· have any children? SHERMAN TREMAINE: No. DR. MOORE: OK. What is your highest

· level of education? SHERMAN TREMAINE: I

· went to the 10th grade. DR. MOORE: And what do

· you like to do for fun? SHERMAN TREMAINE: I don’t work,

· so smoking and drinking pop. DR. MOORE: OK. Have you ever been arrested or

· convicted for anything legally? SHERMAN TREMAINE: No, but

· they have told me they would. They have told me they would

· if I didn’t stop calling 911 about the people outside. DR. MOORE: OK. What about any kind of trauma

· as a child or an adult? Like physical, sexual,

· emotional abuse. SHERMAN TREMAINE: My dad was

· rough on us until he died. DR. MOORE: OK. [MUSIC PLAYING] So thank you for answering

· those questions for me. Now, let’s talk about

· how I can best help you. [MUSIC PLAYING]

· NRNP_6675_Week5_Assignment_Rubric

NRNP_6675_Week5_Assignment_Rubric

Criteria

Ratings

Pts

15to >13.0 pts

Excellent 90%–100%

13to >11.0 pts

Good 80%–89%

11to >10.0 pts

Fair 70%–79%

10to >0 pts

Poor 0%–69%

15 pts

15to >13.0 pts

Excellent 90%–100%

13to >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.

11to >10.0 pts

Fair 70%–79%

10to >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.

15 pts

20to >17.0 pts

Excellent 90%–100%

17to >15.0 pts

Good 80%–89%

15to >13.0 pts

Fair 70%–79%

13to >0 pts

Poor 0%–69%

20 pts

25to >22.0 pts

Excellent 90%–100%

22to >19.0 pts

Good 80%–89%

19to >17.0 pts

Fair 70%–79%

17to >0 pts

Poor 0%–69%

25 pts

5to >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.

4to >3.5 pts

Good 80%–89%

3.5to >3.0 pts

Fair 70%–79%

3to >0 pts

Poor 0%–69%

Reflections are incomplete, inaccurate, or missing.

5 pts

10to >8.0 pts

Excellent 90%–100%

8to >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.

7to >6.0 pts

Fair 70%–79%

6to >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.

5to >4.0 pts

Excellent 90%–100%

Uses correct APA format with no errors

4to >3.5 pts

Good 80%–89%

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

3.5to >3.0 pts

Fair 70%–79%

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

3to >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

5to >4.0 pts

Excellent 90%–100%

Uses correct grammar, spelling, and punctuation with no errors

4to >3.5 pts

Good 80%–89%

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

3.5to >3.0 pts

Fair 70%–79%

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

3to >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

Schizophrenia Spectrum SoapNote Essay-Solution

Subjective:

CC: “I was living and not bothering anyone, and those people, those people, those people won’t just leave me alone.”

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. (Schizophrenia Spectrum SoapNote Essay)

Family psychiatric/substance use: Father labeled crazy and paranoid. Mother had anxiety. No family history of suicide.

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.(Schizophrenia Spectrum SoapNote Essay)

CARDIOVASCULAR: No chest discomfort, pressure, or pain.

RESPIRATORY: No dyspnea, wheeze, or cough.(Schizophrenia Spectrum SoapNote Essay)

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.(Schizophrenia Spectrum SoapNote Essay)

ALLERGY: None reported.

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(Schizophrenia Spectrum SoapNote Essay)

Tox screen: Positive for nicotine

Alcohol: Positive

PANS: 75

Assessment:

Case Formulation and Treatment Plan

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

·!– /wp:paragraph –>

·(no more than 5 years old).

· [MUSIC PLAYING] DR. MOORE: Good afternoon. I’m Dr. Moore. Want to thank you for coming

· in for your appointment today. I’m going to be asking you some

· questions about your history and some symptoms. And to get started,

· I just want to ensure I have the right(Schizophrenia Spectrum SoapNote Essay)

· patient and chart. So can you tell me your

· name and your date of birth? SHERMAN TREMAINE:

· I’m Sherman Tremaine, and Tremaine is my game game. My birthday is November 3, 1968. DR. MOORE: Great. And can you tell

· me today’s date? Like the day of the week,

· and where we are today? SHERMAN TREMAINE: Use any recent

· date, and any location is OK. DR. MOORE: OK, Sherman. What about do you know

· what month this is? SHERMAN TREMAINE: It’s March 18. DR. MOORE: And the

· day of the week? SHERMAN TREMAINE: Oh, it’s a

· Wednesday or maybe a Thursday. DR. MOORE: OK. And where are we today? SHERMAN TREMAINE:

· I believe we’re in your office, Dr. Moore. DR. MOORE: OK, great. So tell me a little bit about

· what brings you in today. What brings you here? SHERMAN TREMAINE: Well,

· my sister made me come in. I was living with my(Schizophrenia Spectrum SoapNote Essay)

· mom, and she died. I was living, and not bothering

· anyone, and those people– those people, they just

· won’t leave me alone. DR. MOORE: What people? SHERMAN TREMAINE: The ones

· outside my window watching. They watch me. I can hear them, and

· I see their shadows. They think I don’t(Schizophrenia Spectrum SoapNote Essay)

· see them, but I do. The government sent

· them to watch me, so my taxes are high,

· so high in the sky. Do you see that bird? DR. MOORE: Sherman,

· how long have you saw or heard these people? SHERMAN TREMAINE: Oh, for weeks,

· weeks and weeks and weeks. Hear that– hear that

· heavy metal music? They want you to think

· it’s weak, but it’s heavy. DR. MOORE: No, Sherman. I don’t see any birds

· or hear any music. Do you sleep well, Sherman? SHERMAN TREMAINE: I try to

· but the voices are loud. They keep me up(Schizophrenia Spectrum SoapNote Essay)

· for days and days. I try to watch TV, but they

· watch me through the screen, and they come in(Schizophrenia Spectrum SoapNote Essay)

· and poison my food. I tricked them though. I tricked them. I locked everything

· up in the fridge. They aren’t getting in there. Can I smoke? DR. MOORE: No, Sherman. There is no smoking here. How much do you usually smoke? SHERMAN TREMAINE: Well,

· I smoke all day, all day. Three packs a day. DR. MOORE: Three packs a day. OK. What about alcohol? When was your last drink? SHERMAN TREMAINE: Oh, yesterday. My sister buys me a 12-pack,

· and tells me to make it last until next week’s grocery run. I don’t go to the grocery store. They play too loud of

· the heavy metal music. They also follow me there. DR. MOORE: What about marijuana? SHERMAN TREMAINE: Yes,

· but not since my mom died three years ago. DR. MOORE: Use any cocaine? SHERMAN TREMAINE: No,

· no, no, no, no, no, no. No drugs ever, clever, ever. DR. MOORE: What about

· any blackouts or seizures or see or hear things(Schizophrenia Spectrum SoapNote Essay)

· from drugs or alcohol? SHERMAN TREMAINE: No, no, never

· a clever [INAUDIBLE] ever. DR. MOORE: What about

·:

· Never clever’s ever. DR. MOORE: OK. What about any medication

·!– /wp:paragraph –>

· what was your reaction to them? SHERMAN TREMAINE: I hate

· Haldol and Thorazine. No, no, I’m not(Schizophrenia Spectrum SoapNote Essay)

· going to take it. Risperidone gave me boobs. No, I’m not going to take it. Seroquel, that is OK. But they’re all poison,

· nope, not going to take it. DR. MOORE: OK. So tell me, any

·!– /wp:paragraph –>

· substance abuse issues? SHERMAN TREMAINE:

· They say that my dad was crazy with

· paranoid schizophrenia. He did in the old

· state hospital. They gave him his beer there. Can you believe that? Not like them today. My mom had anxiety. DR. MOORE: Did any blood

· relatives commit suicide? SHERMAN TREMAINE:

· Oh, no demons there. No, no. DR. MOORE: What about you? Have you ever done anything

· like cut yourself, or had any thoughts about killing(Schizophrenia Spectrum SoapNote Essay)

· yourself or anyone else? SHERMAN TREMAINE:

· I already told you. No demons there. Have been in the hospital three

· times though when I was 20. DR. MOORE: OK. What about any medical issues? Do you have any

· medical problems? SHERMAN TREMAINE: Ooh, I

· take metformin for diabetes. Had or I have a fatty

· liver, they say, but they never saw it. So I don’t know unless

· the aliens told them. DR. MOORE: OK. So who raised you? SHERMAN TREMAINE: My

· mom and my sister. DR. MOORE: And who(Schizophrenia Spectrum SoapNote Essay)

· do you live with now? SHERMAN TREMAINE:

· Myself, but my sister’s plotting with the

· government to change that. They tapped my phone. DR. MOORE: OK. Have you ever been married? Are you single,

· widowed, or divorced? SHERMAN TREMAINE: I’ve

· never been married. DR. MOORE: Do you(Schizophrenia Spectrum SoapNote Essay)

· have any children? SHERMAN TREMAINE: No. DR. MOORE: OK. What is your highest

· level of education? SHERMAN TREMAINE: I

· went to the 10th grade. DR. MOORE: And what do

· you like to do for fun? SHERMAN TREMAINE: I don’t work,

· so smoking and drinking pop. DR. MOORE: OK. Have you ever been arrested or

· convicted for anything legally? SHERMAN TREMAINE: No, but

· they have told me they would. They have told me they would

· if I didn’t stop calling 911 about the people outside. DR. MOORE: OK. What about any kind of trauma

· as a child or an adult? Like physical, sexual,

· emotional abuse. SHERMAN TREMAINE: My dad was

· rough on us until he died. DR. MOORE: OK. [MUSIC PLAYING] So thank you for answering

· those questions for me. Now, let’s talk about

· how I can best help you. [MUSIC PLAYING]

· NRNP_6675_Week5_Assignment_Rubric

NRNP_6675_Week5_Assignment_Rubric

Criteria

Ratings

Pts

15to >13.0 pts

Excellent 90%–100%

13to >11.0 pts

Good 80%–89%

11to >10.0 pts

Fair 70%–79%

10to >0 pts

Poor 0%–69%

15 pts

15to >13.0 pts

Excellent 90%–100%

13to >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.

11to >10.0 pts

Fair 70%–79%

10to >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.

15 pts

20to >17.0 pts

Excellent 90%–100%

17to >15.0 pts

Good 80%–89%

15to >13.0 pts

Fair 70%–79%

13to >0 pts

Poor 0%–69%

20 pts

25to >22.0 pts

Excellent 90%–100%

22to >19.0 pts

Good 80%–89%

19to >17.0 pts

Fair 70%–79%

17to >0 pts

Poor 0%–69%

25 pts

5to >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.

4to >3.5 pts

Good 80%–89%

3.5to >3.0 pts

Fair 70%–79%

3to >0 pts

Poor 0%–69%

Reflections are incomplete, inaccurate, or missing.

5 pts

10to >8.0 pts

Excellent 90%–100%

8to >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.

7to >6.0 pts

Fair 70%–79%

6to >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.

5to >4.0 pts

Excellent 90%–100%

Uses correct APA format with no errors

4to >3.5 pts

Good 80%–89%

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

3.5to >3.0 pts

Fair 70%–79%

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

3to >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

5to >4.0 pts

Excellent 90%–100%

Uses correct grammar, spelling, and punctuation with no errors

4to >3.5 pts

Good 80%–89%

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

3.5to >3.0 pts

Fair 70%–79%

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

3to >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

Schizophrenia Spectrum SoapNote Essay-Solution

Subjective:

CC: “I was living and not bothering anyone, and those people, those people, those people won’t just leave me alone.”

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. (Schizophrenia Spectrum SoapNote Essay)

Family psychiatric/substance use: Father labeled crazy and paranoid. Mother had anxiety. No family history of suicide.

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.(Schizophrenia Spectrum SoapNote Essay)

CARDIOVASCULAR: No chest discomfort, pressure, or pain.

RESPIRATORY: No dyspnea, wheeze, or cough.(Schizophrenia Spectrum SoapNote Essay)

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.(Schizophrenia Spectrum SoapNote Essay)

ALLERGY: None reported.

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(Schizophrenia Spectrum SoapNote Essay)

Tox screen: Positive for nicotine

Alcohol: Positive

PANS: 75

Assessment:

Case Formulation and Treatment Plan

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

·!– /wp:paragraph –>

· 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?

· 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.(Schizophrenia Spectrum SoapNote Essay)

· 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.(Schizophrenia Spectrum SoapNote Essay)