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

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Case study

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 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 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 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 for days and days.

I try to watch TV, but they watch me through the screen,

and they come in 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

THE ASSIGNMENT

Develop a focused SOAP note, including your differential diagnosis and critical-thinking process to formulate a primary diagnosis. Incorporate the following into your responses in the template:

Subjective: What details did the patient provide regarding their chief complaint and symptomology to derive your differential diagnosis? What is the duration and severity of their symptoms? How are their symptoms impacting their functioning in life?

Objective: What observations did you make during the psychiatric assessment? 

Assessment: Discuss the patient’s mental status examination results. What were your differential diagnoses? Provide a minimum of three possible diagnoses with supporting evidence, and list them in order from highest priority to lowest priority. Compare the DSM-5-TR diagnostic criteria for each differential diagnosis and explain what DSM-5-TR criteria rules out the differential diagnosis to find an accurate diagnosis. Explain the critical-thinking process that led you to the primary diagnosis you selected. Include pertinent positives and pertinent negatives for the specific patient case.

Plan: What is your plan for psychotherapy? What is your plan for treatment and management, including alternative therapies? Include pharmacologic and nonpharmacologic treatments, alternative therapies, and follow-up parameters, as well as a rationale for this treatment and management plan. Also incorporate one health promotion activity and one patient education strategy.

Reflection notes: What would you do differently with this patient if you could conduct the session again? Discuss what your next intervention would be if you were able to follow up with this patient. Also include in your reflection a discussion related to legal/ethical considerations (demonstrate critical thinking beyond confidentiality and consent for treatment!), health promotion, and disease prevention, taking into consideration patient factors (such as age, ethnic group, etc.), PMH, and other risk factors (e.g., socioeconomic, cultural background, etc.).

Provide at least three evidence-based, peer-reviewed journal articles or evidenced-based guidelines that relate to this case to support your diagnostics and differential diagnoses. Be sure they are current (no more than 5 years old).

Consider what history would be necessary to collect from this patient.

Consider what interview questions you would need to ask this patient.

FOCUSED SOAP NOTE FOR SCHIZOPHRENIA SPECTRUM, OTHER PSYCHOTIC, AND MEDICATION-INDUCED MOVEMENT DISORDERS