Assignment: Focused SOAP Note for Schizophrenia Spectrum, Other Psychotic, and Medication-Induced Movement Disorder

Assignment: Focused SOAP Note for Schizophrenia Spectrum, Other Psychotic, and Medication-Induced Movement Disorder

Assignment: Focused SOAP Note for Schizophrenia Spectrum, Other Psychotic, and Medication-Induced Movement Disorder

Subjective:

CC (chief complaint): “My sister forced me to come here. You know those people just won’t leave me alone.”

HPI:

Sherman Tremaine is a 53-year-old female client who presents to the psychiatry clinic with reports that her sister compelled her to get psychiatric help. She states that there are people outside her window watching her and will not leave her alone. Sherman mentions that she hears them while they are watching her, and she sees their shadows. According to the client, the people watching her think she does not see them, but she does. She claims that the government sent them to watch her and, as a result, her taxes are so high. She reports having heard the people for several weeks. In addition, she reports having sleeping difficulties because the voices are loud, which keeps her up for several days.

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Medication Trials: The client was previously on Haldol, Thorazine, Risperidone, and Seroquel.

Substance Current Use: Admits to smoking tobacco 3PPD and taking alcohol. She has a history of taking marijuana but stopped three years ago. Denies using other illicit drug substances.

Medical History: The patient has a positive history of diabetes and fatty liver.

• Current Medications: Metformin for Diabetes
• Allergies: No known drug or food allergies.

• Reproductive Hx: No history of gynecologic disorders. Para 0+0

Family Psychiatric History: The patient’s father had paranoid schizophrenia, and the mother had an anxiety disorder. No history of suicide.

Social History: Sherman has been living alone after the death of her parents three years ago. She was raised by her mother and sister. She is currently single and has no children. The client’s highest education level is 10th grade and does not currently work. She denies having any legal history of being arrested or convicted.

ROS:

• GENERAL: Denies fatigue, fever, chills, or weight changes.
• HEENT: Denies vision changes, ear pain, hearing loss, sneezing, nasal discharge, or throat pain.
• SKIN: Denies rash or bruises.
• CARDIOVASCULAR: Denies SOB on exertion, palpitations, chest pain, or edema.
• RESPIRATORY: Denies cough, chest pain, sputum production, or SOB.
• GASTROINTESTINAL: Denies nausea, vomiting, abdominal pain, changes in bowel patterns, or rectal bleeding,
• GENITOURINARY: Denies abnormal PV discharge, pelvic pain, dysuria, or urine color changes.
• NEUROLOGICAL: Denies headache, dizziness, muscle weakness, or burning sensations.
• MUSCULOSKELETAL: Denies muscle pain, joint pain/stiffness, or limitations in movement,
• HEMATOLOGIC: Denies bruising or history of anemia.
• LYMPHATICS: Denies enlarged lymph nodes.
• ENDOCRINOLOGIC: Denies polyuria, polyphagia, excessive sweating, or heat/cold intolerance.

Objective

General: The patient is neat and appropriately dressed for the weather and function. She is alert and maintains eye contact. She is oriented to person, place, date but not the day of the week.

Diagnostic results: No diagnostic tests were ordered.

Assessment

Mental Status Examination: The client is well-groomed and appropriately dressed. The self-reported mood is ‘anxious,’ and affect is constricted. Speech is clear with normal volume and rate. Visual and auditory hallucinations were noted. Persecutory delusions noted. No suicidal or homicidal thoughts/ideations were noted. Short-term and long-term memory is intact. She demonstrates good judgment. Insight is lacking.

Diagnostic Impression

Schizophrenia: The DSM V diagnostic criteria for schizophrenia include the presence of at least two of the following features: Hallucinations, delusions, disorganized speech, disorganized or catatonic behavior, and negative symptoms. Besides, at least one of the features must be hallucinations, delusions, or disorganized speech. Schizophrenia is a differential diagnosis based on the presence of visual and auditory hallucinations and persecutory delusions.

Persecutory Delusional Disorder (PDD): PDD is characterized by an irrational but unshakable belief by an individual that someone is plotting against them or is planning to harm them. The individual is convinced that other people are attempting to do them harm. PDD is a differential diagnosis based on the client’s belief that people are watching her. She believes that they get to her house and poison her food. Besides, she claims that her sister is plotting with the government to change her living status, and they have tapped her phone.

Brief Psychotic Disorder:  The DSM-5 defines Brief psychotic disorder as a sudden onset of psychotic behavior lasting less than one month followed by a full remission with likely future relapses. It is a transient disorder characterized by the onset of one or more of the following psychotic features: Delusions, hallucinations, disorganized speech, and grossly disorganized or catatonic behavior. Pertinent positive findings consistent with Brief psychotic disorder include persecutory delusion and visual and auditory hallucinations.

Case Formulation and Treatment Plan: 

Pharmacologic: Lurasidone (Latuda) 40 mg PO once daily. Latuda is an atypical antipsychotic indicated for treatment of schizophrenia in adults and adolescents (Ganguly et al., 2017). It is antagonizes dopamine D2 and serotonin 5-HT2A receptors.

Non-pharmacologic treatments: 

Psychotherapy: Cognitive behavioral therapy (CBT). CBT is a therapeutic technique that aims to modify undesirable thinking and behavior patterns. It entails practical strategies, which improve positive symptoms in schizophrenia (Ganguly et al., 2017). CBT enables the individual to have healthy thoughts and behaviors.

Diet and physical exercises: Antipsychotics are associated with weight gain. The client will be counseled on healthy dietary patterns and daily physical exercises to counteract the side effect of weight gain.

Follow-up: The client will be scheduled for a follow-up visit every four weeks to evaluate her response to antipsychotics and psychotherapy. The response to therapy will determine if the dose will be increased or medication switched to another antipsychotic.   

Reflection

The patient in the case study exhibited symptoms consistent with those of DSM V criteria for schizophrenia. If I could conduct the session again, I would utilize schizophrenia screening tools such as the Positive and Negative Syndrome Scale (PANSS) or the Brief Psychiatric Rating Scale (BPRS) (Kumari et al., 2017). In the next follow-up visit, I would assess the client for positive symptoms and use the screening tools to determine her response to therapy. Besides, I would inquire about the presence of side effects and their severity to determine if dose modification is needed (Ganguly et al., 2017). Legal and ethical considerations for this patient should focus on principles of beneficence, nonmaleficence, and autonomy. The practitioner should uphold beneficence and nonmaleficence by evaluating the treatment plan to ensure it is safe and is associated with the best treatment outcomes for patients with schizophrenia (Bipeta, 2019).  Health promotion should address smoking cessation since nicotine may worsen some adverse effects of antipsychotic drugs.

References

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (DSM-5®). American Psychiatric Pub.

Bipeta, R. (2019). Legal and Ethical Aspects of Mental Health Care. Indian journal of psychological medicine, 41(2), 108–112. https://doi.org/10.4103/IJPSYM.IJPSYM_59_19

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

Kumari, S., Malik, M., Florival, C., Manalai, P., & Sonje, S. (2017). An Assessment of Five (PANSS, SAPS, SANS, NSA-16, CGI-SCH) commonly used Symptoms Rating Scales in Schizophrenia and Comparison to Newer Scales (CAINS, BNSS). Journal of addiction research & therapy, 8(3), 324. https://doi.org/10.4172/2155-6105.1000324