NRNP 6675 Week5 Assignment : Focused SOAP Note for Schizophrenia Spectrum, Other Psychotic, and Medication-Induced Movement Disorders Essay

 NRNP 6675 Week5 Assignment : Focused SOAP Note for Schizophrenia Spectrum, Other Psychotic, and Medication-Induced Movement Disorders Essay

 Subjective:

CC (chief complaint): “My sister made me come in”

HPI: S.T is a 53-year-old female who reported to the psychiatric unit for evaluation as requested by her sister. The patient thinks that people are watching her most of the time outside the window, and even confirms that she can hear them. She reports that she has been having this experience for weeks. She is also unable to sleep most nights due to loud voices. The patient also claims that when she is watching television, those people in it watch her, and even try to poison her food. She however denies seizures related to intake of drugs or blackouts. No self-injurious behaviors or suicidal ideation were reported.

Past Psychiatric History:

• General Statement: Presents with a history of psychosis.
• Caregivers (if applicable): Currently resides with her sister following their mother’s death.
• Hospitalizations: Hospitalized three times due to psychotic disorders at the age of 29 years.
• Medication trials: Tried Thorazine and Haldol for management of her previous psychotic symptoms, which she hates and claims to be ineffective. She also tried risperidone which led to the enlargement of her breasts. Seroquel is the only drug that she has been taking that has displayed great effectiveness in the management of her symptoms. She is however non-compliant in taking this medication.
• Psychotherapy or Previous Psychiatric Diagnosis: Not reported.

Substance Current Use: Smokes 3 packs of cigarettes every day. Drinks about 12 bottles of alcoholic beverages weekly. Stopped taking marijuana after the death of her mother about 3 years ago. She does not take cocaine or any other illicit drug.

Family Psychiatric/Substance Use History: Mother with a history of anxiety. Father with a history of paranoid schizophrenia. No blood relative has ever committed suicide.

ORDER A PLAGIARISM FREE-PAPER HERE

Psychosocial History: The patient was living with her mother, but she died three years ago. She moved in with her sister afterward. The highest level of education is the 10^th grade. She has no children and has never been married. She is jobless. She has no history of being arrested but has been warned several times. Reports that her father was tough on them before passing on.

 

Medical History: Reports a history of fatty liver and diabetes

 

• Current Medications: Metformin to control her blood sugar levels
• Allergies: No allergies

• Reproductive Hx: Attained menopause at the age of 45 years. Heterosexual with no children as she has never been married.

ROS:

• GENERAL: No fatigue, recent changes in body weight, body weakness, nausea, vomiting, or fever.
• HEENT: Head: No headache, or signs of trauma or injuries. Ears: No itchiness, tenderness, tinnitus, or discharge. Eyes: No visual defects, tearing, itchiness, or double vision. Nose: No sinus problems, congestions, stuffiness, redness, or inflammation. Throat & Mouth: No bleeding gums, sore throat, swallowing difficulties, toothache, or bleeding gums.
• SKIN: No itchiness, eczema, rashes, or hives.
• CARDIOVASCULAR: No chest pressure, palpitations, cyanosis, dyspnea, or edema.
• RESPIRATORY: No sneezing, shortness of breath, coughing, wheezing, or chest congestion.
• GASTROINTESTINAL: No changes in bowel movement, heartburn, nausea, vomiting, hernia, or abdominal pain.
• GENITOURINARY: No changes in urine frequency, urgency, burning sensation when urinating, discharge, nocturia, or dysuria.
• NEUROLOGICAL: No changes in vision, headache, dizziness, or loss of consciousness.
• MUSCULOSKELETAL: No joint or muscle pain, stiffness. Full range of muscle movement.
• HEMATOLOGIC: No bleeding problems, or prolonged healing of bruises.
• LYMPHATICS: No enlargement of lymph nodes.
• ENDOCRINOLOGIC: No polydipsia, polyuria, or excessive thirst.

Objective:

Diagnostic results: Metabolic panel and routine blood works ordered, such as CBC, WBC, and MCV. Urine and blood drug tests were ordered to assess for substance use disorder. Renal function tests, LFTs, T4, and T3 were ordered to assess for any complications resulting from previously administered psychotropic agents. Imaging studies such as CT scans and X-rays of the head were ordered to check for any physical abnormalities which might have contributed to her current symptoms. Additional diagnostic tools utilized include Calgary Depression Scale for Schizophrenia, Clinical Global Impression-Schizophrenia (CGI-SCH), Brief Psychiatric Rating Scale (BPRS), SANS and SAPS Tests, Positive and Negative Syndrome Scale (PANSS), and Rorschach (inkblot) test (Jauhar et al., 2018).

 Assessment:

Mental Status Examination: The patient is well oriented in time, place, and person. Her attention is limited. She however appears to descent in age-appropriate grooming and clothing. She is suspicious in an awkward manner. She is cooperative during the interview but gets distracted most of the time displaying strange beliefs and delusive behavior such as claiming that a bird is in the examination room. Her speech is not fluent. She displays a sad mood, and fear as she thinks her life is in danger. Her thought process is compromised, with irrelevant and unreasonable thought content. perceptual disturbance noted. Displays impairment in recent and remote memory. Her insight is poor. Confirms hallucinations, nightmares, and delirium. Denies suicidal ideation or self-injurious activities.

Diagnostic Impression:

1. Schizophrenia Spectrum and Other Psychotic Disorders: This is a common mental disorder characterized by loss of contact with reality leading to symptoms such as abnormal behavior, disorganized thinking and speech, delusion, and hallucination. To qualify for the diagnosis, the DSM-V requires the patient to display at least two of the above symptoms in addition to catatonic behavior or negative symptoms like nightmares (Palomar-Ciria et al., 2019). The patient in the provided case study displayed most of these symptoms, qualifying for this disorder as the primary diagnosis.
2. Bipolar I Disorder with psychotic features: According to the DSM-V, patients with this disorder normally present with manic episodes in addition to psychotic features such as delusion and hallucination (Kesebir et al., 2020). Additional symptoms include increased psychomotor agitation, racing thoughts, inability to sleep, being easily distracted, and inflated self-esteem among others. The patient did not display maniac episodes, which disqualifies this diagnosis.
3. Delusional Disorder: According to the DSM-V, this disorder is only applicable to patients who present with delusional symptoms for at least one month, without any other associated psychotic symptoms (Perrotta, 2020). The patient in the provided case study however displayed hallucination, among other psychotic features like nightmares and disorganized thought process.

Reflections: The PMHNP did an excellent job in evaluating this patient. She uses polite and non-judgmental communication skills while giving the patient ample time to explain herself. The information provided is quite adequate in making a primary diagnosis of schizophrenia. However, it would have been necessary for the clinician to call in the sister to provide additional information regarding the patient’s behavior at home. Additionally, the patient’s thought process is compromised. As such, the patient is unable to make a sound decision concerning her health, especially in the choice of treatment. As such, the sister who is the only available next of kin has the legal obligation of stepping in and helping the patient in making sound decisions to promote effective treatment outcomes (Jauhar et al., 2018).

Case Formulation and Treatment Plan:

Primary diagnosis: Schizophrenia Spectrum and Other Psychotic Disorders

Psychotherapy: Initiate Cognitive Behavioral Therapy to help promote positive thinking and appropriate behavior (El-Mallakh et al., 2019).

Alternative psychotherapy: Assertive community treatment (ACT), cognitive enhancement therapy (CET), coordinated specialty care (CSC) may be considered effective alternatives to CBT.

Pharmacotherapy: Initiate quetiapine (Rx) Extended-release 300 mg orally on day one. Titrate the dose upwards at intervals of 300mg daily to attain an optimum dose between 400 to 800 mg once daily based on the patient outcome (Maroney, 2020). The patient already displayed great effectiveness and tolerance to the medication.

Patient Education: Inform the patient of the importance of being compliant with the medication to promote the treatment outcome, in addition to the associated side effects and how to manage them (Maroney, 2020).

Health Promotion: Quetiapine is associated with moderate weight gain, as such, the patient needs to adopt appropriate life modifications such as physical exercises and consumption of healthy low calorie foods (Maroney, 2020).

Follow up: The patient should report back to the clinic after one week for an evaluation of the treatment outcome, and appropriate dose adjustment.

References

El-Mallakh, R. S., Rhodes, T. P., & Dobbins, K. (2019). The case for case management in schizophrenia. Professional Case Management, 24(5), 273-276. DOI: 10.1097/NCM.0000000000000385

Jauhar, S., Krishnadas, R., Nour, M. M., Cunningham-Owens, D., Johnstone, E. C., & Lawrie, S. M. (2018). Is there a symptomatic distinction between the affective psychoses and schizophrenia? A machine learning approach. Schizophrenia Research, 202, 241-247. https://doi.org/10.1016/j.schres.2018.06.070

Kesebir, S., Koc, M. I., & Yosmaoglu, A. (2020). Bipolar Spectrum Disorder May Be Associated With Family History of Diseases. Journal of Clinical Medicine Research, 12(4), 251. DOI: 10.14740/jocmr4143

Maroney, M. (2020). An update on current treatment strategies and emerging agents for the management of schizophrenia. Am J Manag Care, 26(3 Suppl), S55-S61. DOI: 10.37765/ajmc.2020.43012

Palomar-Ciria, N., Cegla-Schvartzman, F., Lopez-Morinigo, J. D., Bello, H. J., Ovejero, S., & Baca-Garcia, E. (2019). Diagnostic stability of schizophrenia: a systematic review. Psychiatry Research, 279, 306-314. https://doi.org/10.1016/j.psychres.2019.04.020

Perrotta, G. (2020). Psychotic spectrum disorders: definitions, classifications, neural correlates, and clinical profiles. Annals of Psychiatry and Treatment, 4(1), 070-084. https://doi.org/10.17352/apt.000023

ORDER A PLAGIARISM FREE-PAPER HERE

Assignment: 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.
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.
To Prepare
• Review this week’s Learning Resources. Consider the insights they provide about assessing, diagnosing, and treating schizophrenia spectrum, other psychotic, and medication-induced movement disorders.

Photo Credit: Getty Images/Wavebreak Media
• 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.
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 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.
• 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).

ORDER A PLAGIARISM FREE-PAPER HERE

Rubric Detail

Select Grid View or List View to change the rubric’s layout.

Name: NRNP_6675_Week5_Assignment_Rubric

• Grid View
• List View

		Excellent 90%–100%	Good 80%–89%	Fair 70%–79%	Poor 0%–69%
Create 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		14 (14%) – 15 (15%) 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.	12 (12%) – 13 (13%) 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.	11 (11%) – 11 (11%) 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.	0 (0%) – 10 (10%) 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.
In 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		14 (14%) – 15 (15%) The response thoroughly and accurately documents the patient’s physical exam for pertinent systems. Diagnostic tests and their results are thoroughly and accurately documented.	12 (12%) – 13 (13%) The response accurately documents the patient’s physical exam for pertinent systems. Diagnostic tests and their results are accurately documented.	11 (11%) – 11 (11%) 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.	0 (0%) – 10 (10%) 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.
In 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.		18 (18%) – 20 (20%) 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.	16 (16%) – 17 (17%) 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.	14 (14%) – 15 (15%) 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.	0 (0%) – 13 (13%) 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.
In 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.		23 (23%) – 25 (25%) 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.	20 (20%) – 22 (22%) 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.	18 (18%) – 19 (19%) 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.	0 (0%) – 17 (17%) 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.
• Reflect on this case. Discuss what you learned and what you might do differently. 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 that takes into consideration patient factors (such as age, ethnic group, etc.), PMH, and other risk factors (e.g., socioeconomic, cultural background, etc.).		5 (5%) – 5 (5%) Reflections are thorough, thoughtful, and demonstrate critical thinking.	4 (4%) – 4 (4%) Reflections demonstrate critical thinking.	3.5 (3.5%) – 3.5 (3.5%) Reflections are somewhat general or do not demonstrate critical thinking.	0 (0%) – 3 (3%) Reflections are incomplete, inaccurate, or missing.
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).		9 (9%) – 10 (10%) 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 (8%) – 8 (8%) 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 (7%) – 7 (7%) 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.	0 (0%) – 6 (6%) Two or fewer resources are provided to support the assessment and diagnosis decisions. The resources may not be current or evidence based.
Written Expression and Formatting – The paper follows correct APA format for parenthetical/in-text citations and reference list.		5 (5%) – 5 (5%) Uses correct APA format with no errors	4 (4%) – 4 (4%) Contains 1-2 grammar, spelling, and punctuation errors	3.5 (3.5%) – 3.5 (3.5%) Contains 3-4 grammar, spelling, and punctuation errors	0 (0%) – 3 (3%) Contains five or more grammar, spelling, and punctuation errors that interfere with the reader’s understanding
Written Expression and Formatting – English Writing Standards: Correct grammar, mechanics, and punctuation		5 (5%) – 5 (5%) Uses correct grammar, spelling, and punctuation with no errors	4 (4%) – 4 (4%) Contains 1-2 APA format errors	3.5 (3.5%) – 3.5 (3.5%) Contains 3-4 APA format errors	0 (0%) – 3 (3%) Contains five or more APA format errors
Total Points: 100

Name: NRNP_6675_Week5_Assignment_Rubric