Focused SOAP Note for Schizophrenia Spectrum

NRNP 6675: PMHNP Care Across the Lifespan II

Focused SOAP Note for Schizophrenia Spectrum

Patient Initials: ST.

Age: 53 years

Sex: Male

Subjective:

CC (chief complaint): “I was living, and not bothering anyone, and those people– those people, they just won’t leave me alone”

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HPI: ST a 53-year-old, male, African American type 2 diabetic on metformin who was brought by his sister with delusions that there were people following him sent from the government to watch him as his taxes were very high. The symptoms began suddenly and shortly after his mother passed away and they have been there for several weeks. He further reports that he can see and hear those watching him through the windows and TV and that they have even attempted to poison his food. These delusions were associated with hearing heavy metal music as well as seeing birds in the sky. He additionally reports sleep disturbance due to loud voices.  He denies a history of trauma or any suicidal thoughts. He denies sexual or emotional abuse during childhood however his father was rough since childhood and he might have had physical insults at some point.

Substance Current Use: Smokes three packs of cigars per day. He further stopping marijuana 3 years ago after his mother died. He denies alcohol use or legal issues due to drugs.

Medical History:

  • Current Medications: Metformin 500mg orally twice a day.
  • Allergies: He reports no known food and drug allergies
  • Reproductive Hx: Heterosexual, unmarried with no children.

Past Medical History and Surgical History

He was admitted three times when he was 20 years. No history of previous surgeries or blood transfusion. Diabetic but not hypertensive. HIV negative. Has fatty liver disease. He was previously on haloperidol, chlorpromazine, risperidone, and quetiapine.

Family, Personal and Social History

ST is unemployed, unmarried, and with no children.  10th grade is his highest educational level. He stays alone. His father worked in a state hospital and had paranoid schizophrenia while his mum had an anxiety disorder. He enjoys smoking and drinking pop. No history of violence, aggressive behavior, suicidal or self-injurious thoughts.

Focused SOAP Note for Schizophrenia Spectrum  ROS:

  • GENERAL: He denies hotness of the body, general body malaise, nausea/vomiting, or chills
  • HEENT: He denies headache, blurred vision, double vision, earache, difficulty in hearing, sneezing, runny nose, or sore throat
  • SKIN: Reports no skin loss or rash
  • CARDIOVASCULAR: He denies awareness of heartbeat, shortness of breath on exertion, chest pain, or fatigue
  • RESPIRATORY: He reports no chest pain, difficulty in bleeding, production of sputum or cough
  • GASTROINTESTINAL: he denies constipation, diarrhea, abdominal pain, or difficulty in swallowing
  • GENITOURINARY: He reports frequent urination, denies urinary incontinence and pain on urination
  • NEUROLOGICAL: He reports no loss of sensation to touch
  • MUSCULOSKELETAL: He denies joint pains, muscle pains, back pain, or joint stiffness
  • HEMATOLOGIC: No bleeding, bruising, or anemia
  • LYMPHATICS: No history of splenectomy, no lymphadenopathy
  • ENDOCRINOLOGIC: Reports polyuria and polydipsia. He denies sweating, heat, or cold intolerance

Objective:

Vital Signs: B/P- 123/78 mmHg, P-94 beats/min, RR-18, SPo2- 97%, Wt- 115 kg, BMI-28

General: An middle-aged African American male, untidy with unkempt hair, in good general condition, well-hydrated, and of good nutrition status. No jaundice, pallor, cyanosis, edema, cervical or inguinal lymphadenopathy

Neurologic: GCS 15/15, MMSE of 22/30. Oriented to place, person but not time, deficits in registration, attention, recall, and calculation, equal pupillary reaction to light

Abdominal: Moves with respiration, non-distended on inspection, mildly tender on the right upper quadrant, no organomegaly on palpation, tympanic on percussion, and bowel sound present on auscultation.

Diagnostic results: Random blood glucose of 6.5 mmol. LFTs-Slightly elevated alanine and aspartate aminotransferases. CT head- no cerebral atrophy or intracerebral bleed. Abdominal ultrasound- features suggestive of steatosis.

Assessment:

Mental Status Examination: ST is a 53-year-old African American male, muscular who looks his stated age. He is cooperative with the examiner. He is untidy with unkempt hair but appropriately dressed. There is no evidence of any abnormal motor activity. His speech is clear, coherent, normal in volume and tone. His thought process is goal-directed and logical. There is evidence of a flight of ideas. Similarly, his mood is euthymic, and his affect appropriate to his mood. He was occasionally smiling appropriately. He perceives auditory and visual hallucinations as well as persecutory delusions. He denies any current suicidal or homicidal ideation. Cognitively, he is alert and oriented in place, person but not time. His remote memory is intact but has some relapses in recent memory. His concentration is generally good although sometimes he becomes inattentive. His intellect is good as well as his insight about his current illness

Diagnostic Impression:

  1. Schizophrenia.
  1. has delusions and hallucinations for weeks and weeks which meet Criteria A of DSM V diagnosis of schizophrenia (DSM-5, 2013). Furthermore, he has difficulties maintaining interpersonal relationships, and his academic, social and occupational performance is way below the expected level (Hany et al., 2020). He also has insight into his current illness has previously been on antipsychotic medications. He also experiences disturbances in sleep which are common in schizophrenic individuals (Hany et al., 2020). Additionally, his father had paranoid schizophrenia and his condition cannot be explained by the underlying fatty liver disease, type 2 diabetes(DSM-5, 2013), or substance abuse. His schizophrenia has a good prognosis based on his presentation.
  1. Schizophreniform disorder

Features discussed above to validate the diagnosis of schizophrenia similarly validate the diagnosis of schizophreniform disorder as ST. does not specify the exact duration of his symptoms, but only claims to be many weeks which can be less than 6 months(López-Díaz et al., 2018). His prognosis is also good.

  1. Delusional disorder
  1. presents mainly with persecutory delusions and meets DSM V Criteria A for diagnosis of delusional disorder (DSM-5, 2013). He further meets Criteria B of DSM V diagnosis of this disorder as his hallucinations are in line with the delusions. His behavior is further not bizarre besides his social, academic, and occupational functional impairments (Joseph & Siddiqui, 2020).

Reflections: The experience has given me a chance to apply critical thinking skills to properly recognize the symptoms of delusions, hallucinations, cognitive changes of disorientation, impaired short-term memory and thought process as well as insight. The readings further have enabled me to vividly differentiate schizophrenia from other psychotic states such as schizophreniform disorder, schizoaffective disorder, delusional disorder, and brief psychotic disorder.

Case Formulation and Treatment Plan:

Lab and Diagnostic Tests to be Ordered (if applicable)

  • Random blood glucose – 6.7mmol
  • Hemoglobin A1C- monitor the diabetes
  • Complete blood count- rule out infections, anemia, bleeding disorders
  • Urea and electrolytes- rule out electrolyte abnormalities as well as check kidney function
  • Urinary toxicology screen- check for any illicit drugs

Pharmacologic Treatment

-Antipsychotics-Second generation antipsychotics such as aripiprazole, ziprasidone, quetiapine, or olanzapine in combination with a benzodiazepine such as midazolam to manage behavioral disturbance and nonacute anxiety (Hany et al., 2020)

Continue on metformin and monitor random blood sugars.

Non-pharmacologic treatment

  • Cognitive-behavioral therapy
  • Rehabilitation as well as family therapy
  • Exercise to reduce weight
  • Diet modifications

Education

The patient advised to strictly adhere to the antipsychotic and antidiabetic treatment regimen

Advised on the need to stop smoking

Patient educated on the  side effects of respective agents

Advised to observe a balanced diet

Follow-Ups/Referrals

Follow up by a psychiatrist

Linking the patient to a diabetic support group to help him access treatment and education

Refer to endocrinologist

Focused SOAP Note for Schizophrenia Spectrum References

DSM-5. (2013). Psychiatry.Org. https://www.psychiatry.org/psychiatrists/practice/dsm

Hany, M., Rehman, B., Azhar, Y., & Chapman, J. (2020). Schizophrenia. In StatPearls. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK539864/

Joseph, S. M., & Siddiqui, W. (2020). Delusional Disorder. In StatPearls. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK539855/

López-Díaz, Á., Lara, I., & Luis Fernández-González, J. (2018). Acute schizophrenia-like psychotic disorder: A critical appraisal of its diagnostic validity through a case series. Innovations in Clinical Neuroscience15(1–2), 12–13. https://www.ncbi.nlm.nih.gov/pubmed/30023137