SOAP Note: Schizophrenia Spectrum

Subjective:

CC (chief complaint):

Delusions and hallucinations.

HPI:

C.M, a 27-year-old female Hispanic patient comes for a psychiatric evaluation. She was last well about two months ago when she started experiencing delusions and hallucinations. The patient was constantly on the lookout believing that someone was spying on her with the motive of harming her.

SOAP Note: Schizophrenia Spectrum

The patient also started experiencing auditory hallucinations. She claims that she often hears voices of several men and women talking and laughing at her constantly. The delusions and hallucinations have been there for the past two months with no recollection of similar symptoms previously. Over the last month, the patient has reported low energy levels on several occasions and often withdrawing herself from close family members and friends.

Substance Current Use:

The patient denies any alcohol, tobacco, or drug use.

Medical History:

The patient has no known chronic illnesses. No previous surgeries. No prior hospital admissions.

  • Current Medications:

The patient is currently not on any medication.

  • Allergies

NKDFA.

  • Reproductive Hx:

LMP 04/06/2022. The cycle is 30 days lasting 5 days. Regular flow. G0T0P0A0L0. No contraceptive. Currently single. The patient is a victim of both physical and sexual assault from a previous relationship.

  • Family Hx:

Family history of schizophrenia. No other known chronic illnesses among close family members.

ROS:

  • GENERAL: No reports of fever, body aches, or any other concerns.
  • HEENT: No history of trauma, headache, or falls. No complications related to the throat, nose, and ears.
  • SKIN: No history of rash, lesions, or concerns with eczema.
  • CARDIOVASCULAR: No complains of chest pain, no palpitations, no orthopnea.
  • RESPIRATORY: No chest pain, no cough, no difficulty in breathing.
  • GASTROINTESTINAL: No change in appetite. No history of abnormal bowel movements.
  • GENITOURINARY: No hematuria, no dysuria, no urgency, no frequency.
  • NEUROLOGICAL: No syncope, no dizziness, no blurry vision, no tinnitus.
  • MUSCULOSKELETAL: No pain in the muscles or joints.
  • HEMATOLOGIC: No history of easy bruising or bleeding.
  • LYMPHATICS: Denies any lymph node swelling.
  • ENDOCRINOLOGIC: Denies increased thirst or urination.

Objective:

VS: Temp: 98.0 F, BP: 99/69, HR: 96, RR: 17, 100% on RA, Height: 5ft, 3in Wt.: 139 lbs.

BMI: 24.6. Lies within the normal range.

General: The patient is not sick looking and is in fair general condition with no signs of respiratory distress.

Skin: No abnormal lesions were observed on the skin.

Head: Normal shape and size.

Eyes: No abnormalities detected. The pupils respond appropriately to stimulation by light.

ENT: No abnormalities were observed on the ears and nose. The tympanic membrane is intact. Hearing is unaffected. The throat looks normal with no signs of inflammation.

Neck: No abnormalities on the neck.

CVS: Apex beat is not displaced. There is a normal heart rate and rhythm. Auscultation reveals normal S1 and S2 sounds with no murmurs.

RS: Trachea is central. Vesicular and bronchial breath sounds were heard. No additional sounds.

Abdomen: No visible scars. No distention. No tenderness or masses were elicited.

Musculoskeletal: Muscle tone and strength intact. Normal range of movement observed.

Assessment:

MSE:

C.M is a 27-year-old Hispanic female patient who comes in for the evaluation. Her appearance and stated age are appropriate. The patient is well responsive throughout the session. Her blouse is buttoned inappropriately. Her hair is quite unkempt. The patient displays no tics or any other abnormal movements. The patient communicates incoherently, responding to questions asked with unrelated responses and at times moving away from the issue at hand to discuss unrelated matters.

The patient often repeats what she had said earlier. Her thought is impaired. There is evidence of looseness of association and flight of ideas. Her mood is euthymic, but she demonstrates a blunt affect. Incongruency is noted. Auditory and visual hallucinations are present in this patient. Delusions are present with the patient constantly worried that someone wants to harm her. There are no thoughts of inflicting harm to self or others. Cognitively, she is alert. C.M is appropriately oriented. Her memory is not impaired. Concentration is impaired. Insight is lacking in her current condition.

Diagnostic Impression:

The primary diagnosis is schizophreniform disorder.

Differential diagnoses are substance-induced schizophrenia and delusional disorder.

Schizophreniform disorder is a psychotic disorder lasting between one to six months. The condition greatly affects an individual’s level of cognition, emotions, and actions. The condition affects both genders, with a peak incidence among women being reported between the ages of 24 to 35 years (Kahn et al., 2018). Patients often present with delusions, hallucinations, disorganized speech, and diminished energy levels.

In most instances, patients are often untidy and unkempt, often withdrawing from close family members and friends. These symptoms align with the patient’s presenting complaints and findings on examination, making this the most probable diagnosis.

The substance-induced psychotic disorder is often associated with the start or cessation of the use of alcohol or other drugs. Patients often present with delusions, hallucinations, impaired speech, impaired mood, and poor general hygiene (Wilson et al., 2018). These findings are similar to the patient’s presenting complaint. She, however, denies any alcohol or drug use. Further laboratory investigations are required to rule out any substance use and confirm what she said.

Delusional disorders are mental health conditions where patients experience various delusions of different kinds. In most instances, there is little to no impact on an individual’s well-being, and one may continue functioning normally. In severe instances, psychotic symptoms may ensue. Pertinent positives, in this case, include the history of delusions and hallucinations, disorganized speech, social withdrawal, and a family history of schizophrenia. In addition, mood and affect incongruency and lack of insight are other pertinent positives. Pertinent negatives include no alcohol or drug use, the patient being well oriented and memory being intact.

Case Formulation and Treatment Plan:

Pharmacological Interventions

Atypical antipsychotics are often used in the management of schizophreniform disorder. These include risperidone, olanzapine, and quetiapine (Alphs et al., 2022).

Nonpharmacologic Interventions

Cognitive-behavioral therapy (CBT), psychoeducation, cognitive remediation, social and coping skills, and family interventions are proven nonpharmacologic interventions for the condition (Ganguly et al., 2018).

Alternative Therapies

            Alternative therapies that can prove helpful include talk therapy, family therapy, career coaching, and communication and social skills.

Follow-up Parameters

            Assessment of the patient should be done monthly. Symptoms should have completely subsided by 6 months.

Rationale For Management

The management plan is to ensure the protection and stabilization of the patient. Minimizing psychosocial complications and enabling the patient to lead a normal life with minimal adverse effects is another critical goal of management.

Health Promotion Activity

            Educating the patient on coping with life’s stresses is a critical component of health promotion.

Patient Education Strategy

            The best education strategy is dependent on the patient’s literacy level and ability to embrace the use of technology in healthcare.

Reflection

            If I were to conduct the session again, I would inquire further into the family history of schizophrenia. Probing further into the drug and substance use history to know if the patient is lying is another thing I would do. In follow-up meetings, I would work on the patient’s communication and social skills. It is essential to take into account confidentiality, conflict of interest, operational challenges, placebo related, exploitation, informed consent, vulnerability, exploitation, and therapeutic misconception (Brown et al., 2020) as key legal/ethical considerations.

References

  • Alphs, L., Brown, B., Turkoz, I., Baker, P., Fu, D. J., & Nuechterlein, K. H. (2022). The Disease Recovery Evaluation and Modification (DREaM) study: Effectiveness of paliperidone palmitate versus oral antipsychotics in patients with recent-onset schizophrenia or schizophreniform disorder. Schizophrenia Research, 243, 86–97. https://doi.org/10.1016/j.schres.2022.02.019
  • Brown, C., Ruck Keene, A., Hooper, C. R., & O’Brien, A. (2020). Isolation of patients in psychiatric hospitals in the context of the COVID-19 pandemic: An ethical, legal, and practical challenge. International Journal Of Law And Psychiatry, 71, 101572. https://doi.org/10.1016/j.ijlp.2020.101572
  • 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
  • Kahn, R. S., Winter van Rossum, I., Leucht, S., McGuire, P., Lewis, S. W., Leboyer, M., Arango, C., Dazzan, P., Drake, R., Heres, S., Díaz-Caneja, C. M., Rujescu, D., Weiser, M., Galderisi, S., Glenthøj, B., Eijkemans, M., Fleischhacker, W. W., Kapur, S., Sommer, I. E., & OPTiMiSE study group (2018). Amisulpride and olanzapine followed by open-label treatment with clozapine in first-episode schizophrenia and schizophreniform disorder (OPTiMiSE): a three-phase switching study. The lancet. Psychiatry, 5(10), 797–807. https://doi.org/10.1016/S2215-0366(18)30252-9
  • Wilson, L., Szigeti, A., Kearney, A., & Clarke, M. (2018). Clinical characteristics of primary psychotic disorders with concurrent substance abuse and substance-induced psychotic disorders: A systematic review. Schizophrenia Research, 197, 78–86. https://doi.org/10.1016/j.schres.2017.11.001

SOAP Note Instructions: Schizophrenia Spectrum

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.
  • 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-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).