SOAP Note: Schizophrenia Spectrum Example

Subjective:

CC (chief complaint):

Delusions and hallucinations.

HPI:

C.M is a 27-year-old African American female patient who was 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. 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.

SOAP Note: Schizophrenia Spectrum Example

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: Denies headache, trauma, or falls. Denies any concerns with the ears, nose, or throat.
  • SKIN: Denies any rash, lesions, or concerns with eczema.
  • CARDIOVASCULAR: Denies any chest pain, cyanosis, heart racing, or sweating.
  • RESPIRATORY: Denies any cough, congestion, wheezing, or difficulty breathing.
  • GASTROINTESTINAL: Denies weight loss, nausea, vomiting, constipation, or diarrhea.
  • GENITOURINARY: Negative for burning or blood in the urine.
  • NEUROLOGICAL: Denies changes in senses.
  • MUSCULOSKELETAL: Denies pain, trauma, and numbness.
  • HEMATOLOGIC: Denies 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. It is within the normal range.

General: Well-nourished and hydrated, no apparent distress. Appropriately dressed.

Skin: No evidence of rash or lesions.

Head: Normocephalic.

Eyes: The lids and conjunctiva are normal. Pupils are irises are normal fundoscopic exam reveals a red reflex present bilaterally.

ENT: Normal external ears and nose. Normal external auditory canals and tympanic membranes. Hearing is grossly normal. Oropharynx: normal mucosa, palate, and posterior pharynx.

Neck: Supple and no lymphadenopathy.

CV: Normal rate and rhythm. Normal S1 and S2 heart sounds heard on auscultation with no S3 or S4. No murmurs. Femoral pulse 2+ bilaterally.

Lungs: Normal respiratory rate and pattern with no apparent distress. Bilateral breath sounds clear on auscultation without rales, rhonchi, or wheezes.

Abdomen: Normal bowel sounds. No masses, tenderness, or organomegaly elicited.

Musculoskeletal: Grossly normal tone and muscle strength. Normal range of motion in extremities.

Assessment:

Mental Status Examination:

C.M is a 27-year-old African American female who looks appropriate for her stated age. She is relatively cooperative with the examiner. Her blouse is buttoned inappropriately. Her hair is quite unkempt. No evidence of abnormal motor activity. 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. Mood and affect are, therefore, incongruent. The patient reports both auditory and visual hallucinations. Delusions are present with the patient constantly worried that someone wants to harm her. She denies any current suicidal or homicidal ideation. Cognitively, she is alert. The patient is well-oriented to time, place, and person. Her recent, remote and long-term memory is intact. Concentration is impaired. She has no insight into her 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 the 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, informed consent, conflict of interest, therapeutic misconception, placebo related, vulnerability, exploitation, and operational challenges (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

Focused Soap Note for Schizophrenia Spectrum, Other Psychotic, and Medical-Induced Movement Disorders Instructions

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).