NRNP 6675 PMHNP Care Across the Lifespan II: Focused SOAP Note for Schizophrenia Spectrum, Other Psychotic, and Medication-Induced Movement Disorders


NRNP 6675 PMHNP Care Across the Lifespan II: Focused SOAP Note for Schizophrenia Spectrum, Other Psychotic, and Medication-Induced Movement Disorders

NRNP 6675 PMHNP Care Across the Lifespan II Focused SOAP Note for Schizophrenia Spectrum, Other Psychotic, and Medication-Induced Movement Disorders

Subjective:

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

HPI: Sherman Tremaine is a 55-year-old Caucasian man on psychiatric evaluation because his sister persuaded him to. He reports that after his mother died, there are people disturbing him. He states that there are that people outside his window spying on him, and he hears and see their shadows. The patient claims that they were government spies who have escalated his taxes. This started several weeks ago. He reports that he does not sleep adequately for several days due to the loud voices. The patient states that he cannot watch television since the spies watch him through it and go to his house to poison his food. Consequently, he locks his food in the fridge to confuse them.

Substance Current Use: Smokes 3PPD. Takes alcohols 12-pack of beer per week. He was using marijuana but quit three years ago after his mother’s death. Denies using cocaine or other drugs.

Medical History: Has a history of diabetes and fatty liver.

 

  • Current Medications: Metformin.
  • Allergies: NKFDA
  • Reproductive Hx: No history of STIs.

ROS:

  • GENERAL: Denies low energy levels, fever, or malaise.
  • HEENT: Negative for visual disturbance, hearing loss, nasal discharge, sneezing, or pain when swallowing.
  • SKIN: Denies itching or rashes.
  • CARDIOVASCULAR: Denies edema, chest discomfort, or SOB on exertion.
  • RESPIRATORY: No cough, wheezing, or sputum.
  • GASTROINTESTINAL: Denies vomiting, abdominal discomfort, or rectal bleeding.
  • GENITOURINARY: No dysuria or penile discharge.
  • NEUROLOGICAL: Denies headache, paralysis, seizures, or black spells.
  • MUSCULOSKELETAL: Negative for musculoskeletal pain.
  • HEMATOLOGIC: No bruising or anemia.
  • LYMPHATICS: No lymph swelling.
  • ENDOCRINOLOGIC: No brittle nails, excessive sweating, polydipsia, or polyuria.

Objective:

Diagnostic results: Psychotic symptoms are not associated with any characteristic diagnostic results. Lab tests that can be carried out to rule out other or associated disorders are CBC count; LFTs, Thyroid tests, and renal function tests; Urine drug test for drugs of abuse, like cocaine, alcohol, opioids, and cannabis (Stępnicki et al., 2018).

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Assessment:

Mental Status Examination: Caucasian male patient in his 50’s. The patient is alert but appears distracted and frequently looks out the

NRNP 6675 PMHNP Care Across the Lifespan II Focused SOAP Note for Schizophrenia Spectrum, Other Psychotic, and Medication-Induced Movement Disorders
NRNP 6675 PMHNP Care Across the Lifespan II Focused SOAP Note for Schizophrenia Spectrum, Other Psychotic, and Medication-Induced Movement Disorders

window. Despite the hot sunny weather, he is in a heavy fur coat and gloves. He is oriented to person and place but cannot identify the day. His speech varies from clear to inaudible. He has illogical and magical thoughts. Visual and auditory hallucinations are present. Persecutory delusions were noted. He has impaired short-term memory and judgment.

Diagnostic Impression:

Schizophrenia: The diagnostic criterion for schizophrenia requires one of the symptoms to be delusions, or hallucinations, disorganized speech (Stępnicki et al., 2018). The patient meets these diagnostic criteria since he presents with hallucinations (visual and auditory), delusions (persecutory), and inappropriate appearance.

Persecutory Delusional Disorder (PDD): PDD is the most common delusional disorder. Diaconescu et al. (2019) explain that PDD manifests with paranoia, with an individual being convinced that others are plotting to cause them harm. PDD is a likely diagnosis due to the client’s irrational belief that there are people outside his window watching him and poisoning his food.

Bipolar Disorder– Manic phase: The manic phase is characterized by grandiosity, reduced sleep, talking excessively, flight of ideas, racing thoughts, poor judgment, and distractibility (Brieler & Keegan-Garrett, 2022). This is a differential due to the patient’s positive symptoms of distractibility, reduced sleep, and illogical and magical thoughts.

Reflections: The diagnostic impression of schizophrenia aligns with the patient’s presentation and is thus acceptable. I learned that delusions, hallucinations, or disorganized speech are crucial in diagnosing schizophrenia. In a different case, I would use tools to assess the severity of the patient’s psychotic symptoms, like the Brief Psychiatric Rating Scale or the Positive and Negative Syndrome Scale (Stępnicki et al., 2018). Respect for the patient’s autonomy is crucial in this case. The patient’s treatment preferences should be considered in treatment planning to promote adherence. Health promotion should target the patient’s lifestyle to improve glycemic control and prevent diabetes complications.

Case Formulation and Treatment Plan:

Psychopharmacology: Aripiprazole (Abilify) 15 mg/day PO for 2 weeks.

If tolerability is established after two weeks, the treatment will be changed to:

Abilify Maintena 400 mg IM once monthly. Once-monthly IM injections will promote treatment adherence since the patient reports that the medications are all poisonous.

Abilify is used for treatment of schizophrenia in the acute and maintenance phase. The commonly reported adverse effects of Abilify are headache, nausea, vomiting, tremor, insomnia, and constipation (Qian et al., 2021).

Psychotherapy: Cognitive behavioral therapy (CBT) will be an adjunct to antipsychotic therapy. CBT will aim to alleviate the psychological stress caused by psychotic symptoms and help the patient cope (Kart et al., 2021).

Health education: The patient will be educated on the importance of smoking cessation to improve his health outcomes and prevent microvascular diabetic complications that cause foot amputations.

Follow-up: A follow-up will be scheduled after four weeks to assess the patient’s response to treatment.

 

NRNP 6675 PMHNP Care Across the Lifespan II: Focused SOAP Note for Schizophrenia Spectrum, Other Psychotic, and Medication-Induced Movement Disorders References

Brieler, J. A., & Keegan-Garrett, E. (2022). Diagnosis and Treatment of Bipolar Illness in the Primary Care Office. Missouri medicine119(3), 213–218.

Diaconescu, A. O., Hauke, D. J., & Borgwardt, S. (2019). Models of persecutory delusions: a mechanistic insight into the early stages of psychosis. Molecular psychiatry24(9), 1258–1267. https://doi.org/10.1038/s41380-019-0427-z

Kart, A., Özdel, K., & Türkçapar, M. H. (2021). Cognitive Behavioral Therapy in Treatment of Schizophrenia. Noro psikiyatri arsivi58(Suppl 1), S61–S65. https://doi.org/10.29399/npa.27418

Qian, L., Xuemei, L., Jitao, L., Yun’Ai, S., & Tianmei, S. (2021). Dose-Dependent Efficacy of Aripiprazole in Treating Patients With Schizophrenia or Schizoaffective Disorder: A Systematic Review and Meta-Analysis of Randomized Controlled Trials. Frontiers in psychiatry12, 717715. https://doi.org/10.3389/fpsyt.2021.717715

Stępnicki, P., Kondej, M., & Kaczor, A. A. (2018). Current Concepts and Treatments of Schizophrenia. Molecules (Basel, Switzerland)23(8), 2087. https://doi.org/10.3390/molecules23082087

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