NRNP 6675 Focused SOAP Note for Schizophrenia Spectrum, Other Psychotic, and Medication-Induced Movement Disorders
Subjective:
Chief Complaint (CC): “My sister made me come in.”
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History of Present Illness (HPI): S.T. is a 53-year-old Caucasian female patient who was admitted to the psychiatric unit at the insistence of her sister. The patient reports a persistent feeling that people are observing her through her room’s window, along with auditory hallucinations of them talking about poisoning her. She believes this has been ongoing for several weeks. She also expresses paranoia when watching television, believing that people on the screen are conspiring to poison her food. The patient denies any medication use and a history of seizures. She has no suicidal thoughts or intentions.
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Past Psychiatric History:
– General Statement: The patient has a history of psychosis.
– Caregivers (if applicable): She now resides with her sister following their mother’s death.
– Hospitalizations: The patient has been hospitalized for mental health reasons three times before the age of 29.
– Medication trials: Previous medications included Thorazine and Haldol, but she discontinued them due to perceived ineffectiveness. She experienced breast enlargement with risperidone, which she found unattractive. She acknowledges the effectiveness of Seroquel but doesn’t consistently adhere to the prescribed dosages.
– Psychotherapy or Previous Psychiatric Diagnosis: No history of psychotherapy or prior psychiatric diagnoses.
Substance Current Use: The patient smokes three packs of cigarettes daily and consumes 12 bottles of wine regularly. She stopped using marijuana after her mother’s death.
Family Psychiatric/Substance Use History: Both parents have a history of mental illness. Her mother had an anxiety disorder, and her father was diagnosed with paranoid schizophrenia. There is no history of suicide in her family.
Psychosocial History: Following her mother’s death three years ago, the patient and her sister moved in together. She completed high school but has never been married and has no children. She is currently unemployed, with no documented arrests. She reports good sleep and a healthy appetite.
Medical History: Fatty liver and diabetes.
– Current Medications: Managing blood sugar with metformin.
– Allergies: No known drug, food, or environmental allergies.
– Reproductive History: Identifies as heterosexual, single, and childless.
Review of Systems (ROS):
– GENERAL: Denies symptoms such as fatigue, fever, weight loss, nausea, or vomiting.
– HEENT: No headaches, injuries, ear issues, eye problems, nasal congestion, sinusitis, throat discomfort, dental issues, or sore throats.
– SKIN: No rashes, itching, or hives; skin feels warm, moist, and comfortable.
– CARDIOVASCULAR: Denies chest pain, orthopnea, shortness of breath, lower limb swelling, palpitations, or syncope.
– RESPIRATORY: No chest discomfort, cough, shortness of breath, snoring, or hemoptysis.
– GASTROINTESTINAL: Denies nausea, vomiting, abdominal swelling, diarrhea, constipation, or bloody stools.
– GENITOURINARY: No frequent or urgent urination, incontinence, nighttime urination, painful urination, or blood in urine.
– NEUROLOGICAL: No headaches, balance problems, dizziness, weakness, numbness, or neurological deficits.
– MUSCULOSKELETAL: No joint pain or stiffness; normal joint range of motion.
– HEMATOLOGIC: No history of easy bruising, abnormal bleeding, or clotting disorders.
– LYMPHATICS: No history of swollen lymph nodes.
– ENDOCRINOLOGIC: No fatigue, significant weight changes, excessive thirst, hunger, or urination.
Objective:
Diagnostic results: Routine blood tests, including CBC and WBC, were conducted, as well as a comprehensive metabolic panel. Liver and renal function tests were performed to assess the impact of previous psychiatric medications. Imaging studies such as MRIs and CT scans were requested to rule out physical causes for the patient’s symptoms. Diagnostic tools such as the Calgary Depression Scale for Schizophrenia, Brief Psychiatric Rating Scale (BPRS), SANS and SAPS Tests, and Positive and Negative Syndrome Scale (PANSS) were employed (Jauhar et al., 2018).
Assessment:
Mental Status Examination: The 53-year-old patient appears well-groomed and appropriately dressed. She is oriented to time, place, and people but seems uncomfortable. During the interview, she is cooperative but easily distracted with a limited attention span. Her thought process is impaired, and she exhibits depressive symptoms. She displays intact short-term and long-term memory but experiences delirium and hallucinations. She denies suicidal thoughts or self-harming behaviors.
Diagnostic Impression:
1. Schizophrenia Spectrum and Other Psychotic Disorders: The patient presents with symptoms consistent with schizophrenia, including bizarre behavior, hallucinations, delirium, and confusion (Palomar-Ciria et al., 2019). The DSM-V requires the presence of at least two of these symptoms, in addition to negative symptoms or catatonic behavior, for a diagnosis. Most of these symptoms are evident in this patient, and she has a history of psychosis, making this the most likely diagnosis.
2. Bipolar I Disorder with psychotic features: Bipolar I disorder often involves manic episodes with psychotic symptoms like hallucinations and delusions (Kesebir et al., 2020). However, the patient in this case study exhibits only psychotic symptoms and no manic episodes, ruling out this diagnosis.
3. Delusional Disorder: Delusions can be a symptom in various mental disorders, but the DSM-V recognizes this as a distinct disorder when a patient experiences delusions for at least one month without other associated symptoms of another mental disorder (Perrotta, 2020). The patient in this case meets the criteria for this disorder as she reports delusions along with other psychotic symptoms.
Reflections: The PMHNP conducted an adequate mental assessment with a compassionate and non-judgmental approach. However, due to the patient’s impaired thought process, contacting her sister for further information on her mental status was necessary (Jauhar et al., 2018). This places the PMHNP in a position where they must balance the patient’s right to privacy and confidentiality while disclosing the diagnosis and treatment to the patient’s sister to assist with medication management.
Case Formulation and Treatment Plan:
Primary diagnosis: Schizophrenia Spectrum and Other Psychotic Disorders
Psychotherapy: Cognitive behavioral therapy and interpersonal therapy (El-Mallakh et al., 2019).
Alternative psychotherapy: Family counseling in addition to Coordinated Specialty Care (CSC).
Pharmacotherapy: Prescribe extended-release tablets of Quetiapine (Rx) at 300 milligrams to be taken orally once daily. The dosage may be increased by 300 mg per week to achieve the optimal therapeutic effect (Maroney, 2020).
Patient Education: Emphasize the importance of medication adherence to improve treatment outcomes (Maroney, 2020).
Health Promotion: Encourage the patient to maintain a healthy lifestyle, including regular exercise and smoking cessation (Maroney, 2020).
Follow-up: Schedule weekly clinic visits for dose adjustments.
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 an asymptomatic distinction between 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 a 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
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