NRNP 6675 :Focused SOAP Note for Schizophrenia Spectrum, Other Psychotic, and Medication-Induced Movement Disorders Essay Paper

NRNP 6675 :Focused SOAP Note for Schizophrenia Spectrum, Other Psychotic, and Medication-Induced Movement Disorders Essay Paper

NRNP 6675 :Focused SOAP Note for Schizophrenia Spectrum, Other Psychotic, and Medication-Induced Movement Disorders Essay Paper

Subjective:

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

HPI: S.T. is a Caucasian female patient who is 53 years old and was admitted to the psychiatric unit at the request of her sister. The patient said that the majority of the time she has the sensation that people are observing her via the window on the outside of the room. She asserts that she can hear them. According to what she claimed, these occurrences had been going on for weeks. While the patient was watching television, she insisted that the persons she saw on the screen were plotting to poison her food to murder her. Denies having used medicines and or having a history of seizures. There were no reports of having suicidal thoughts or intentionally hurting herself in any way.

ORDER A PLAGIARISM-FREE PAPER HERE ON; NRNP 6675 :Focused SOAP Note for Schizophrenia Spectrum, Other Psychotic, and Medication-Induced Movement Disorders Essay Paper

Past Psychiatric History:

• General Statement: The patient has a past that is marked by episodes of psychosis.
• Caregivers (if applicable): Due to their mother’s death, she now shares a home with her sister.
• Hospitalizations: substantiates prior mental hospitalizations on three separate occasions by the time she was 29 years old.
• Medication trials: Thorazine and Haldol were previously used to treat the patient’s mental problems, but she stopped taking them since she felt they were not helping. However, she developed larger breasts while on risperidone, which she finds unattractive. Verifies Seroquel’s excellent efficacy. However, she seldom adheres to the prescribed dosages.
• Psychotherapy or Previous Psychiatric Diagnosis: None.

Substance Current Use: The patient admits to smoking three packs of cigarettes a day regularly. She also often consumes 12 bottles of wine. But once her mother died, she gave up smoking pot.

Family Psychiatric/Substance Use History: Both the patient’s mother and the patient’s father have been diagnosed with mental illnesses. The patient’s mother has a history of anxiety disorder, while the patient’s father was diagnosed with paranoid schizophrenia disorder. She says that none of her family has ever committed suicide.

Psychosocial History: After their mother’s death three years ago, the patient and her sister moved in together. She has only completed high school. She says she has never been married and has no kids. No one is hiring her. There are no documented arrests for her, yet. She confirms having good sleep and eating well.

Medical History: Fatty liver and diabetes.

• Current Medications: Managing blood sugar using metformin.
• Allergies: No documented sensitivities to drugs, foods, or the environment.

• Reproductive Hx: Identifies as heterosexual yet is single and childless.

ROS:

• GENERAL: Denies having any symptoms such as lethargy, fever, leanness, nausea, or weight loss.
• HEENT: Head: denies any evidence of a headache or injury. No soreness, itching, discharge, or ringing in the ears. No redness, tears, itching, or vision impairments in the eyes. Nose: denies stuffiness, sinusitis, irritation, or congestion. Throat & Mouth: Denies dental issues, bleeding gums, swallowing issues, or sore throats.
• SKIN: No hives, rashes, or itching; just warm, moist, and comfortable.
• CARDIOVASCULAR: denies experiencing chest pressure, orthopnea, dyspnea, edema in the lower limbs, palpitations, or syncope.
• RESPIRATORY: denies experiencing chest discomfort, shortness of breath, hemoptysis, cough, or snoring.
• GASTROINTESTINAL: denies experiencing nausea, vomiting, hematemesis, abdominal swelling, diarrhea, constipation, or bloody stools.
• GENITOURINARY: denies having frequent or urgent urination, incontinence, nighttime urination, burning while urinating, or pee that contains blood.
• NEUROLOGICAL: denies experiencing headaches, balance issues, dizziness, weakness, numbness, or abrupt loss of neurological function.
• MUSCULOSKELETAL: denies any joint soreness or stiffness. demonstrates the complete range of motion in all joints.
• HEMATOLOGIC: denies a history of easy bruising, irregular bleeding, or hypercoagulability.
• LYMPHATICS: denies having swollen lymph nodes in the past.
• ENDOCRINOLOGIC: denies tiredness, a weight increase or loss, polyuria, polyphagia, or polydipsia.

Objective:

Diagnostic results: Standard blood tests like CBC and WBC were taken. The fundamental metabolic panel was also kept track of. To evaluate the impact of the previously used psychiatric medications, liver and renal function tests were also requested. To rule out physical reasons for the patient’s symptoms, imaging investigations like MRIs and CT scans are requested (Jauhar et al., 2018). The Calgary Depression Scale for Schizophrenia, Brief Psychiatric Rating Scale (BPRS), SANS and SAPS Tests, and Positive and Negative Syndrome Scale are further diagnostic instruments used (PANSS).

Assessment:

Mental Status Examination: The patient, who was 53 years old, arrived well-groomed and dressed appropriately for his age. She has a good sense of time, location, and the people around her. However, she gives off the impression of being uncomfortable. During the course of the interview, she is cooperative; yet, she is quickly distracted and has a limited focus span. Her ability to think has been impaired. She seems to be depressed. Exhibits the proper amount of both short-term and long-term memory. In addition to that, she exhibits symptoms of delirium and hallucinations. Denies having suicidal thoughts or engaging in self-harming actions.

Diagnostic Impression:

1. Schizophrenia Spectrum and Other Psychotic Disorders: Schizophrenia symptoms include acting in bizarre ways because of a disconnection from reality (Palomar-Ciria et al., 2019). In addition to hallucinations, other symptoms might include delirium, confusion, and bizarre behavior. Two of the aforementioned symptoms, in addition to negative symptoms or catatonic conduct, are required by the DSM-V for a diagnosis. Most of these symptoms were present in the patient in the presented case study, and the patient had a history of psychosis, therefore this is the most likely diagnosis.
2. Bipolar I Disorder with psychotic features: The DSM-V makes it very apparent that people who have this condition often exhibit manic episodes together with psychotic symptoms such as hallucination and delusion (Kesebir et al., 2020). The patient in the presented case study solely exhibited psychotic symptoms and did not have any manic episodes; as a result, this diagnosis cannot be made for them.
3. Delusional Disorder: Delusion is a symptom that is present in the majority of different mental diseases. However, the DSM-V defined this as a separate disorder when a patient comes with delusion clinical manifestations a month with no other related symptoms indicating another mental disease. This is the case when a patient meets the criteria for this condition (Perrotta, 2020). In addition to having delusions, the patient in the supplied case study reported having several other psychotic symptoms.

Reflections: The mental assessment that was performed by the PMHNP was carried out acceptably and had sufficient information to enable a medical diagnosis to be made. The clinician made a concerted effort to engage the patient in the conversation using a kind and non-condemnatory tone, which enabled the patient to feel at ease while discussing her problems. However, since the patient’s ability to think was impaired, the patient’s sister needed to be contacted so that further information on her mental status could be obtained (Jauhar et al., 2018). As a consequence of this, the PMHNP is required to respect the patient’s right to privacy and confidentiality while at the same time revealing the patient’s diagnosis and treatment to the patient’s sister so that the sister may assist the patient in taking her prescription at home.

 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: Extended-release tablets of Quetiapine (Rx) 300 milligrams should be taken orally once a day. To get the optimum amount necessary for a beneficial result, increase the dose by increments of 300 mg every week (Maroney, 2020).

Patient Education: Inform the patient of the significance of taking her medicine exactly as it was given to her to improve the results of the therapy (Maroney, 2020).

Health Promotion: In addition to eating healthily, the patient has to be encouraged to get regular exercise and should be counseled to give up smoking (Maroney, 2020).

Follow-up: The patient is required to return to the clinic once each week for the dosage to be modified.

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

BUY A CUSTOM- PAPER HERE ON; NRNP 6675 :Focused SOAP Note for Schizophrenia Spectrum, Other Psychotic, and Medication-Induced Movement Disorders Essay Paper

 

Psychotic disorders change one’s sense of reality and cause abnormal thinking and perception. Patients presenting with psychotic disorders may suffer from delusions or hallucinations or may display negative symptoms such as lack of emotion or withdraw from social situations or relationships. Symptoms of medication-induced movement disorders can be mild or lethal and can include, for example, tremors, dystonic reactions, or serotonin syndrome.

For this Assignment, you will complete a focused SOAP note for a patient in a case study who has either a schizophrenia spectrum, other psychotic, or medication-induced movement disorder.

Resources

 

Be sure to review the Learning Resources before completing this activity.
Click the weekly resources link to access the resources.

WEEKLY RESOURCES

Learning Resources

Required Readings

• Boland, R. Verdiun, M. L. & Ruiz, P. (2022). Kaplan & Sadock’s synopsis of psychiatry (12th ed.). Wolters Kluwer.
  • Chapter 2, “Neurodevelopmental Disorders and Other Childhood Disorders”
    • Section 2.16,  “Early-Onset Schizophrenia” (pp. 207-210)
  • Chapter 5, “Schizophrenia Spectrum and Other Psychotic Disorders”

• Thapar, A., Pine, D. S., Leckman, J. F., Scott, S., Snowling, M. J., & Taylor, E. A. (Eds.). (2015). Rutter’s child and adolescent psychiatry (6th ed.). Wiley Blackwell.
  • Chapter 43, “Pharmacological, Medically-Led and Related Disorders”
  • Chapter 57, “Schizophrenia and Psychosis”
• Zakhari, R. (2021). The psychiatric-mental health nurse practitioner certification review manual. Springer Publishing Company.
  • Chapter 9, “Psychotic Disorders and Delusions”

Document: Focused SOAP Note Template

Download Focused SOAP Note Template
Document: Focused SOAP Note Exemplar

Download Focused SOAP Note Exemplar

Required Media

PsychScene Hub. (2017, April 24). Movement disorders with antipsychotic medication

Links to an external site. – Conversations with Dr. Stephen Stahl [Video]. YouTube. https://www.youtube.com/watch?v=ipW5AcbFzzE
Vallejo, E. (2020). Realistic schizophrenia simulation

Links to an external site. [Video]. YouTube. https://www.youtube.com/watch?v=63lHuGMbscU
Walden University. (2021). Case study: Sherman Tremaine. Walden University Canvas. https://waldenu.instructure.com

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).

By Day 7 of Week 5

Submit your Focused SOAP Note.

 

submission information

Before submitting your final assignment, you can check your draft for authenticity. To check your draft, access the Turnitin Drafts from the Start Here area.

1. To submit your completed assignment, save your Assignment as WK5Assgn_LastName_Firstinitial
2. Then, click on Start Assignment near the top of the page.
3. Next, click on Upload File and select Submit Assignment for review.

BUY A CUSTOM- PAPER HERE ON; NRNP 6675 :Focused SOAP Note for Schizophrenia Spectrum, Other Psychotic, and Medication-Induced Movement Disorders Essay Paper

Rubric

NRNP_6675_Week5_Assignment_Rubric

NRNP_6675_Week5_Assignment_Rubric

Criteria	Ratings	Pts
This criterion is linked to a Learning Outcome Create documentation in the Focused SOAP Note Template about your assigned patient.In the Subjective section, provide: • Chief complaint• History of present illness (HPI)• Past psychiatric history• Medication trials and current medications• Psychotherapy or previous psychiatric diagnosis• Pertinent substance use, family psychiatric/substance use, social, and medical history• Allergies• ROS	15 to >13.0 ptsExcellent 90%–100% The response throughly and accurately describes the patient’s subjective complaint, history of present illness, past psychiatric history, medication trials and current medications, psychotherapy or previous psychiatric diagnosis, pertinent histories, allergies, and review of all systems that would inform a differential diagnosis. 13 to >11.0 ptsGood 80%–89% The response accurately describes the patient’s subjective complaint, history of present illness, past psychiatric history, medication trials and current medications, psychotherapy or previous psychiatric diagnosis, pertinent histories, allergies, and review of all systems that would inform a differential diagnosis. 11 to >10.0 ptsFair 70%–79% The response describes the patient’s subjective complaint, history of present illness, past psychiatric history, medication trials and current medications, psychotherapy or previous psychiatric diagnosis, pertinent histories, allergies, and review of all systems that would inform a differential diagnosis but is somewhat vague or contains minor innacuracies. 10 to >0 ptsPoor 0%–69% The response provides an incomplete or inaccurate description of the patient’s subjective complaint, history of present illness, past psychiatric history, medication trials and current medications, psychotherapy or previous psychiatric diagnosis, pertinent histories, allergies, and review of all systems that would inform a differential diagnosis. Or the subjective documentation is missing.	15 pts
This criterion is linked to a Learning Outcome In the Objective section, provide:• Physical exam documentation of systems pertinent to the chief complaint, HPI, and history• Diagnostic results, including any labs, imaging, or other assessments needed to develop the differential diagnoses	15 to >13.0 ptsExcellent 90%–100% The response thoroughly and accurately documents the patient’s physical exam for pertinent systems. Diagnostic tests and their results are thoroughly and accurately documented. 13 to >11.0 ptsGood 80%–89% The response accurately documents the patient’s physical exam for pertinent systems. Diagnostic tests and their results are accurately documented. 11 to >10.0 ptsFair 70%–79% Documentation of the patient’s physical exam is somewhat vague or contains minor innacuracies. Diagnostic tests and their results are documented but contain minor innacuracies. 10 to >0 ptsPoor 0%–69% The response provides incomplete or inaccurate documentation of the patient’s physical exam. Systems may have been unnecessarily reviewed. Or the objective documentation is missing.	15 pts
This criterion is linked to a Learning Outcome In the Assessment section, provide:• Results of the mental status examination, presented in paragraph form• At least three differentials with supporting evidence. List them from top priority to least priority. Compare the DSM-5 diagnostic criteria for each differential diagnosis and explain what DSM-5 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.	20 to >17.0 ptsExcellent 90%–100% The response thoroughly and accurately documents the results of the mental status exam…. Response lists at least three distinctly different and detailed possible disorders in order of priority for a differential diagnosis of the patient in the assigned case study, and it provides a thorough, accurate, and detailed justification for each of the disorders selected. 17 to >15.0 ptsGood 80%–89% The response accurately documents the results of the mental status exam…. Response lists at least three distinctly different and detailed possible disorders in order of priority for a differential diagnosis of the patient in the assigned case study, and it provides an accurate justification for each of the disorders selected. 15 to >13.0 ptsFair 70%–79% The response documents the results of the mental status exam with some vagueness or innacuracy…. Response lists at least three different possible disorders for a differential diagnosis of the patient and provides a justification for each, but may contain some vagueness or innacuracy. 13 to >0 ptsPoor 0%–69% The response provides an incomplete or inaccurate description of the results of the mental status exam and explanation of the differential diagnoses. Or the assessment documentation is missing.	20 pts
This criterion is linked to a Learning Outcome In the Plan section, provide:• Your plan for psychotherapy• 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. • Incorporate one health promotion activity and one patient education strategy.	25 to >22.0 ptsExcellent 90%–100% The response provides an evidence-based, detailed, and appropriate plan for psychotherapy for the patient…. The response provides an evidence-based, detailed, and appropriate plan for treatment and management, including pharmacologic and nonpharmacologic treatments, alternative therapies, and follow-up parameters. A strong rationale for the plan is provided that demonstrates critical thinking and content understanding…. The response includes at least one evidence-based health promotion activity and one evidence-based patient education strategy. 22 to >19.0 ptsGood 80%–89% The response provides an evidence-based and appropriate plan for psychotherapy for the patient…. The response provides an evidence-based and appropriate plan for treatment and management, including pharmacologic and nonpharmacologic treatments, alternative therapies, and follow-up parameters. An adequate rationale for the plan is provided…. The response includes at least one health promotion activity and one patient education strategy. 19 to >17.0 ptsFair 70%–79% The response provides a somewhat vague or inaccurate plan for psychotherapy for the patient…. The response provides a somewhat vague or inaccurate plan for treatment and management, including pharmacologic and nonpharmacologic treatments, alternative therapies, and follow-up parameters. The rationale for the plan is weak or general…. The response includes one health promotion activity and one patient education strategy, but it may contain some vagueness or innacuracy. 17 to >0 ptsPoor 0%–69% The response provides an incomplete or inaccurate plan for psychotherapy for the patient…. The response provides an incomplete or inaccurate plan for treatment and management, including pharmacologic and nonpharmacologic treatments, alternative therapies, and follow-up parameters. The rationale for the plan is inaccurate or missing…. The health promotion and patient education strategies are incomplete or missing.	25 pts
This criterion is linked to a Learning Outcome • Discussion include what may be done differently with this patient if student conducted the session again. Discussed the next intervention if you could follow up with this patient. The discussion was related to legal/ethical considerations (demonstrated critical thinking beyond confidentiality and consent for treatment!), social determinates of health, health promotion, and disease prevention that take into consideration patient factors (such as age, ethnic group, etc.), PMH, and other risk factors (e.g., socioeconomic, cultural background, etc.).	5 to >4.0 ptsExcellent 90%–100% Reflections are thorough, thoughtful, and demonstrate critical thinking. Reflections contain a discussion of all elements described within assignment directions. 4 to >3.5 ptsGood 80%–89% Reflections demonstrate critical thinking. Reflections contain 2 out of 3 (legal/ethical considerations, social determinate of health, health promotion) with consideration of patient factors and risk factors. 3.5 to >3.0 ptsFair 70%–79% Reflections are somewhat general or do not demonstrate critical thinking. Reflections contain 2 out of 3 (legal/ethical considerations, social determinate of health, health promotion) without consideration of patient factors and risk factors. 3 to >0 ptsPoor 0%–69% Reflections are incomplete, inaccurate, or missing.	5 pts
This criterion is linked to a Learning Outcome 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).	10 to >8.0 ptsExcellent 90%–100% The response provides at least three current, evidence-based resources from the literature to support the assessment and diagnosis of the patient in the assigned case study. The resources reflect the latest clinical guidelines and provide strong justification for decision making. 8 to >7.0 ptsGood 80%–89% The response provides at least three current, evidence-based resources from the literature that appropriately support the assessment and diagnosis of the patient in the assigned case study. 7 to >6.0 ptsFair 70%–79% Three evidence-based resources are provided to support the assessment and diagnosis of the patient in the assigned case study, but they may only provide vague or weak justification. 6 to >0 ptsPoor 0%–69% Two or fewer resources are provided to support the assessment and diagnosis decisions. The resources may not be current or evidence based.	10 pts
This criterion is linked to a Learning Outcome Written Expression and Formatting – The paper follows correct APA format for parenthetical/in-text citations and reference list.	5 to >4.0 ptsExcellent 90%–100% Uses correct APA format with no errors 4 to >3.5 ptsGood 80%–89% Contains 1-2 APA format for parenthetical/in-text citations and reference list errors 3.5 to >3.0 ptsFair 70%–79% Contains 3-4 APA format for parenthetical/in-text citations and reference list errors 3 to >0 ptsPoor 0%–69% Contains five or more APA format for parenthetical/in-text citations and reference list errors	5 pts
This criterion is linked to a Learning Outcome Written Expression and Formatting – English Writing Standards: Correct grammar, mechanics, and punctuation	5 to >4.0 ptsExcellent 90%–100% Uses correct grammar, spelling, and punctuation with no errors 4 to >3.5 ptsGood 80%–89% Contains 1-2 grammar, spelling, and punctuation format errors 3.5 to >3.0 ptsFair 70%–79% Contains 3-4 grammar, spelling, and punctuation format errors 3 to >0 ptsPoor 0%–69% Contains five or more grammar, spelling, and punctuation format errors that interfere with the reader’s understanding	5 pts
Total Points: 100