Focused SOAP Note for Schizophrenia Spectrum, Other Psychotic, and Medication-Induced Movement Disorders

Assignment: Focused SOAP Note for Schizophrenia Spectrum, Other Psychotic, and Medication-Induced Movement Disorders

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.

To Prepare

Review this week’s Learning Resources. Consider the insights they provide about assessing, diagnosing, and treating schizophrenia spectrum, other psychotic, and medication-induced movement disorders.
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).

Medication Review

Review the FDA-approved use of the following medicines related to treating schizophrenia-spectrum and other psychotic disorders:

Psychosis

Schizoaffective disorder

alprazolam (adjunct)
  amisulpride
  aripiprazole
  asenapine
  blonanserin
  carbamazepine (adjunct)
  chlorpromazine
  clonazepam (adjunct)
  clozapine
  cyamemazine
  flupenthixol
  fluphenazine
  haloperidol
  iloperidone
  lamotrigine (adjunct)
  lorazepam (adjunct)
  loxapine
  lurasidone

mesoridazine
  molindone
  olanzapine
  paliperidone
  perospirone
  perphenazine
  pimozide
  pipothiazine
  quetiapine
  risperidone
  sertindole
  sulpiride
  thioridazine
  thiothixene
  trifluoperazine
  valproate (divalproex) (adjunct)
  ziprasidone
  zotepine
  zuclopenthixol

amisulpride
  aripiprazole
  asenapine
  carbamazepine (adjunct)
  chlorpromazine
  clozapine
  cyamemazine
  flupenthixol
  haloperidol
  iloperidone
  lamotrigine (adjunct)
  l-methylfolate (adjunct)
  loxapine
  lurasidone
  mesoridazine
  molindone
  olanzapine
  paliperidone

perospirone
  perphenazine
  pipothiazine
  quetiapine
  risperidone
  sertindole
  sulpiride
  thioridazine
  thiothixene
  trifluoperazine
  valproate (divalproex) (adjunct)
  ziprasidone
  zotepine
  zuclopenthixol

Schizophrenia

Cataplexy syndrome

Catatonia

Extrapyramidal side effects

perphenazine
  pipothiazine
  quetiapine
  risperidone
  sertindole
  sulpiride
  thioridazine
  thiothixene
  trifluoperazine
  valproate (divalproex) (adjunct)
  ziprasidone
  zotepine
  zuclopenthixol
  Seasonal affective disorder
  bupropion
  Sedation-induction
  hydroxyzine
  midazolam

clomipramine
imipramine
sodiu

Sadock, B. J., Sadock, V. A., & Ruiz, P. (2015). Kaplan & Sadock’s synopsis of psychiatry (11th ed.). Wolters Kluwer. (For review as needed)

Chapter 7, “Schizophrenia Spectrum and Other Psychotic Disorders”
Chapter 29.2, “Medication-Induced Movement Disorders”
Chapter 29.3, “α2-Adrenergic Receptor Agonists, α1-Adrenergic Receptor Antagonists: Clonidine, Guanfacine, Prazosin, and Yohimbine”

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”

REQUIRED MEDIA