Posted: July 5th, 2022

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Carefully read and answer each bullet point of the assignment (answer briefly).
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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 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.

• 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).

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

Student Name
Faculty Name
Assignment Due Date

Focused SOAP Note for Schizophrenia Spectrum, Other Psychotic, and Medication-Induced Movement Disorders
CC (chief complaint): I see people watching me, they are outside my window, I can hear them , and see their shadows.
HPI: Name: Sherman Tremainem , Age: 53 yrs, Date: 18th march Wednesday, Race: Hispanic, Gender: male, Purpose of evaluation: abnormal behaviours, Current medication: diabetic medication, and anti-psychotic medication, reffereal reason: refered by the sister for abnormal behaviour.
Substance Current Use:
use of alcohol, tobacco and marijuana
Medical History:

Sherman is diabetic, and takes metformin as a medication. Sherman has been in hospital three times when twenty years old.
• Current Medications:
Prescribed with Thoarzine, Haldol, Risperidone, and seroquel, though consider the medication as poison. The medicatin is for mental health issue, but th epatient does not like th tking some of th medicines, such as the Risperidone, , haldol, and thorazide. The patient only likes seroquel.
• Reproductive Hx:
Never been married before, or have children
• GENERAL: sherman shows high levels of weakness, and fatique, has disorganized speech containing word salad, disorganized motor behavooir, and appear to lack emotions.
• COGNITION: Have hallusionation, and delusions.
• HEENT: no hearing loss, no running nose, no sneezing, no visual loss, no blurred vision, or sore throat.
• SKIN: The skin is pale due to smoking, and no rashes observed
• CARDIOVASCULAR: sherman has chest pains, and chest discomfort. The patient however has no edema, or chest pressure.
• RESPIRATORY: no shortness of breath, and frequently coughs.GASTROINTESTINAL: no diarrhoea, no abdominal pain, no nausea or anorexia.
• GENITOURINARY: no burning durign urination, no unirantion hesistancy, no odd color, but presence of odoe from the mouth, and body
• NEUROLOGICAL: Suffering from headache, no seizures, and block outs. No dizziness, syncope, numbness, or ataxia.
• MUSCULOSKELETAL: no back pain, stiffness, or joint pain
• HEMATOLOGIC: No bleeding, no anemia diagnosis,or bruising
• LYMPHATICS: no enlarged nodes, no history of splenectomy.
• ENDOCRINOLOGIC: No reports of heat tolerance, cold or sweating.
Diagnostic results:
Ablood test, and urine test are required to test the presence of alcohol and oyther drugs needed.
The magnetic resonance imaging(MRI) which assist in picturing the brain, and body. Also, a computed temography (CT) would assst in checking other problems, such as brain tumor.
Another test required are the cognitive tests, such as personlaity tests , like the Rorchach test.
Mental Status Examination:
Sherman Tremainem is a fifty-three years old male, although she does not look like his age. The patient is very cooperative, has a good memory, and up to date. For instance, the patient knows what day and date it is and the current location. Unfortunately, the patient is not well-groomed, not clean, or dressed appropriately. Sherman Tremainem has disorganized motor behavior; the speech is disorganized and unclear, although the volume and tone are average. The patient’s thoughts are logical and goal-oriented, primarily to find a solution and answer all s the weird noises and visions. Sherman denies every auditory, and visual hallucinations, have delusion thinking, and has a euthymic mood (Legge,et,al.,2020). For instance, the patient says that the government sent people to watch over her and poison her food, locking up everything in the fridge. The patient denies having any suicidal thoughts, self-harm, or homicidal ideation but testifies that the family has a history of mental health issues. Sherman’s father was diagnosed with paranoid schizophrenia, and the mother was diagnosed with anxiety. Also, the patient does not deny having been a victim of childhood trauma because the father was rough until death. Cognitively, the patient is well oriented and alert the memory is intact, good insight, and a high concentration.
Diagnostic Impression:
A blood and urine test has been ruled out because the patient needs a drug test that shows the level of drugs, such as marijuana and alcohol, in the bloodstream. The level of drugs assists in understanding whether the signs and symptoms are caused by the high level of drugs in the body.
Magnetic resonance imaging(MRI) is another critical test that involves conducting a scan on the patients to discover any abnormality in the brain and the rest of the body. Computed tomography or a CT scan can be used instead of the MRI to identify any other problems, such as the presence of a brain tumor (Heiberg, et ,al., 2020). The test, however, provides information on whether the patient is mentally fit and whether the hallucinations and delusion are caused by a type of mental health issue, such as schizophrenia, any form of medication-induced movement disorder, and psychotic issues.
A cognitive test is ruled out to test the patient’s understanding of things, and a personality test. The tests assist in understanding the patient’s cognitive capabilities to assess the level of image and severity of the mental condition. Psychiatrists should conduct a diagnosis as early as possible to assist Sherman in managing the illness by offering medication and psychotherapy. The tests have been ruled out because the patient may be going through a psychotic disorder, such as schizophrenia disorder, delusion disorder, substance-induced psychotic disorder, and psychotic disorder caused by intakes of medication, such as hyperactivity, the involuntary motion of body parts, tiredness, and swelling of breasts, such as the case of Sherman(Heiberg, et ,al., 2020). On the other hand, failure to use haloperidol suddenly leads to unpleasant withdrawal symptoms.
I agree with my receptors assessment and diagnostic impressions of the patient because Sherman might be suffering from a psychotic disorder, which may be contributed by childhood trauma and the use of narcotics. Additionally, I agree with the assessment, and diagnostic of drug tests, conducting an MRI and a cognitive test to identify the root cause of the issue. Sherman is suffering from a mental health issue, primarily a psychotic issue, which makes him have false beliefs and use drugs to prevent hearing metal music, seeing unreal things, such as birds and people at teh window, and voices of people spying on him (Zipursky, et,al.,2020). Sherman is a victim of childhood trauma and mental health genome from the father and mother. For instance, according to the case, the father had paranoid schizophrenia, making the patient likely to be suffering from the same condition. Schizophrenia is genetic and may be contributed by naturally occurring brain chemicals, such as glutamate and dopamine. I have learned that mental health issue is real and affect people of all ages, and sex. Also, a mental health issue is the leading cause of drug abuse, such as the use of marijuana and alcohol (Zipursky, et,al.,2020). On the other hand, I have learned that mental health issues, such as schizophrenia, are genetic, hence transferred from one offspring to another. However, Sherman’s treatment and diagnostic should remain confidential, where the information should only be disclosed to close family members, such as the sister. However, the patient should be put under supervision and treatment, hence should not be allowed to stay alone to avoid self-harm and commit suicide.

Case Formulation and Treatment Plan:
Psychotic disorders, such as schizophrenia, are treated through a combination of medication and psychotherapy. The patient’s drugs should be prescribed, including the new atypical antipsychotics, such as clozapine, asenapine, ziprasidone, quetiapine, olanzapine, and other antipsychotics. The older antipsychotics, such as Haldol, and Thorazine, have more side effects, as experienced by Sherman. The medications, however, should only be taken twice a month to manage the condition (Legge,et,al.,2020) .
Psychotherapy is also an important mode of treatment that would play a significant role in assisting people with the condition (Potkin,et,al.,2020). Both individual and family therapy would play an essential role in understanding the underlying condition and testing the sister to assess any mental health genome. Sherman should be hospitalized to manage the symptoms, avoid self-harm cases, and injure others, such as the sister (Legge,et,al.,2020). With consistent treatment and follow-up, Sherman can recover and live better, primarily through the help of counseling and mental health training’. Training Sherman on taking narcotics and alcohol would assist in preventing the condition from worsening up. A person with schizophrenia should not take alcohol and other drugs whatsoever; instead should take medication to prevent and reduce hallucination and delusion. Mixing drugs, such as prescribed medication and herbs or over-the-counter medication, may have serious side effects. The antipsychotic medication prescribed should not contain ethanol or lovers to prevent mild interaction with metformin. The patient should not also take narcotics, and alcohol, since the drugs would accelerate the mental health issue and disrupt the healing process (Legge,et,al.,2020).The client is advised to continue managing the condition by attending therapy sessions at least three times a month. If the patient becomes severe, the patient should call 911 and a client’s crisis line 1800. The client is supposed to return to the clinic for medical assessment, which would assist in addressing chronic and provides a higher level of care when needed.

Heiberg, I. H., Nesvåg, R., Balteskard, L., Bramness, J. G., Hultman, C. M., Næss, Ø., … & Høye, A. (2020). Diagnostic tests and treatment procedures performed prior to cardiovascular death in individuals with severe mental illness. Acta Psychiatrica Scandinavica, 141(5), 439-451.
Legge, S. E., Dennison, C. A., Pardiñas, A. F., Rees, E., Lynham, A. J., Hopkins, L., … & Walters, J. T. (2020). Clinical indicators of treatment-resistant psychosis. The British Journal of Psychiatry, 216(5), 259-266.
Potkin, S. G., Kane, J. M., Correll, C. U., Lindenmayer, J. P., Agid, O., Marder, S. R., … & Howes, O. D. (2020). The neurobiology of treatment-resistant schizophrenia: paths to antipsychotic resistance and a roadmap for future research. NPJ schizophrenia, 6(1), 1-10.
Zipursky, R. B., Odejayi, G., Agid, O., & Remington, G. (2020). You say “schizophrenia” and I say “psychosis”: just tell me when I can come off this medication. Schizophrenia research, 225, 39-46.

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