Posted: September 29th, 2022

Week 5 Focused SOAP Note for Schizophrenia Spectrum

NRNP 6675 Week 5 Focused SOAP Note for Schizophrenia Spectrum

Task: Focused SOAP Note for Schizophrenia Spectrum, Different Psychotic, and Treatment-Induced Motion Problems
Psychotic problems change one’s sense of actuality and trigger irregular pondering and notion. Sufferers presenting with psychotic problems could endure from delusions or hallucinations or could show destructive signs akin to lack of emotion or withdraw from social conditions or relationships. Signs of medication-induced motion problems could be delicate or deadly and might embrace, for instance, tremors, dystonic reactions, or serotonin syndrome.

For this Task, you’ll full a targeted SOAP observe for a affected person in a case research who has both a schizophrenia spectrum, different psychotic, or medication-induced motion dysfunction.

To Put together
Overview this week’s Studying Sources. Think about the insights they supply about assessing, diagnosing, and treating schizophrenia spectrum, different psychotic, and medication-induced motion problems.

Picture Credit score: Getty Photos/Wavebreak Media

Overview the Focused SOAP Note template, which you’ll use to finish this Task. There may be additionally a Focused SOAP Note Exemplar offered as a information for Task expectations.

Overview the video, Case Examine: Sherman Tremaine. You’ll use this case as the premise of this Task. On this video, a Walden college member is assessing a mock affected person. The affected person shall be represented onscreen as an avatar.

Think about what historical past could be vital to gather from this affected person.

Think about what interview questions you would want to ask this affected person.

The Task
Develop a targeted SOAP observe, together with your differential prognosis and critical-thinking course of to formulate a main prognosis. Incorporate the next into your responses within the template:

Subjective: What particulars did the affected person present concerning their chief criticism and symptomology to derive your differential prognosis? What’s the period and severity of their signs? How are their signs impacting their functioning in life?

Goal: What observations did you make in the course of the psychiatric Assessment?

Assessment: Talk about the affected person’s psychological standing examination outcomes. What have been your differential diagnoses? Present a minimal of three doable diagnoses with supporting proof, and listing them so as from highest precedence to lowest precedence. Examine the DSM-5-TR diagnostic standards for every differential prognosis and clarify what DSM-5-TR standards guidelines out the differential prognosis to search out an correct prognosis. Clarify the critical-thinking course of that led you to the first prognosis you chose. Embody pertinent positives and pertinent negatives for the particular affected person case. Assessment: Speak concerning the outcomes of the affected person’s psychological standing examination. What completely different diagnoses did you make? Give not less than three doable diagnoses with proof to again them up, and listing them from most vital to least vital. Examine the DSM-5-TR diagnostic standards for every differential prognosis and clarify what DSM-5-TR standards guidelines out the differential prognosis to search out the right prognosis. Clarify the way you used essential pondering to give you the principle prognosis you selected. Embody each the optimistic and destructive issues which are vital to the affected person’s case.

Plan: What’s your plan for psychotherapy? What’s your plan for therapy and administration, together with various therapies? Embody pharmacologic and nonpharmacologic therapies, various therapies, and follow-up parameters, in addition to a rationale for this therapy and administration plan. Additionally incorporate one well being promotion exercise and one affected person schooling technique.

Reflection notes: What would you do in another way with this affected person when you may conduct the session once more? Talk about what your subsequent intervention could be when you have been capable of observe up with this affected person. Additionally embrace in your reflection a dialogue associated to authorized/moral issues (exhibit essential pondering past confidentiality and consent for therapy!), well being promotion, and illness prevention, considering affected person components (akin to age, ethnic group, and so forth.), PMH, and different threat components (e.g., socioeconomic, cultural background, and so forth.).

Present not less than three evidence-based, peer-reviewed journal articles or evidenced-based tips that relate to this case to help your diagnostics and differential diagnoses. Be certain they’re present (not more than 5 years previous).

SOAP Note: Schizophrenia Spectrum Instance Method
Subjective:

CC (chief criticism):

Delusions and hallucinations.

HPI:

C.M, a 27-year-old feminine Hispanic affected person comes for a psychiatric analysis. She was final properly about two months in the past when she began experiencing delusions and hallucinations. The affected person was continuously looking out believing that somebody was spying on her with the motive of harming her. The affected person additionally began experiencing auditory hallucinations. She claims that she usually hears voices of a number of women and men speaking and laughing at her continuously. The delusions and hallucinations have been there for the previous two months with no recollection of comparable signs beforehand. Over the past month, the affected person has reported low vitality ranges on a number of events and sometimes withdrawing herself from shut members of the family and pals.

Substance Present Use:

The affected person denies any alcohol, tobacco, or drug use.

Medical Historical past:

The affected person has no identified power sicknesses. No earlier surgical procedures. No prior hospital admissions.

Present Drugs:
The affected person is presently not on any treatment.

Allergy symptoms
NKDFA.

Reproductive Hx:
LMP 04/06/2022. The cycle is 30 days lasting 5 days. Common stream. G0T0P0A0L0. No contraceptive. Presently single. The affected person is a sufferer of each bodily and sexual assault from a earlier relationship.

Household Hx:
Household historical past of schizophrenia. No different identified power sicknesses amongst shut members of the family.

ROS:

GENERAL: No experiences of fever, physique aches, or some other considerations.
HEENT: No historical past of trauma, headache, or falls. No problems associated to the throat, nostril, and ears.
SKIN: No historical past of rash, lesions, or considerations with eczema.
CARDIOVASCULAR: No complains of chest ache, no palpitations, no orthopnea.
RESPIRATORY: No chest ache, no cough, no problem in respiration.
GASTROINTESTINAL: No change in urge for food. No historical past of irregular bowel actions.
GENITOURINARY: No hematuria, no dysuria, no urgency, no frequency.
NEUROLOGICAL: No syncope, no dizziness, no blurry imaginative and prescient, no tinnitus.
MUSCULOSKELETAL: No ache within the muscle tissue or joints.
HEMATOLOGIC: No historical past of simple bruising or bleeding.
LYMPHATICS: Denies any lymph node swelling.
ENDOCRINOLOGIC: Denies elevated thirst or urination.
Goal:

VS: Temp: 98.zero F, BP: 99/69, HR: 96, RR: 17, 100% on RA, Top: 5ft, 3in Wt.: 139 lbs.

BMI: 24.6. Lies inside the regular vary.

Basic: The affected person just isn’t sick trying and is in truthful basic situation with no indicators of respiratory misery.

Pores and skin: No irregular lesions have been noticed on the pores and skin.

Head: Regular form and measurement.

Eyes: No abnormalities detected. The pupils reply appropriately to stimulation by mild.

ENT: No abnormalities have been noticed on the ears and nostril. The tympanic membrane is undamaged. Listening to is unaffected. The throat appears to be like regular with no indicators of irritation.

Neck: No abnormalities on the neck.

CVS: Apex beat just isn’t displaced. There’s a regular coronary heart price and rhythm. Auscultation reveals regular S1 and S2 sounds with no murmurs.

RS: Trachea is central. Vesicular and bronchial breath sounds have been heard. No further sounds.

Stomach: No seen scars. No distention. No tenderness or plenty have been elicited.

Musculoskeletal: Muscle tone and power intact. Regular vary of motion noticed.

Assessment:

MSE:

C.M is a 27-year-old Hispanic feminine affected person who is available in for the analysis. Her look and acknowledged age are applicable. The affected person is properly responsive all through the session. Her shirt is buttoned inappropriately. Her hair is sort of unkempt. The affected person shows no tics or some other irregular actions. The affected person communicates incoherently, responding to questions requested with unrelated responses and at instances shifting away from the difficulty at hand to debate unrelated issues. The affected person usually repeats what she had mentioned earlier. Her thought is impaired. There may be proof of looseness of affiliation and flight of concepts. Her temper is euthymic, however she demonstrates a blunt have an effect on. Incongruency is famous. Auditory and visible hallucinations are current on this affected person. Delusions are current with the affected person continuously nervous that somebody needs to hurt her. There aren’t any ideas of inflicting hurt to self or others. Cognitively, she is alert. C.M is appropriately oriented. Her reminiscence just isn’t impaired. Focus is impaired. Perception is missing in her present situation. NRNP 6675 Week 5 Focused SOAP Note for Schizophrenia Spectrum

Diagnostic Impression:

The first prognosis is schizophreniform dysfunction.

Differential diagnoses are substance-induced schizophrenia and delusional dysfunction.

Schizophreniform dysfunction is a psychotic dysfunction lasting between one to 6 months. The situation drastically impacts a person’s stage of cognition, feelings, and actions. The situation impacts each genders, with a peak incidence amongst ladies being reported between the ages of 24 to 35 years (Kahn et al., 2018). Sufferers usually current with delusions, hallucinations, disorganized speech, and diminished vitality ranges. In most cases, sufferers are sometimes untidy and unkempt, usually withdrawing from shut members of the family and pals. These signs align with the affected person’s presenting complaints and findings on examination, making this essentially the most possible prognosis.

The substance-induced psychotic dysfunction is usually related to the beginning or cessation of the usage of alcohol or different medicine. Sufferers usually current with delusions, hallucinations, impaired speech, impaired temper, and poor basic hygiene (Wilson et al., 2018). These findings are just like the affected person’s presenting criticism. She, nonetheless, denies any alcohol or drug use. Additional laboratory investigations are required to rule out any substance use and make sure what she mentioned. Delusional problems are psychological well being circumstances the place sufferers expertise varied delusions of various sorts. In most cases, there may be little to no affect on a person’s well-being, and one could proceed functioning usually. In extreme cases, psychotic signs could ensue. Pertinent positives, on this case, embrace the historical past of delusions and hallucinations, disorganized speech, social withdrawal, and a household historical past of schizophrenia. As well as, temper and have an effect on incongruency and lack of perception are different pertinent positives. Pertinent negatives embrace no alcohol or drug use, the affected person being properly oriented and reminiscence being intact.

Case Formulation and Therapy Plan:

Pharmacological Interventions

Atypical antipsychotics are sometimes used within the administration of schizophreniform dysfunction. These embrace risperidone, olanzapine, and quetiapine (Alphs et al., 2022 NRNP 6675 Week 5 Focused SOAP Note for Schizophrenia Spectrum).

Nonpharmacologic Interventions

Cognitive-behavioral remedy (CBT), psychoeducation, cognitive remediation, social and coping abilities, and household interventions are confirmed nonpharmacologic interventions for the situation (Ganguly et al., 2018).

Different Therapies

Different therapies that may show useful embrace speak remedy, household remedy, profession teaching, and communication and social abilities.

Comply with-up Parameters

Assessment of the affected person must be finished month-to-month. Signs ought to have fully subsided by 6 months.

Rationale For Administration

The administration plan is to make sure the safety and stabilization of the affected person. Minimizing psychosocial problems and enabling the affected person to guide a traditional life with minimal adversarial results is one other essential purpose of administration.

Well being Promotion Exercise

Educating the affected person on dealing with life’s stresses is a essential part of well being promotion.

Affected person Schooling Technique

One of the best schooling technique relies on the affected person’s literacy stage and skill to embrace the usage of expertise in healthcare.

Reflection

If I have been to conduct the session once more, I’d inquire additional into the household historical past of schizophrenia. Probing additional into the drug and substance use historical past to know if the affected person is mendacity is one other factor I’d do. In follow-up conferences, I’d work on the affected person’s communication and social abilities. It’s important to consider confidentiality, battle of curiosity, operational challenges, placebo associated, exploitation, knowledgeable consent, vulnerability, exploitation, and therapeutic false impression (Brown et al., 2020) as key authorized/moral issues.

NRNP 6675 Week 5 Focused SOAP Note for Schizophrenia Spectrum References
Alphs, L., Brown, B., Turkoz, I., Baker, P., Fu, D. J., & Nuechterlein, Okay. H. (2022). The Illness Restoration Analysis and Modification (DREaM) research: Effectiveness of paliperidone palmitate versus oral antipsychotics in sufferers with recent-onset schizophrenia or schizophreniform dysfunction. Schizophrenia Analysis, 243, 86–97. https://doi.org/10.1016/j.schres.2022.02.019

Brown, C., Ruck Keene, A., Hooper, C. R., & O’Brien, A. (2020). Isolation of sufferers in psychiatric hospitals within the context of the COVID-19 pandemic: An moral, authorized, and sensible problem. Worldwide Journal Of Regulation And Psychiatry, 71, 101572. https://doi.org/10.1016/j.ijlp.2020.101572

Ganguly, P., Soliman, A., & Moustafa, A. A. (2018). Holistic Administration of Schizophrenia Signs Utilizing Pharmacological and Non-pharmacological Therapy. Frontiers in Public Well being, 6, 166. https://doi.org/10.3389/fpubh.2018.00166

Kahn, R. S., Winter van Rossum, I., Leucht, S., McGuire, P., Lewis, S. W., Leboyer, M., Arango, C., Dazzan, P., Drake, R., Heres, S., Díaz-Caneja, C. M., Rujescu, D., Weiser, M., Galderisi, S., Glenthøj, B., Eijkemans, M., Fleischhacker, W. W., Kapur, S., Sommer, I. E., & OPTiMiSE research group (2018). Amisulpride and olanzapine adopted by open-label therapy with clozapine in first-episode schizophrenia and schizophreniform dysfunction (OPTiMiSE): a three-phase switching research. The lancet. Psychiatry, 5(10), 797–807. https://doi.org/10.1016/S2215-0366(18)30252-9

Wilson, L., Szigeti, A., Kearney, A., & Clarke, M. (2018). Medical traits of main psychotic problems with concurrent substance abuse and substance-induced psychotic problems: A scientific evaluate. Schizophrenia Analysis, 197, 78–86. https://doi.org/10.1016/j.schres.2017.11.001

By Day 7 of Week 5
Submit your Focused SOAP Note.

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