Posted: December 16th, 2022

Psychotic disorders

FOCUSED SOAP NOTE FOR SCHIZOPHRENIA SPECTRUM, OTHER PSYCHOTIC, AND MEDICATION-INDUCED MOVEMENT DISORDERS
Psychotic disorders are a group of mental illnesses that affect a person’s ability to think, feel, and behave in a way that is consistent with reality. People with psychotic disorders may experience hallucinations, delusions, or other types of abnormal thoughts or perceptions. These symptoms can be distressing and disrupt a person’s daily life.

There are several types of psychotic disorders, including schizophrenia, schizoaffective disorder, and brief psychotic disorder. Symptoms and treatment options vary depending on the specific disorder.

Treatment for psychotic disorders often includes a combination of medications, such as antipsychotic medications, and therapy, such as cognitive-behavioral therapy or family therapy. It is important for individuals with psychotic disorders to receive treatment as soon as possible to help manage symptoms and improve their overall quality of life.
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.
• Sadock, B. J., Sadock, V. A., & Ruiz, P. (2015). Kaplan & Sadock’s synopsis of psychiatry (11th ed.). Wolters Kluwer. (For review as needed)
•
o Chapter 7, “Schizophrenia Spectrum and Other Psychotic Disorders”
o Chapter 29.2, “Medication-Induced Movement Disorders”
o 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.
•
o Chapter 43, “Pharmacological, Medically-Led and Related Disorders”
o Chapter 57, “Schizophrenia and Psychosis”

• Zakhari, R. (2021). The psychiatric-mental health nurse practitioner certification review manual. Springer Publishing Company.
•
o Chapter 9, “Psychotic Disorders and Delusions”

• 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
[MUSIC PLAYING]
DR. MOORE: Good afternoon.
I’m Dr. Moore.
Want to thank you for coming in for your appointment today.
I’m going to be asking you some questions about your history
and some symptoms.
And to get started, I just want to ensure
I have the right patient and chart.
So can you tell me your name and your date of birth?
SHERMAN TREMAINE: I’m Sherman Tremaine,
and Tremaine is my game game.
My birthday is November 3, 1968.
DR. MOORE: Great.
And can you tell me today’s date?
Like the day of the week, and where we are today?
SHERMAN TREMAINE: Use any recent date, and any location is OK.
DR. MOORE: OK, Sherman.
What about do you know what month this is?
SHERMAN TREMAINE: It’s March 18.
DR. MOORE: And the day of the week?
SHERMAN TREMAINE: Oh, it’s a Wednesday or maybe a Thursday.
DR. MOORE: OK.
And where are we today?
SHERMAN TREMAINE: I believe we’re
in your office, Dr. Moore.
DR. MOORE: OK, great.
So tell me a little bit about what brings you in today.
What brings you here?
SHERMAN TREMAINE: Well, my sister made me come in.
I was living with my mom, and she died.
I was living, and not bothering anyone, and those people–
those people, they just won’t leave me alone.
DR. MOORE: What people?
SHERMAN TREMAINE: The ones outside my window watching.
They watch me.
I can hear them, and I see their shadows.
They think I don’t see them, but I do.
The government sent them to watch me,
so my taxes are high, so high in the sky.
Do you see that bird?
DR. MOORE: Sherman, how long have
you saw or heard these people?
SHERMAN TREMAINE: Oh, for weeks, weeks and weeks and weeks.
Hear that– hear that heavy metal music?
They want you to think it’s weak, but it’s heavy.
DR. MOORE: No, Sherman.
I don’t see any birds or hear any music.
Do you sleep well, Sherman?
SHERMAN TREMAINE: I try to but the voices are loud.
They keep me up for days and days.
I try to watch TV, but they watch me through the screen,
and they come in and poison my food.
I tricked them though.
I tricked them.
I locked everything up in the fridge.
They aren’t getting in there.
Can I smoke?
DR. MOORE: No, Sherman.
There is no smoking here.
How much do you usually smoke?
SHERMAN TREMAINE: Well, I smoke all day, all day.
Three packs a day.
DR. MOORE: Three packs a day.
OK.
What about alcohol?
When was your last drink?
SHERMAN TREMAINE: Oh, yesterday.
My sister buys me a 12-pack, and tells me to make it last
until next week’s grocery run.
I don’t go to the grocery store.
They play too loud of the heavy metal music.
They also follow me there.
DR. MOORE: What about marijuana?
SHERMAN TREMAINE: Yes, but not since my mom
died three years ago.
DR. MOORE: Use any cocaine?
SHERMAN TREMAINE: No, no, no, no, no, no, no.
No drugs ever, clever, ever.
DR. MOORE: What about any blackouts or seizures
or see or hear things from drugs or alcohol?
SHERMAN TREMAINE: No, no, never a clever [INAUDIBLE] ever.
DR. MOORE: What about any DUIs or legal issues
from drugs or alcohol?
SHERMAN TREMAINE: Never clever’s ever.
DR. MOORE: OK.
What about any medication for your mental health?
Have you tried those before, and what was your reaction to them?
SHERMAN TREMAINE: I hate Haldol and Thorazine.
No, no, I’m not going to take it.
Risperidone gave me boobs.
No, I’m not going to take it.
Seroquel, that is OK.
But they’re all poison, nope, not going to take it.
DR. MOORE: OK.
So tell me, any blood relatives have
any mental health or substance abuse issues?
SHERMAN TREMAINE: They say that my dad
was crazy with paranoid schizophrenia.
He did in the old state hospital.
They gave him his beer there.
Can you believe that?
Not like them today.
My mom had anxiety.
DR. MOORE: Did any blood relatives commit suicide?
SHERMAN TREMAINE: Oh, no demons there.
No, no.
DR. MOORE: What about you?
Have you ever done anything like cut yourself, or had
any thoughts about killing yourself or anyone else?
SHERMAN TREMAINE: I already told you.
No demons there.
Have been in the hospital three times though when I was 20.
DR. MOORE: OK.
What about any medical issues?
Do you have any medical problems?
SHERMAN TREMAINE: Ooh, I take metformin for diabetes.
Had or I have a fatty liver, they say,
but they never saw it.
So I don’t know unless the aliens told them.
DR. MOORE: OK.
So who raised you?
SHERMAN TREMAINE: My mom and my sister.
DR. MOORE: And who do you live with now?
SHERMAN TREMAINE: Myself, but my sister’s
plotting with the government to change that.
They tapped my phone.
DR. MOORE: OK.
Have you ever been married?
Are you single, widowed, or divorced?
SHERMAN TREMAINE: I’ve never been married.
DR. MOORE: Do you have any children?
SHERMAN TREMAINE: No.
DR. MOORE: OK.
What is your highest level of education?
SHERMAN TREMAINE: I went to the 10th grade.
DR. MOORE: And what do you like to do for fun?
SHERMAN TREMAINE: I don’t work, so smoking and drinking pop.
DR. MOORE: OK.
Have you ever been arrested or convicted for anything legally?
SHERMAN TREMAINE: No, but they have told me they would.
They have told me they would if I didn’t stop calling 911
about the people outside.
DR. MOORE: OK.
What about any kind of trauma as a child or an adult?
Like physical, sexual, emotional abuse.
SHERMAN TREMAINE: My dad was rough on us until he died.
DR. MOORE: OK.
[MUSIC PLAYING]
So thank you for answering those questions for me.
Now, let’s talk about how I can best help you.
[MUSIC PLAYING]

• Document: Focused SOAP Note TemplateDownload Focused SOAP Note Template

• Document: Focused SOAP Note Exemplar
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Week (enter week #): (Enter assignment title)

Student Name
College of Nursing-PMHNP, Walden University
NRNP 6675: PMHNP Care Across the Lifespan II
Faculty Name
Assignment Due Date

Subjective:
CC (chief complaint):
HPI:
Substance Current Use:
Medical History:

• Current Medications:
• Allergies:
• Reproductive Hx:
ROS:
• GENERAL:
• HEENT:
• SKIN:
• CARDIOVASCULAR:
• RESPIRATORY:
• GASTROINTESTINAL:
• GENITOURINARY:
• NEUROLOGICAL:
• MUSCULOSKELETAL:
• HEMATOLOGIC:
• LYMPHATICS:
• ENDOCRINOLOGIC:
Objective:
Diagnostic results:
Assessment:
Mental Status Examination:
Diagnostic Impression:
Reflections:
Case Formulation and Treatment Plan:

References

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Tags: Psychotic disorders