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
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).
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