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Psychotic disorders change one’s sense of reality and cause abnormalthinking and perception. Patients presenting with psychotic disordersmay suffer from delusions or hallucinations or may display negativesymptoms such as lack of emotion or withdraw from social situations orrelationships. Symptoms of medication-induced movement disorders can bemild or lethal and can include, for example, tremors, dystonicreactions, or serotonin syndrome.
For this Assignment, you willcomplete a focused SOAP note for a patient in a case study who haseither a schizophrenia spectrum, other psychotic, or medication-inducedmovement 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
- Reviewthe Focused SOAP Note template, which you will use to complete thisAssignment. There is also a Focused SOAP Note Exemplar provided as aguide for Assignment expectations.
- Review the video, Case Study: Sherman Tremaine.You will use this case as the basis of this Assignment. In this video, aWalden faculty member is assessing a mock patient. The patient will berepresented 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
Developa focused SOAP note, including your differential diagnosis andcritical-thinking process to formulate a primary diagnosis. Incorporatethe following into your responses in the template:
- Subjective: Whatdetails did the patient provide regarding their chief complaint andsymptomology to derive your differential diagnosis? What is the durationand severity of their symptoms? How are their symptoms impacting theirfunctioning in life?
- Objective: What observations did you make during the psychiatric assessment?
- Assessment:Discuss the patient’s mental status examination results. What were yourdifferential diagnoses? Provide a minimum of three possible diagnoseswith supporting evidence, and list them in order from highest priorityto lowest priority. Compare the DSM-5-TR diagnostic criteria for each differential diagnosis and explain what DSM-5-TRcriteria rules out the differential diagnosis to find an accuratediagnosis. Explain the critical-thinking process that led you to theprimary diagnosis you selected. Include pertinent positives andpertinent negatives for the specific patient case.
- Plan:What is your plan for psychotherapy? What is your plan for treatmentand management, including alternative therapies? Include pharmacologicand nonpharmacologic treatments, alternative therapies, and follow-upparameters, as well as a rationale for this treatment and managementplan. Also incorporate one health promotion activity and one patienteducation strategy.
- Reflection notes: Whatwould you do differently with this patient if you could conduct thesession again? Discuss what your next intervention would be if you wereable to follow up with this patient. Also include in your reflection adiscussion related to legal/ethical considerations (demonstrate criticalthinking beyond confidentiality and consent for treatment!), healthpromotion, and disease prevention, taking into consideration patientfactors (such as age, ethnic group, etc.), PMH, and other risk factors(e.g., socioeconomic, cultural background, etc.).
- Provide atleast three evidence-based, peer-reviewed journal articles orevidenced-based guidelines that relate to this case to support yourdiagnostics and differential diagnoses. Be sure they are current (nomore than 5 years old).