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.
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). Case study to refer is [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, a 54-year-old male, reports that he was brought to the appointment by his sister after his mother died. He claims that he was living with his mother and not bothering anyone, but now people are watching him outside his window, and he can hear their voices and see their shadows. He states that the government has sent them to watch him because his taxes are high. He has been experiencing these symptoms for weeks, and they have been impacting his sleep, as he can’t sleep due to the voices being too loud. Sherman reports that he is not able to watch TV, as the people outside watch him through the screen and even poison his food. He smokes three packs of cigarettes per day and reports that he has been smoking all day. He also reports that he hasn’t been drinking lately.
During the psychiatric assessment, Sherman was cooperative with no signs of distress. He had no grooming issues, and his hygiene was acceptable. His affect was flat, and his speech was coherent, relevant, and goal-directed. Sherman was oriented to person, place, and time but was unsure about the exact day of the week. He appeared to be preoccupied with external stimuli and was observed to have auditory and visual hallucinations. Sherman’s mood was anxious, and he had a negative attitude towards the assessment process. He was cooperative with the mental status exam.
Sherman presents with symptoms of paranoid delusions, auditory and visual hallucinations, and a negative attitude towards the assessment process. Based on his history and presentation, the following differential diagnoses are being considered:
Schizophrenia Spectrum and Other Psychotic Disorders: Sherman has been experiencing delusions, auditory and visual hallucinations, and a negative attitude towards the assessment process, which are all consistent with the criteria for schizophrenia spectrum and other psychotic disorders. However, the presence of delusions and auditory hallucinations is the primary reason to consider this diagnosis as the highest priority.
Brief Psychotic Disorder: The abrupt onset of symptoms after his mother’s death, which has been present for a few weeks, suggests the possibility of a brief psychotic disorder. The duration of the symptoms and the impact on his sleep are consistent with this diagnosis.
Substance/Medication-Induced Psychotic Disorder: The high level of smoking and the possibility of substance abuse raises the possibility of substance-induced psychotic disorder.
For Sherman, psychotherapy will be the primary mode of treatment. In the initial phase, the focus will be on establishing rapport with the patient and gaining his trust. Cognitive-behavioral therapy (CBT) will be used to help him challenge his beliefs and reduce his anxiety levels. Additionally, antipsychotic medication may be prescribed to manage his symptoms, including delusions and hallucinations. Clozapine or risperidone will be considered for treatment. Alternative therapies such as mindfulness-based stress reduction and electroconvulsive therapy will be considered if necessary. A follow-up appointment will be scheduled in two weeks to monitor Sherman’s progress. A health promotion activity will include smoking cessation interventions, and a patient education strategy will be used to educate Sherman about the importance of medication compliance and seeking help if he experiences side effects from the medication.
If I could conduct the session again, I would consider asking more questions about Sherman’s medical history, specifically in relation to his smoking and substance abuse history. I would also ensure that the environment is calm and relaxing to reduce his anxiety levels during the assessment process. If I were to follow up with this patient, my next intervention would be to conduct a full medical evaluation, including a physical examination and blood work to rule out any medical conditions that may be contributing to his symptoms.
Legal/ethical considerations: In addition to obtaining informed consent and maintaining patient confidentiality,