Posted: September 7th, 2024

Assignment: Focused SOAP Note, Case Study: Sherman Tremaine

Assignment: Focused SOAP Note for
Schizophrenia Spectrum, Other Psychotic,
and Medication-Induced Movement
Disorders
Case Study: Sherman Tremaine
Assignment: Focused SOAP Note for
Schizophrenia Spectrum, Other Psychotic,
and Medication-Induced Movement
Disorders
Case Study: Sherman Tremaine

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.
To Prepare
Review this week’s Learning Resources. Consider the
insights they provide about assessing, diagnosing, and
treating schizophrenia spectrum, other psychotic, and
medication-induced movement disorders.
Photo Credit: Getty Images/Wavebreak Media
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:
10/1/22, 8:13 AM ANSWERED!! Case Study: Sherman Tremaine
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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: Assignment help – 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 diagnostic
criteria for each differential diagnosis and explain what DSM5 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? Assignment help – 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).
EXPERT ANSWER AND EXPLANATION
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SOAP Note for Schizophrenia
Patient Initials: Sherman Tremaine Age: 53 years Gender:
Male
SUBJECTIVE DATA:
Chief Complaint (CC): “He was made to come in by his
sister.”
History of Present Illness (HPI): Sherman Tremaine is a 53-
years-old African American male who visited my office saying
that he was made to come in by his sister. Sherman notes
that people have been watching him for weeks and his taxes
have raised. He says that the government sent these people
to watch him. The patient’s symptoms alleviate when he
listens to music.
Medical trials and Current Medications:
No medical trials but reports using Haldol, Thorazine, and
Seroquel previously. Takes metformin for diabetes.
Allergies: Denies food, environmental, or drug allergies.
Past Medical History: The patient was diagnosed with
diabetes and fatty liver.
Past Psychiatric/Physical History (PMH): Have been in the
hospital three times though when he was 20.
Past Surgical History (PSH): No past surgeries.
Personal/Social History: The patient smokes three packets
a day, drunks 12 packets of alcohol a week, and used
marijuana last three years ago. Denies substance abuse.
History of Violence: His dad was abusive.
Immunization History: The patient does not remember
immunization dates.
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Significant Family History: The patient is single, never
married, and has no children. The patient’s mother had
anxiety and father had paranoid schizophrenia.
Lifestyle: The patient has his sister has his main social
support.
Review of Systems:
General: Denies fatigue, fever, weight changes, or weakness.
Respiratory: No shortness of breath, sputum, or
cough.
Cardiovascular/Peripheral Vascular: No chest pain
or chest discomfort.
Psychiatric: Positive for sleeping problems.
Neurological: No headache or other neurological
problems.
Skin: No sores, dryness, or rashes.
OBJECTIVE DATA:
Physical Exam:
Vital signs: Wt. 180lbs, Ht. 5’8’’, T 36.4, HR 76, HH 18, BP
134/98
General: Sherman is oriented to place, date, and people.
However, the patient does not know whether today is
Wednesday or Thursday. The patient is well groomed and
wears clothes that conforms to weather of the day and climate
of the year. The patient answers most questions correctly.
Chest/Lungs: Regular heart rhythm and rate. No murmurs.
Heart/Peripheral Vascular: Lungs clear. No wheezes, chest
cracks, or rhonchi.
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Psychiatric: The patient experiences hallucinations and
delusions. He says that there are people outside his window
watching him. He notes that these people were sent by the
government. He says that he hears loud voices and also
notes that people from his TV want to poison him but he tricks
them.
Diagnostic Tests
MRI-Pending
DSM-5-Schizophrenia
PSYRATS – Hallucinations Subscale-Positive for
hallucinations.
PSYRATS – Delusions Subscale-Positive for delusions
ASSESSMENT:
1. Schizophrenia-Primary disorder for this case.
2. Brief Psychotic Disorder
3. Schizoaffective Disorder
4. Delusional Disorders
The primary diagnosis for this case is schizophrenia.
According to Ng et al. (2019), symptoms of schizophrenia
include disorganized speech, delusions, catatonic behavior,
negative symptoms, and hallucinations. According to DSM-5,
one must experience at least two of the five symptoms for
them to be said to have schizophrenia (American Psychiatric
Association, 2013). The patient has hallucinations and
delusions, making the disorder a primary diagnosis. The
diagnosis has also been supported by PSYRATS, a mental
health tool used to assess patients’ mental status (Chong et
al., 2020).
PLAN:
Treatment Plan: I would recommend that the patient be
prescribed Invega Sustenna 234 mg intramuscular X1. The
medication can improve the patient’s heath by improving his
10/1/22, 8:13 AM ANSWERED!! Case Study: Sherman Tremaine

judgment, thinking, and mood (Pesa et al., 2017). Apart from
medication, the patient will also be advised to go for talk
therapy once a week. Galbusera et al. (2018) note that a
combination of talk therapy and medication can highly
improve the mental health of schizophrenic patients.
Health Promotion: The patient should avoid smoking and
alcohol.
Follow-Up: The patient should come for re-evaluation and
check-up after four weeks.
REFLECTION:
If I was given another chance to work on the case, I would
have recommended that the patient be taken to a
psychologist for counseling. A combination of medication and
therapy can improve the health of the patient.
References
American Psychiatric Association. (2013). Diagnostic and
statistical manual of mental disorders (5th ed). Arlington, VA:
American Psychiatric Publishing.
Chong, B., Wahab, S., Muthukrishnan, A., Tan, K. L., Ch’ng,
M. L., & Yoong, M. T. (2020). Prevalence and Factors
Associated with Suicidal Ideation in Institutionalized Patients
with Schizophrenia. Psychology research and behavior
management, 13, 949–962.
https://doi.org/10.2147/PRBM.S266976
Galbusera, L., Finn, M. T., & Fuchs, T. (2018). Interactional
synchrony and negative symptoms: An outcome study of
body-oriented psychotherapy for schizophrenia.
Psychotherapy Research, 28(3), 457-469.
https://doi.org/10.1080/10503307.2016.1216624
Ng, Q. X., Soh, A. Y. S., Venkatanarayanan, N., Ho, C. Y. X.,
Lim, D. Y., & Yeo, W. S. (2019). A systematic review of the
effect of probiotic supplementation on schizophrenia
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symptoms. Neuropsychobiology, 78(1), 1-6.
https://www.karger.com/Article/Abstract/498862
Pesa, J. A., Doshi, D., Wang, L., Yuce, H., & Baser, O.
(2017). Health care resource utilization and costs of California
Medicaid patients with schizophrenia treated with paliperidone
palmitate once monthly or atypical oral antipsychotic
treatment. Current Medical Research and Opinion, 33(4)

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