Assignment Focused SOAP Note for Schizophrenia Spectrum, Other Psychotic, and Medication-Induced Movement Disorders

Subjective:

CC (chief complaint): “My sister asked me to come here.”

HPI: ST is a 53-year-old African American male who was asked to come for mental health assessment by his sister. The patient reports seeing people watching and spying on him from his window. He also hears people talking to him when he switches on his TV. ST says that the people talking to him and watching him as spies sent by the government to arrest him the moment, he calls the police.

The says that the alleged spies are working with his sister to arrest him. His delusions and hallucinations have affected his social and professional life. He rates the delusions and hallucinations on a scale of 9/10.

Substance Current Use: He says that he smokes all day. His sister brings him 12 packets of cigarettes a week. He also drinks alcohol weekly. He smoked marijuana last three years ago. No history of drug use.

Medical History: Well-managed diabetes and fatty liver.

• Current Medications: History of Haldol and Thorazine and notes that he rated them. He stopped taking Risperdal because they enlarge his breasts.
• Allergies: No allergies
• Reproductive Hx: No reproductive issues.

ROS:

• GENERAL: No weight change, appetite change, weakness, fatigue, or chills.
• HEENT: Noncontributory.
• SKIN: No rash or itching.
• CARDIOVASCULAR: No palpations, edema, chest pain, or pressure.
• RESPIRATORY: No sputum or shortness of breath.
• GASTROINTESTINAL: No nausea, abdominal pain, vomiting, or diarrhea.
• GENITOURINARY: No UTI, urinary urgency, or odor.
• NEUROLOGICAL: No ataxia, dizziness, or headaches.
• MUSCULOSKELETAL: No joint or muscle stiffness or pain.
• HEMATOLOGIC: No anemia, HIV, or bruising.
• LYMPHATICS: No enlarged nodes.
• ENDOCRINOLOGIC: No sweat or cold problems.

Objective:

• Vital signs: 5’9, Wt. 159lbs, HR 80, BP 130/95, T 35.7, RR 20.
• Cardiovascular:Clear chest walls, no lifts, hives, or thrills. No heart murmurs. No gallops. Regular heart rhythm and rate.
• Heart/Peripheral Vascular: Normal RR. Lungs clear without fluids.

Diagnostic results:

• Brief Clinical Assessment Scale for Schizophrenia (BCASS): BCASS is often used to screen for schizophrenia (Yildiz et al., 2021). Yildiz et al. (2021) reported that BSCASS is a reliable and valid tool for screening for schizophrenia in people with symptoms of delusions and hallucinations. The tool takes about 30 minutes to complete.

Assessment:

Mental Status Examination: The patient looks at his stated age. He is well-groomed and kempt. He is oriented to place, time, and people. His speech is normal and his mood is consistent with affect. However, he does not maintain eye contact. He answers questions properly. He reports delusions and hallucinations. No suicidal or homicidal thoughts. Memory and concentration are intact. Judgment and insight are also intact.

Diagnostic Impression: 

1. Schizophrenia DSM-5 295.90 (F20. 9)
2. Schizoaffective Disorder DSM-5 295.70 (F25.0)
3. Delusion Disorder DSM-5 297.1 (F22)

The primary diagnosis is schizophrenia. According to McCutcheon et al. (2020), schizophrenia is a mental health condition that causes delusions and hallucinations. The symptoms of schizophrenia include negative symptoms, delusions, hallucinations, catatonic behavior, and disorganized speech (American Psychiatric Association (APA), 2013).

DSM-5 highlights that at least two symptoms should be noted for one to be diagnosed with schizophrenia (APA, 2013). One of the symptoms should either be hallucinations or delusions. The patient has both hallucinations and delusions making the disorder a primary diagnosis. The second diagnosis is schizoaffective disorder.

A patient with schizoaffective disorder causes schizophrenia symptoms and depressed mood (Peterson et al., 2019). According to DSM-5, patients should be diagnosed with schizoaffective disorder if they have depressed mood and schizophrenia symptoms (APA, 2013). The disorder was included in the diagnosis because the patient has delusions and hallucinations.

However, the patient does not have a