Sherman Tremaine SOAP note

Sherman Tremaine SOAP note

Case Study

HPI: The session begins with Dr. Moore meeting Sherman Tremaine, a male avatar patient, who was born on November 3rd, 1968. Sherman appears well-dressed but avoids eye contact and fidgets during the session. He indicates that the current date is March 18th, either a Wednesday or Thursday, in Dr. Moore’s office. Sherman mentions his reason for the session, stating his sister compelled him to seek help after their mother’s death, claiming people outside were bothering him. Leaning with a subtle tilt, he gestures toward phantom silhouettes casting glances through the window, asserting they’ve been deployed by governmental bodies to observe him and unjustly inflate his tax liabilities. Sherman reports experiencing auditory and visual hallucinations of these people for weeks, alongside delusions of persecution. He mentions hearing loud voices that disrupt his sleep and believes they tamper with his food. Despite locking his food away, he feels paranoid about contamination. Sherman discloses his substance use, including heavy smoking and occasional alcohol consumption, influenced by his sister’s purchases. He denies cocaine use but admits to past marijuana use, emphasizing he dislikes medication due to adverse effects, citing risperidone’s side effect of gynecomastia. He brings up his father’s past with paranoid schizophrenia and his mother’s struggles with anxiety. Sherman denies suicidal ideation or self-harm history, although he acknowledges prior hospitalizations in his twenties. He takes metformin for diabetes but questions the diagnosis’s validity. Sherman discloses familial dynamics, expressing distrust towards his sister and alleging government conspiracy. Despite these concerns, he maintains a casual demeanor and denies a criminal history, except for frequent calls to 911 about perceived threats.

Introduction – Sherman Tremaine Soap note

Schizophrenia spectrum, as well as other psychotic disorders, are characterized by hallucinations, delusions, disorganized behaviors, and negative symptoms. Schizophrenia emerges in late adulthood and is marked with psychotic episodes. These conditions alter an individual daily life and affect their relationship, self-care, and work. In the provided case study, Sherman presents with psychotic symptoms, visual and auditory hallucinations, paranoid ideation as well as persecutory delusions. He has a family history of paranoid schizophrenia and has a history of hospitalization, heavy cigarette smoking, occasional alcohol use, and marijuana use that calls for the differentiation of psychotic disorders from substance induced conditions. Therefore, this case study ensures accurate assessment and collaborative treatment to manage symptoms and promote good quality of life.

Patient information:

Name: S.T

Date of Birth: 1968

Subjective:

CC (chief complaint):

People outside are bothering me, and my sister has compelled me to seek help.

HPI:

The onset: A few weeks ago is when the symptoms started.

The course: Persistent symptoms since onset.

Duration: Symptoms lasted for some weeks.

Characteristics:               Hallucinations: He has visual and auditory hallucinations. He mentions hearing loud voices that disrupt his sleep and people observing him through the window.               Delusions: He believes that people have been deployed by the government bodies to observe him and inflate tax liabilities. He also believes his food is being tampered with.Aggravating factor: Not mentioned.Relieving factor: Not mentioned.Associated symptoms: sleep disruptions due to voices.Substance use: heavy smoking, alcohol consumption, as well as past marijuana use.He dislikes medication because of side effects, like risperidone, because it causes gynecomastia.               Substance Current Use: He accepts heavy smoking, occasional alcohol consumption, and past marijuana use, but he denies cocaine use.

Medical History: He had prior hospitalization in his twenties and was diagnosed with diabetes, which he questions the validity of the diagnosis.

• Current Medications: Metformin.
• Allergies: No allergy reported.

• Reproductive Hx: It is not provided.

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ROS:

• GENERAL: He denies fever, weakness, fatigue or weight loss.
• HEENT: Eyes: He denies visual loss, double vision, or blurred vision. Ear, Nose and Throat: There is no hearing loss, congestion, sneezing or sore throat.
• SKIN: Denies any itching or rash.
• CARDIOVASCULAR: Denies no chest pain, edema or palpitations.
• RESPIRATORY: Denies no shortness of breath, sputum or cough.
• GASTROINTESTINAL: He denies anorexia, nausea, vomiting, and diarrhea.
• GENITOURINARY: He denies urgency, burning on urination and hesitancy.
• NEUROLOGICAL: He denies headache, numbness, dizziness and seizures.
• MUSCULOSKELETAL: he denies muscle pain, back pain, joint stiffness and pain.
• HEMATOLOGIC: no bleeding, bruising or bleeding.
• LYMPHATICS: No enlarged lymph nodes.
• ENDOCRINOLOGIC: Denies heat and cold intolerance and sweating.

Objective:

Diagnostic results:

Complete Blood count (CBC): CBC is done to assess for infection, anemia and hematologic diseases that manifest psychiatric symptoms (Juchnowicz et al., 2023). These tests include the hematocrit, platelet, white blood cell, red blood, and hemoglobin count that help rule out the condition.

Toxicology: This is done to identify the substances that could worsen or trigger psychotic symptoms, like cocaine, marijuana, and alcohol, as well as other drugs. For individuals with acute psychotic symptoms, it is advisable to do toxicology screening to rule out if it’s induced by substance use (Fiorentini et al., 2021). This is done by blood tests and urine to detect substances like marijuana, alcohol, cocaine and prescription drugs Sherman Tremaine Soap note.

Imaging studies, the MRI or CT scan: Through imaging studies, brain abnormalities like lesions, tumors and brain atrophy occur because psychotic symptoms are ruled out (Dabiri et al., 2022). Imaging studies are recommended for patients with a new onset of psychosis if neurological signs are present.

Positive and Negative Syndrome Scale (PANSS)

Its components are the positive scale, negative scale, and general psychopathology scale. Positive scale measures for delusions, hallucinations as well as conceptual disorganization. Negative scale measures for emotional withdrawal, blunted effort, and poor rapport. Psychopathology scale measures guilt, feelings as well as concentration difficulties. It is used to assess for severe symptoms of schizophrenia. Positive symptoms include hallucinations rated at 6, persecutory delusions rated 6, and conceptual disorganization rated 4. The negative symptoms include emotional withdrawal, rated 4; blunted affect rated five and poor rapport, rated 3. They are consistent with paranoid schizophrenia

Assessment:

Mental Status Examination:

Appearance: he was well dressed, fidgeted and avoided eye contact.

Behavior: he was fidgeting, had subtle leaning tilt and had gestures towards imaginary things.

Mood: He was paranoid but distrustful.

Affect: He maintains a casual demeanor.

Thought process: He had persecutory delusions and delusional thinking.

Perception: He had visual as well as auditory hallucinations.

Insight: He has poor insight because of delusions and irrationality.

Judgment: He has impaired judgment, evidenced by frequent calls to 911.

Diagnostic Impression:

Paranoid schizophrenia (F20.0): He has visual and auditory hallucinations, persecutory delusions, and some symptoms that characterize paranoid schizophrenia. He believes that there are people deployed by the government to observe him as well as his tax liabilities inflation. He also has an auditory hallucination where there are sounds that disrupt his sleep. He sees phantom silhouettes outside. His father has schizophrenia, and it supports the diagnosis. Using the DSM-5-TR criteria, he meets the criteria because of symptoms like hallucinations and delusions as well as altered functioning like disrupted sleep and paranoia (Palit, 2023). He also has distrust issues and denies the history of psychiatric history.

Substance-Induced Psychotic Disorder (F19. 959): This disorder involves delusions and hallucinations that are directly related to substance. He has a history of heavy smoking, past marijuana use, and occasional alcohol consumption. DSM-5-TR criteria for diagnosis require that the symptoms are present during the withdrawal and intoxication periods (Gicas et al., 2022). They must be present during as well as soon after withdrawal or intoxication of the substances used. Despite his history of substance use, his symptoms are present even without the heavy usage of the substances, thus ruling out the diagnosis.

Delusional Disorder (F22): This is the persecutory type that is characterized by delusions taking longer than one month without symptoms like impaired functions outside delusions impacts, disorganized and delusions. He believes that people are observing him fit this disorder. DSM-5-TR criteria hold that the hallucinations, if present, are related to the delusion the person is experiencing (González-Rodríguez & Seeman, 2022). In his case, the hallucinations, both auditory and visual, are not related to his delusions.

The primary diagnosis is paranoid schizophrenia.

The rationale for this is that his hallucinations, both auditory and visual, as well as delusions, are characteristics of schizophrenia. Additionally, there is a family history of schizophrenia. They are the pertinent positives for his case, indicating schizophrenia. The absence of current substance use usage, withdrawal or intoxications helps rule out the substance-induced psychotic disorder, while the hallucination’s presence rules out the delusional disorder diagnosis. They are the pertinent negatives. Sherman Tremaine Soap note

Reflections:

After this case review, I come to an agreement with the assessments as well as the diagnostic imprint of Sherman’s paranoid schizophrenia. The diagnosis is supported by his symptoms, which include visual and auditory hallucinations as well as delusions. The case emphasized the need for comprehensive psychiatric assessment, history, symptoms, and diagnostic tests to help in getting the potential diagnosis and differentiating the diagnosis. I have learned that it is important to consider medical factors as well as psychiatric factors during diagnosis formation. I also learned the importance of understanding various causes of psychotic symptoms and helping in giving the correct diagnosis.

What I would do differently is I would explore in-depth the substance use and its relationship with psychotic symptoms exhibited by him. I would try to create rapport with him to improve his trust in people and, in return, be able to obtain information accurate information because he would be truthful when trust is won.

I would ensure informed consent and confidentiality when dealing with him. Also, I would ensure his safety as well as other people’s safety with his history of calls to 911 that could be a result of perceived threats. I would also ensure he understands his condition and the importance of medication to manage symptoms despite the previous side effects of drugs he had used.

The health promotion would involve educating him on the benefits of medication adherence, psychotherapy and lifestyle medication, like quitting smoking and alcohol. Given his diabetes history, regular exercise and a balanced diet are essential for his health. I would educate on the antipsychotic drugs’ side effects because they can affect metabolic factors. The treatment should address the specific needs of the patient. I would involve him in care and be culturally sensitive.

Case Formulation and Treatment Plan:

Psychotherapy

Cognitive Behavioral Therapy(CBT). This helps reduce paranoia and underscores reality testing. This helps him differentiate realistic from altered perception, and this would reduce his delusions of being watched (Kingdon & Turkington, 2022). This helps decrease the intensity and frequency of delusions.

Supportive therapy: This is to help him build trust with those around him and enhance his coping skills. It helps improve stress management, offers emotional support, and ensures he gets a sense of security. This is achieved through showing empathy, active listening, and being experienced in rapport creation and trust.

Pharmacologic treatment

Initiation of aripiprazole, an antipsychotic drug. The starting dose is 10 mg OD. It has low metabolic side effects compared to risperidone that he had been prescribed (Preda & Shapiro, 2020). Also, he has a low risk of gynecomastia development that he experienced earlier. Its usage would be monitored for efficacy and side effects like nausea, akathisia, as well as dizziness. For diabetes management, metformin would be continued because he is already on medication. Monitoring of blood sugars would be essential when on medication to ensure it is well controlled. Additionally, to help with sleep disturbances, trazodone 50 mg should be prescribed. It has efficacy in treating insomnia for patients with psychiatric conditions and has no dependence risk associated with its usage (Jaffer et al., 2017).

Non-pharmacologic treatment

He should be enrolled in a smoking cessation program to address his heavy smoking that would affect his health. This program involves support groups, behavioral counseling and medications like bupropion. Also, alcohol consumption should be reduced because it has negative results on mental health. Alcoholics Anonymous support groups could be used to help him quit alcohol use Sherman Tremaine Soap note.

References

Dabiri, M., Dehghani Firouzabadi, F., Yang, K., Barker, P. B., Lee, R. R., & Yousem, D. M. (2022). Neuroimaging in schizophrenia: A review article. Frontiers in neuroscience, 16, 1042814. https://doi.org/10.3389/fnins.2022.1042814

Fiorentini, A., Cantù, F., Crisanti, C., Cereda, G., Oldani, L., & Brambilla, P. (2021). Substance-induced psychoses: an updated literature review. Frontiers in psychiatry, 12, 694863. https://doi.org/10.3389/fpsyt.2021.694863

Gicas, K. M., Parmar, P. K., Fabiano, G. F., & Mashhadi, F. (2022). Substance-induced psychosis and cognitive functioning: A systematic review. Psychiatry Research, 308, 114361. https://doi.org/10.1016/j.psychres.2021.114361

González-Rodríguez, A., & Seeman, M. V. (2022). Differences between delusional disorder and schizophrenia: A mini narrative review. World journal of psychiatry, 12(5), 683. https://doi.org/10.5498%2Fwjp.v12.i5.683

Jaffer, K. Y., Chang, T., Vanle, B., Dang, J., Steiner, A. J., Loera, N., … & Ishak, W. W. (2017). Trazodone for insomnia: a systematic review. Innovations in clinical neuroscience, 14(7-8), 24. Sherman Tremaine Soap note

Juchnowicz, D., Dzikowski, M., Rog, J., Waszkiewicz, N., Karakuła, K. H., Zalewska, A., … & Karakula-Juchnowicz, H. (2023). The usefulness of a complete blood count in the prediction of the first episode of schizophrenia diagnosis and its relationship with oxidative stress. Plos one, 18(10), e0292756. https://doi.org/10.1371/journal.pone.0292756

Kingdon, D. G., & Turkington, D. (2022). Cognitive-behavioral therapy of schizophrenia. Psychology Press.

Palit, S. (2023). The science of paranoid schizophrenia, the science of biomedical research and the visionary future. SAR Journal of Psychiatry and Neuroscience, 4(6), 25-26. DOI: 10.36346/sarjpn.2023.v04i06.001

Preda, A., & Shapiro, B. B. (2020). A safety evaluation of aripiprazole in the treatment of schizophrenia. Expert opinion on drug safety, 19(12), 1529-1538. https://doi.org/10.1080/14740338.2020.1832990  Sherman Tremaine Soap note