SHERMAN TREMAIN Schizophrenia Spectrum Case study SOAP note
Patient particular’s
Name: Sherman Tremaine
Age: 54 years
Gender: male
Ethnicity: American
Subjective Data
Chief complaint
: hallucinations
History of presenting illness:
Sherman Tremaine is a 54years old male who is not self-aware of having a mental illness. The patient has hallucinations both visual and auditory because he says some people cannot leave him to enjoy his time. He explains that he cannot sleep at night because of the loud metal music in his house. The patient has episodes of delirium and paranoia because he states that people watching him on the television are contemplating poisoning him. He has withdrawn social behavior because he wants to stay alone and has disorganized speech. He denies suicidal ideation, self-harm, and hopelessness.
Substance use history
: he smokes cigarettes and drinks pop. He admits to having ever taken marijuana but stopped three years ago. He denies the use of cocaine and other illegal drugs
Current medication
: metformin
PLACE ORDER HERE
Psychiatric medication trial:
the patient was on haldol and Thorazine but stopped because of the side effects. He was put on risperidone but stopped after putting on weight. He states that Seroquel is better though he is not compliant with medication.
Allergies
: he denies food, drug, latex, and environmental allergies.
Past medical history:
the patient has diabetes mellitus, fatty liver disease, and schizophrenia.
Family history:
the patient is the last born in a family of three. His mother passed three years ago and had an anxiety disorder. His father passed on a while ago and has paranoid schizophrenia. He denies a family history of suicidal events. SHERMAN TREMAIN Schizophrenia Spectrum Case study SOAP note
Social history:
the patient is single and has no children. He has been living with his mother and sister until his mother’s demise. He has studied up to 10
th
grade. He does not work. He enjoys smoking and drinking pops. He recalls his childhood traumas because his father was rough.
Review of systems
General:
the patient denies fever, fatigue, sweating, chills, rigors, and weight loss.
Heent:
the patient denies headache, dizziness, eye pain, blurring of vision,
Skin:
the patient denies skin rash and itchiness.
Cardiovascular:
he denies chest pain, palpitations, syncope, claudication, edema, orthopnea, dyspnea, and tachycardia.
Respiratory
: he denies cough, sputum, wheezing, shortness of breath, and difficulties in breathing.
Gastrointestinal
: he denies nausea, vomiting, abdominal pain, diarrhea, reflux, and reduced appetite.
Genitourinary:
he denies dysuria, hematuria, polyuria, oliguria, urethral discharge, and lower abdominal pain.
Neurological:
the patient denies dizziness, numbness of extremities, paralysis, facial droop, and tremors.
Musculoskeletal:
he denies muscle pain, joint pain, and muscle stiffness.
Hematologic
: he denies bleeding tendencies and easy bruising.
Lymphatics
: he denies lower limb swelling, fever, and recurrent infections.
Endocrinologic
: he denies heat and or cold intolerance, unintentional weight loss or weight gain, polyuria, polyphagia, and polydipsia.
Objective Data
General:
the patient is in fair general condition and calm. He has no pallor, jaundice, cyanosis, edema, dehydration, or lymphadenopathy.
Vitals:
his blood pressure is 115/88mmhg, the temperature at 36.6 degrees Celsius, weight is 66kgs, height is 161cm, oxygen circulation is at 95% room air, and respiratory rate at 16breaths per cycle.
Heent
: the head is round with no mass, swelling, or scar. The eyes are clear and moist. The nose is intact without scars and erythema and the mucus membrane is moist. The ears have no scars, swelling, wax impaction, and discharge, the mouth is pink and moist with no swollen tonsil gland.
Respiratory system:
the chest expands symmetrically when breathing. There is no mass or scar on the chest wall. There is a resonant percussion note and vesicular breath sounds on auscultation. There are no rhonchi, stridor, or crackles.
Cardiovascular system:
the heart is at 5
th
ics mcl. The peripheral pulses are present with normal volume, regular rhythm, and rate without bruits. The heart sounds s1 s2 are present without murmurs, parasternal heaves, and thrills. SHERMAN TREMAIN Schizophrenia Spectrum Case study SOAP note
Abdominal examination:
the abdomen is round with a normal contour. The bowel sounds are present in the four quadrants and there is a tympanic percussion note. There is no shifting dullness or organ enlargement.
Diagnostic investigations:
there are no specific tests for making a diagnosis of schizophrenia. However, one should rule out other diseases that may cause schizophrenia. A thyroid function test rules out hypothyroidism and hyperthyroidism. A complete blood count rules out sepsis, thrombocytopenia, and anemia. Renal function tests rule out kidney injury and electrolyte disturbance. Liver function test rules out chronic liver diseases like encephalopathy.
Assessment
Mental State Examination
Sherman Tremaine is neat and well-groomed for the time and occasion. He is oriented in person and place but disoriented to time. He seems agitated, does not maintain eye contact, and fidgets during the interview. He has coherent speech and language but goes off-topic occasionally. He seems to introduce new vocabulary during the interview. The patient has thought of insertions of people harming him and loosening of association when he states that the police officers want to arrest him for calling 911. The patient has evident delirium and hallucinations in the interview. He has no emotional expression, has poor judgment and insight regarding his illness, and his cognitive abilities are intact.
Differential diagnoses
Schizophrenia is a chronic and severe mental disorder that affects how a person thinks, feels, and behaves. It is characterized by a combination of symptoms, including hallucinations, delusions, disorganized thinking and speech, lack of motivation, and difficulties in social interaction (Keepers et al., 2020). Positive symptoms of schizophrenia perceiving things that are not there and/or hearing voices, having false beliefs, disorganized thinking and speech, and abnormal motor behavior. The negative symptoms are reduced emotional expression, social withdrawal, diminished motivation, and difficulties with speech and communication. Schizophrenia usually develops in late adolescence or early adulthood, although it can occur at any age. The exact cause of schizophrenia is unknown, but it is believed to result from a combination of genetic, environmental, and neurochemical factors (Keepers et al., 2020). The patient has schizophrenia because of the presenting signs and symptoms. The onset of these symptoms was in his early adulthood. Additionally, he had a traumatic environment when growing up and has a positive family history of schizophrenia.
Delusional disorder is a mental disorder characterized by the presence of persistent delusions without the presence of other prominent psychotic symptoms, such as hallucinations or significant disorganized thinking (González-Rodríguez et al., 2022). Delusions are fixed, false beliefs that are not based on reality and are not typically accepted by others within the person’s culture or background. Delusional disorder can manifest in different types such as persecutory delusions where one is being harassed, harmed, or targeted in some way. Grandiose delusions are beliefs of having exceptional abilities, wealth, or fame that are not grounded in reality. Erotomanic delusions are beliefs that someone, usually of higher status, is in love with the individual, despite lack of evidence. Patients with delusional disorder often have a strong conviction in the truth of their delusions and may have limited insight into their condition. The delusional disorder does not typically cause significant impairment in cognitive functioning or daily functioning outside of the specific area affected by the delusion (González-Rodríguez et al., 2022). However, the impact on relationships, social interactions, and overall well-being can vary depending on the content and severity of the delusion.
Substance-induced psychotic disorder is a mental disorder characterized by the presence of psychotic symptoms, including hallucinations, delusions, or disorganized thinking, that are directly caused by the use of or withdrawal from substances such as drugs or medications. These substances can include alcohol, hallucinogens, amphetamines, cocaine, cannabis, sedatives, and others (Tandon & Shariff, 2019). The psychotic symptoms of substance-induced psychotic disorder are directly linked to substance use. The symptoms emerge during intoxication or withdrawal from the substance and are not better explained by another primary mental disorder. The duration of substance-induced psychotic symptoms can be brief and resolved within a few hours or days after substance use has ceased, or they can last for an extended period if substance use continues. This is not the patient’s diagnosis because these symptoms are not associated with substance use SHERMAN TREMAIN Schizophrenia Spectrum Case study SOAP note.
Plan
Pharmacologic Treatment
Seroquel-initiate at 50mg once daily and gradually increase the dosage by 50mg weekly while monitoring for tolerance, therapeutic efficiency, and side effects (Maan et al., 2017).
Non-Pharmacological Treatment:
Psychoeducation: educating individuals with schizophrenia and their families about the illness, its symptoms, treatment options, and coping strategies is crucial (Škodlar & Henriksen, 2019). It helps improve understanding, adherence to medication, and relapse prevention.
Individual therapy: cognitive-behavioral therapy helps individuals identify and change negative thought patterns and develop coping skills.
Family therapy: involving family members in therapy can provide support, improve communication, and enhance understanding of the illness (Škodlar & Henriksen, 2019). It can also help in addressing family dynamics and promoting a supportive environment.
Reflection Note
The assessment aimed to gather information about the patient’s current mental state, symptomatology, functioning, and treatment history. During the assessment, I observed several key findings indicative of schizophrenia presented with positive symptoms, including auditory hallucinations and persecutory delusions. The content of the delusions revolved around an external entity thus leading to significant distress and impaired functioning. The patient also exhibited disorganized thinking and speech, with tangentiality and difficulty maintaining a coherent conversation. The primary focus will be on addressing symptom management, improving insight, and enhancing overall functioning and quality of life. I will collaborate with the multidisciplinary team to ensure a comprehensive approach to care. Patients with schizophrenia provided valuable insights into their symptom profiles and functioning. By tailoring a comprehensive treatment plan that combines pharmacological and non-pharmacological interventions, we aim to alleviate symptoms, enhance insight, and improve the overall quality of life.
References
González-Rodríguez, A., Seeman, M. V., Izquierdo, E., Natividad, M., Guàrdia, A., Román, E., & Monreal, J. A. (2022). Delusional disorder in old age: A hypothesis-driven review of recent work focusing on epidemiology, clinical aspects, and outcomes.
International Journal of Environmental Research and Public Health
,
19
(13), 7911.
https://doi.org/10.3390/ijerph19137911
Keepers, G. A., Fochtmann, L. J., Anzia, J. M., Benjamin, S., Lyness, J. M., Mojtabai, R., … & (Systematic Review). (2020). The American Psychiatric Association practice guideline for the treatment of patients with schizophrenia.
American Journal of Psychiatry
,
177
(9), 868-872.
https://doi.org/10.1176/appi.ajp.2020.177901
Maan, J. S., Ershadi, M., Khan, I., & Saadabadi, A. (2017). Quetiapine.
https://www.ncbi.nlm.nih.gov/books/NBK459145/
Škodlar, B., & Henriksen, M. G. (2019). Toward a phenomenological psychotherapy for schizophrenia.
Psychopathology
,
52
(2), 117-125.
https://doi.org/10.1159/000500163
Tandon, R., & Shariff, S. M. (2019). Substance-induced psychotic disorders and schizophrenia: pathophysiological insights and clinical implications.
American Journal of Psychiatry
,
176
(9), 683-684.
https://doi.org/10.1176/appi.ajp.2019.19070734
SHERMAN TREMAIN Schizophrenia Spectrum Case study SOAP note
TO PREPARE – SHERMAN TREMAIN Schizophrenia Spectrum Case study SOAP note
• 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 – SHERMAN TREMAIN Schizophrenia Spectrum Case study SOAP note
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).
Transcript from case study – SHERMAN TREMAIN Schizophrenia Spectrum Case study SOAP note
[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:
I’m Sherman Tremaine, and Tremaine is my game game. My birthday is November 3, 1968. DR. MOORE: Great. And can you tell
me today’s date? Like the day of the week,
and where we are today? SHERMAN TREMAINE: Use any recent
date, and any location is OK. DR. MOORE: OK, Sherman. What about do you know
what month this is? SHERMAN TREMAINE: It’s March 18. DR. MOORE: And the
day of the week? SHERMAN TREMAINE: Oh, it’s a
Wednesday or maybe a Thursday. DR. MOORE: OK. And where are we today? SHERMAN TREMAINE:
I believe we’re in your office, Dr. Moore. DR. MOORE: OK, great. So tell me a little bit about
what brings you in today. What brings you here? SHERMAN TREMAINE: Well,
my sister made me come in. I was living with my
mom, and she died. I was living, and not bothering
anyone, and those people– those people, they just
won’t leave me alone. DR. MOORE: What people? SHERMAN TREMAINE: The ones
outside my window watching. They watch me. I can hear them, and
I see their shadows. They think I don’t
see them, but I do. The government sent
them to watch me, so my taxes are high,
so high in the sky. Do you see that bird? DR. MOORE: Sherman,
how long have you saw or heard these people? SHERMAN TREMAINE: Oh, for weeks,
weeks and weeks and weeks. Hear that– hear that
heavy metal music? They want you to think
it’s weak, but it’s heavy. DR. MOORE: No, Sherman. I don’t see any birds
or hear any music. Do you sleep well, Sherman? SHERMAN TREMAINE: I try to
but the voices are loud. They keep me up
for days and days. I try to watch TV, but they
watch me through the screen, and they come in
and poison my food. I tricked them though. I tricked them. I locked everything
up in the fridge. They aren’t getting in there. Can I smoke? DR. MOORE: No, Sherman. There is no smoking here. How much do you usually smoke? SHERMAN TREMAINE: Well,
I smoke all day, all day. Three packs a day. DR. MOORE: Three packs a day. OK. What about alcohol? When was your last drink? SHERMAN TREMAINE: Oh, yesterday. My sister buys me a 12-pack,
and tells me to make it last until next week’s grocery run. I don’t go to the grocery store. They play too loud of
the heavy metal music. They also follow me there. DR. MOORE: What about marijuana? SHERMAN TREMAINE: Yes,
but not since my mom died three years ago. DR. MOORE: Use any cocaine? SHERMAN TREMAINE: No,
no, no, no, no, no, no. No drugs ever, clever, ever. DR. MOORE: What about
any blackouts or seizures or see or hear things
from drugs or alcohol? SHERMAN TREMAINE: No, no, never
a clever [INAUDIBLE] ever. DR. MOORE: What about
any DUIs or legal issues from drugs or alcohol? SHERMAN TREMAINE:
Never clever’s ever. DR. MOORE: OK. What about any medication
for your mental health? Have you tried those before, and
what was your reaction to them? SHERMAN TREMAINE: I hate
Haldol and Thorazine. SHERMAN TREMAIN Schizophrenia Spectrum Case study SOAP note No, no, I’m not
going to take it. Risperidone gave me boobs. No, I’m not going to take it. Seroquel, that is OK. But they’re all poison,
nope, not going to take it. DR. MOORE: OK. So tell me, any
blood relatives have any mental health or
substance abuse issues? SHERMAN TREMAINE:
They say that my dad was crazy with
paranoid schizophrenia. He did in the old
state hospital. They gave him his beer there. Can you believe that? Not like them today. My mom had anxiety. DR. MOORE: Did any blood
relatives commit suicide? SHERMAN TREMAINE:
Oh, no demons there. No, no. DR. MOORE: What about you? Have you ever done anything
like cut yourself, or had any thoughts about killing
yourself or anyone else? SHERMAN TREMAINE:
I already told you. No demons there. Have been in the hospital three
times though when I was 20. DR. MOORE: OK. What about any medical issues? Do you have any
medical problems? SHERMAN TREMAINE: Ooh, I
take metformin for diabetes. Had or I have a fatty
liver, they say, but they never saw it. So I don’t know unless
the aliens told them. DR. MOORE: OK. So who raised you? SHERMAN TREMAINE: My
mom and my sister. DR. MOORE: And who
do you live with now? SHERMAN TREMAINE:
Myself, but my sister’s plotting with the
government to change that. They tapped my phone. DR. MOORE: OK. Have you ever been married? Are you single,
widowed, or divorced? SHERMAN TREMAINE: I’ve
never been married. DR. MOORE: Do you
have any children? SHERMAN TREMAINE: No. DR. MOORE: OK. What is your highest
level of education? SHERMAN TREMAINE: I
went to the 10th grade. DR. MOORE: And what do
you like to do for fun? SHERMAN TREMAINE: I don’t work,
so smoking and drinking pop. DR. MOORE: OK. Have you ever been arrested or
convicted for anything legally? SHERMAN TREMAINE: No, but
they have told me they would. They have told me they would
if I didn’t stop calling 911 about the people outside. DR. MOORE: OK. What about any kind of trauma
as a child or an adult? Like physical, sexual,
emotional abuse. SHERMAN TREMAINE: My dad was
rough on us until he died. DR. MOORE: OK. [MUSIC PLAYING] So thank you for answering
those questions for me. Now, let’s talk about
how I can best help you. [MUSIC PLAYING] SHERMAN TREMAIN Schizophrenia Spectrum Case study SOAP note