Delusional Disorder SOAP Note Examples – Assignment 2: Focused SOAP Note and Patient Case Presentation

Assignment 2: Focused SOAP Note and Patient Case Presentation, Delusional Disorder SOAP Note Examples, and SOAP Note Examples. Are you looking for answers to a similar assignment? Our team has competent and qualified writers to help with any of your assignments. All you need to do is place an order with us

To Prepare

Review the Kaltura Media Uploader resource for help creating your self-recorded Kaltura video

• Select an adult patient that you examined during the last 4 weeks who presented with a disorder other than the disorder present in your Week 3 Case Presentation.
• Create a Focused SOAP Note on this patient using the template provided in the Learning Resources. There is also a completed Focused SOAP Note Exemplar provided to serve as a guide to assignment expectations.PleaseNote:
  • All SOAP notes must be signed, and each page must be initialed by your Preceptor.Note: Electronic signatures are not accepted.
  • When you submit your note, you should include the complete focused SOAP note as a Word document and PDF/images of each page that is initialed and signed by your Preceptor.
  • You must submit your SOAP note using SafeAssign.Note: If both files are not received by the due date, faculty will deduct points per the Walden Grading Policy.
• Then, based on your SOAP note of this patient, develop a video case study presentation. Take time to practice your presentation before you record.
• Include at least five scholarly resources to support your assessment, diagnosis, and treatment planning.
• Ensure that you have the appropriate lighting and equipment to record the presentation.

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The Assignment (Delusional Disorder SOAP Note Examples)

Record yourself presenting the complex case study for your clinical patient. In your presentation:

• Dress professionally with a lab coat and present yourself in a professional manner.
• Display your photo ID at the start of the video when you introduce yourself.
• Ensure that you do not include any information that violates the principles of HIPAA (i.e., don’t use the patient’s name or any other identifying information).
• Present the full complex case study. Include chief complaint; history of present illness; any pertinent past psychiatric, substance use, medical, social, family history; most recent mental status exam; current psychiatric diagnosis including differentials that were ruled out; and plan for treatment and management.
• Report normal diagnostic results as the name of the test and “normal” (rather than specific value). Abnormal results should be reported as a specific value.
• Be succinct in your presentation, and do not exceed 8 minutes. Specifically address the following for the patient, using your SOAP note as a guide:
  • 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 patient mental status examination results. What were your differential diagnoses? Provide a minimum of three possible diagnoses and why you chose them. List them from highest priority to lowest priority. What was your primary diagnosis, and why? Describe how your primary diagnosis aligns with DSM-5 diagnostic criteria and supported by the patient’s symptoms.
  • Plan: What was your plan for psychotherapy? What was 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. Be sure to include at least 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 over? If you are able to follow up with your patient, explain whether these interventions were successful and why or why not. If you were not able to conduct a follow up, discuss what your next intervention would be.
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Subjective: (Delusional Disorder SOAP Note Examples)

CC (chief complaint):  ‘All Mr. Neeling wants is to fire me.’

HPI: Nija Bramming (N.B) is a 25-year-old Indian female who presents to the clinic after her Boss (Mr Neeling) referred her due to concerns that she (N.B) was having some difficulties at work. She complains that all that the Boss wants to do is to fire her. She claims this is because Eric (her immediate supervisor) is in love with her. She admits Eric has his girlfriend as she too has a boyfriend but is convinced their Boss feels she is the one to blame. She reports that Eric has not made any overt sexual moves, but she is aware he lusts for her. She reports that Eric has a way of walking towards her, gives her the easiest assignments, and asks that she voice her opinion a lot during the weekly meetings. She considers herself a strong, beautiful woman, and while some like Eric are attracted to her, others like the Boss are threatened, making him think she is out to replace him in the coming years, hence why Mr. Neeling wants to fire her. Over the last three weeks before this visit, the Boss reports she has done much and, on her admission, feels probably would not be a bad thing if they fired her.

Additionally, N.B. feels she is the one who should be suing the company for discrimination, causing her unnecessary stress and health problems. The patient reports having pain at the back of the neck that radiates to the back and which keeps getting worse. Besides the pain, untold suffering, and a broken heart, the patient thinks she has cancer, although no physician has confirmed this. The patient, however, has a medical history of hypothyroidism, which she manages, daily with a prescription of levothyroxine.

Past Psychiatric History:

• General Statement:

Ms. Branning has no history of psychotherapy but was diagnosed with hypothyroidism that is currently managed daily with Levothyroxine 100mcg twice a day.

• Caregivers (if applicable): Not Applicable(N/A)
• Hospitalizations: No known hospital admissions
• Medication trials: No past psychotropic medications have been administered
• Psychotherapy or Previous Psychiatric Diagnosis: Declined to divulge any information regarding past psychotherapy or psychiatric diagnosis.

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Substance Current Use and History:

Denies taking alcohol or using illegal drugs

Family Psychiatric/Substance Use History:

Unknown-Denies any of her family members have mental health issues, remain guarded and declined to respond to questions on past psychiatric history. Similarly, she declined to have the psychiatrist speak to parents for collaborative information.

Psychosocial History:

Born and raised by both parents as an only child currently living in Santa Monica, CA. She graduated with a bachelor’s in business degree and worked in office supply sales. She has a boyfriend, and the relationship does not appear to have any issues contributing to the current psychosis.

Medical History: (Delusional Disorder SOAP Note Examples)

• Current Medications: Levothyroxine 100 mcg twice a day to manage hypothyroidism. The patient has enjoyed a relatively healthy life with no medical issues.
• Allergies:Medical tape
• Reproductive Hx:

Reports regular monthly periods.

ROS:

• GENERAL: No fevers, chills, shakes, sweats, or weight changes.
• HEENT: No head trauma, no changes to vision, double vision, eye inflammation or infections, no hearing changes or discharge from ears, No nasal discharge, obstruction, sinus pain, or epistaxis. No hoarseness.
• SKIN: Negative for photosensitivity, no skin discolouration, no new or changing moles, no ulcers or hair loss, no dry skin.
• CARDIOVASCULAR: No edema, intolerance to exercises, no chest pain, shortness of breath, or palpitations.
• RESPIRATORY: No wheezing or shortness of breath, no coughing or sputum.
• GASTROINTESTINAL: No appetite issues, no PICA, no vomiting, no nausea, no blood in stool, no changes in bowel movement
• GENITOURINARY: No history of STIs, no pain, burning sensation, no discharge, no pruritis
• NEUROLOGICAL: No changes in memory, no loss of sensation, no tremors, no seizures, no difficulty speaking.
• MUSCULOSKELETAL: Positive for neck pain that radiates to the back.
• HEMATOLOGIC: No history of easy bruising or bleeding
• LYMPHATICS: No lymphadenopathy
• ENDOCRINOLOGIC: Positive for thyroid disease- hypothyroidism, negative for excessive thirst, urination, no heat or cold intolerance

Objective: (Delusional Disorder SOAP Note Examples)

Physical exam: if applicable

Vitals: T 98.4 P-80 R 18 BP 128/78 Ht 5’0 Wt. 120 lbs.

Patient is a healthy-appearing, well-nourished woman in no acute distress. Her skin has normal turgor, normal texture, warm and dry with no pallor. Eyes have no scleral icterus, have normal pink mucosa. Neck has no lymphadenopathy, and the heart has no thrills or heaves, RRR, S1S2 with no S3 or S4, no murmurs or gallops. Lungs clear to auscultation bilaterally, extremities no edema, clubbing, or cyanosis. Abdomen non-distended, non-tender to palpation, no masses. Neuro Alert and oriented X3 tandem gait normal and symmetric

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Diagnostic results:

TSH Test-above 5.7 mIU/L

Assessment:

Mental Status Examination

Orientation: oriented to person, place, and time

 Appearance woman of Asian ethnicity, executively dressed, hair well groomed.

Attitude: composed, cooperative

Speech: clear, constant, normal rate, rhythm, and volume

Mood: Euphoric, significant grandiosity

Affect Mood –congruent

Thought process: Logical, delusional, and grandiose

Thought content: No hallucinations (auditory or visual), no suicidal/homicidal ideation, significant mixed delusions (of erotomanic- believes Eric her supervisor is in love with her, grandiose –considers herself beautiful and strong and could easily replace her Boss in a few years, somatic believes she has cancer with no medical proof)

Memory: Remote, recent, and immediate- fair

Concentration- sufficient

Intellectual function- average

Judgement-Significantly impaired

Insight significantly impaired

Differential Diagnoses:

1. Delusional Disorder (in the Acute Stage) DSM-5 297.1(F22) – Confirmed

The patient manifests at least one of the three symptoms of psychotic disorders- delusions categorized as delusional disorders. Subsequently, a diagnosis of Delusional disorder (in the acute stage) DSM-5 297.1 (F22) is herein confirmed, although the symptoms have lasted for only three weeks and not one month. Medically speaking, a delusion is a belief held with a strong conviction, although evidence disproving it is stronger than any evidence supporting the claim (Kulkarni et al., 2016). There are proposed three criteria for delusional beliefs, with the first being that the said belief is held with absolute conviction (certainty). For example, in the case of Ms. Bramming, she strongly believes that Eric (her supervisor) is in love with her, while on her admission; she reports that each of them has their love partner. She further notes that Eric has never made any inappropriate overtures. She knows of her lust because he gives her the easiest assignments and encourages her to voice her opinions during the weekly meetings. Eric’s gestures, if true, could be out of concern for her to execute responsibilities within her potential and the need to reach out to her in giving her views. She also thinks that their supposed love is getting in the way of her Boss (who also, by implication, is lusting for her were it not for Eric) hence the latter’s desire to exact his revenge by firing her. She further admits the Boss has not sexually harassed her, and the Boss is concerned about her well-being judging by the last three weeks. The certainty that she has cancer against medical evidence is proof that she would level against the company if they fired her.

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The second aspect of N.B.’s delusions is her belief that cannot be changed with proof to the contrary (incorrigibility). For example, when the psychiatrist reassures her that a broken heart is unknown to cause cancer, she posits that one never knows until it happens (Up the groove, 2018). The third and last criteria of delusional beliefs are that the belief cannot be true (falsity or impossibility) like she knows she is being sexually harassed against any evidence. It is important to acknowledge that the patient reports non-bizarre delusions of diverse nature. The three themes that emerge are asexual/ romance involvement (erotomania with Eric, the supervisor, and a Boss who wants to fire her because he (Mr. Neeling) thinks it is her fault. Nowhere does she report that it is against the company’s policy for employees to fall in love with their workmates. Bates et al. (2019) note that the second theme is grandiosity, where she thinks her strong attitude and beauty threaten the Boss, not to mention her being more competent enough to replace him in a couple of years.

Lastly, there is the somatic change delusion where she feels she has cancer courtesy of neck pain, and the broken heart and suffering are the cause of her health issues. The delusional disorders diagnosis was considered because the patient does not meet Criterion A for Schizophrenia as the delusions are not accompanied by hallucinations, disorganized speech, or disorganized behavior. There was also no physiological or organic cause of the patient’s symptoms like drug abuse, side effects of current medication, or other psychotic disorders like depressive or bipolar disorder.

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2. Schizoaffective Disorder (SAD) -DSM-5 295.70-Refuted (Delusional Disorder SOAP Note Examples)

            The patient exhibits several psychotic symptoms, which are a prominent feature of schizoaffective disorder. However, according to the American Psychiatric Association (2013), a confirmatory diagnosis of SAD requires illness during which time a major mood episode is exhibited (Parker et al., 2014). Furthermore, hallucinations must also appear simultaneously with delusions for not less than two weeks. The absence of depression, hallucinations, and mood disorders in Ms. Branning helped rule out SAD (Parker, 2019).

3. Schizophrenia DSM-5 295.90(F20.9)-Refuted (Delusional Disorder SOAP Note Examples)

            The Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-5) notes that Schizophrenia manifests with a range of dysfunctions at the cognitive, behavioral, and emotional levels. For a diagnosis of Schizophrenia to be made, the patient must display two or more symptoms of delusions, hallucinations, disorganized speech, and completely disorganized behavior, amongst others. These are used to refute a schizophrenia diagnosis despite delusional beliefs (Patel et al., 2015). The patient must have experienced one of the first three symptoms together with other psychotic or mood disorders for not less than a month. The signs of disturbance have to continue for six or more months. All these factors were instrumental in my decision to refute a diagnosis of Schizophrenia in Ms. Nijah Branning.

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Reflections:

Having diagnosed N.B. as a psychotic disorder categorized as a delusional disorder, I concur with my preceptor’s assessment and diagnostic impression of the patient. Several reasons prompted me to agree with the preceptor, but the limited scope of this essay means only a few will be highlighted. Suffice it to say, although not explicitly highlighted, the five components of axial diagnosis should be incorporated (Allsopp, 2017). To comprehensively understand the five axes, Axis I captures clinical disorders, Axis II personality disorders, Axis III general medical disorders, and Axis IV psychosocial and environmental factors. Lastly, Axis V embraces the global assessment of functioning. As stated elsewhere in this SOAP note, psychosis describes a condition that mainly manifests as a loss of contact with reality and may involve major disruptions in the individual’s perception, cognition, behavior, and feeling.

Like many other patients, N.B.’s first episode occurs in her early adult life, which is significantly important in developing her identity, relationships, and vocational plans on a long-term basis. It is noteworthy that the patient exhibits positive symptoms that point towards delusions. The trained and experienced psychiatric professional has a legal and ethical responsibility to factor in the possible causes of the patient’s psychosis-like exposure to substance abuse, major stress, acquired or inherited medical conditions, and mood disorders. 

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Health Promotion and Disease Prevention of Delusional Disorders and Other Psychosis 

The psychiatrist should initiate early interventions that commence with the correct diagnosis, followed by the befitting specialist treatment. The success of the therapeutic interventions largely depends on increasing community understanding of Schizophrenia and other psychotic disorders, how to recognize the early signs, and reducing the stigma associated with these conditions. Confidentiality and involvement of the patient’s family should be incorporated in all phases of the psychotic disorder.

Whether the patient’s cause of the delusional is linked to genetics, biological or environmental factors reducing, the stress experienced by an individual contributes to preventing the onset of delusional symptoms. Therefore, measures that help the patient cope manage, and ultimately reduce stress like exercising, developing a hobby, and building support networks help promote an individual’s health (González-Rodríguez & Seeman, 2020). The individual should also avoid poor lifestyle habits like substance and drug abuse or living a sedentary lifestyle. Once diagnosed, the psychiatrist should utilize a multimodal approach that combines appropriate medication and psychotherapy (Waller et al., 2015). Medications to use are conventional antipsychotics like chlorpromazine, fluphenazine, and haloperidol, amongst others. In addition, atypical antipsychotics like risperidone and clozapine or tranquillizers and antidepressants should be considered, particularly if the individual has high levels of anxiety and sleep problems. In addition, various psychosocial treatments like individual psychotherapy, cognitive behavioral therapy, and family therapy have proven effective in treating and managing delusional disorders. A delusional disorder patient’s outlook largely depends on the individual, the type of delusional disorder, circumstances in the person’s life, support network, and willingness to adhere to the treatment. Failure to seek treatment makes the delusional disorder become a life-long condition.

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References

Allsopp, K. (2017). The functions of psychiatric diagnosis. The University of Liverpool (United Kingdom).

Bates, C., Cooper, L. B., & Spears, T. L. (2019). Delusional Disorder: Grandiose Type.

Bipeta, R. (2019). Legal and ethical aspects of mental health care.

González-Rodríguez, A., & Seeman, M. V. (2020). Addressing Delusions in Women and Men with Delusional Disorder: Key Points for Clinical Management. International Journal of Environmental Research and Public Health, 17(12), 4583.

Kulkarni, K. R., Arasappa, R., Prasad, K. M., Zutshi, A., Chand, P. K., Muralidharan, K., & Murthy, P. (2016). Clinical presentation and course of persistent delusional disorder: data from a tertiary care center in India. The primary care companion for CNS disorders, 18(1).

Parker, G. (2019). How Well Does the DSM-5 Capture Schizoaffective Disorder? The Canadian Journal of Psychiatry, 64(9), 607-610.

Parker, G. F. (2014). DSM-5 and psychotic and mood disorders. Journal of the American Academy of Psychiatry and the Law Online, 42(2), 182-190.

Patel, R., Gonzalez, L., Joelson, A., & Korenis, P. (2015). Schizophrenia with somatic delusions: a case report. J Psychiatry, 18(290), 2.

Upthegrove, R. (2018). Delusional beliefs in the clinical context. In Delusions in context (pp. 1-34). Palgrave Macmillan, Cham.

Waller, H., Emsley, R., Freeman, D., Bebbington, P., Dunn, G., Fowler, D., & Garety, P. (2015). Thinking Well: a randomized controlled feasibility study of a new CBT therapy targeting reasoning biases in people with distressing persecutory delusional beliefs. Journal of Behavior Therapy and Experimental Psychiatry, 48, 82-89.

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