Date:
Patient: [Patient Name], [MRN]
Attending Physician: [Physician Name]
Reason for Visit: Evaluation/Follow-up for catatonia.
SOAP
Subjective (S):
History of Present Illness:
Inquire about the onset, duration, and progression of catatonic symptoms.
Explore for potential triggers, such as changes in medication, recent medical illness, or psychological stressors.
Gather information from family or caregivers about their observations of the patient’s behavior and any changes.
Mental Status Exam:
Briefly describe the patient’s mental status, including:
Mood (e.g., depressed, anxious, euthymic)
Thought content (presence of delusions or hallucinations)
Cognitive function (alertness, orientation, memory)
Insight and judgment
Past Psychiatric History:
Summarize any relevant past psychiatric diagnoses (e.g., schizophrenia, bipolar disorder, mood disorder) and past episodes of catatonia (if applicable).
Review past medication history and treatment response.
Objective (O):
Physical Exam:
Perform a general physical exam to assess for any underlying medical conditions that might contribute to catatonia (e.g., dehydration, electrolyte imbalances, infection).
Note any abnormal motor signs suggestive of catatonia (see below).
Bush-Francis Catatonia Rating Scale (BFCRS) Score (if used):
Briefly document the BFCRS score, which helps quantify the severity of catatonic symptoms.
Catatonic Motor Signs:
Stupor: Reduced responsiveness to stimuli.
Immobility (waxy flexibility): Maintaining a fixed posture for extended periods.
Negativism: Resistance to instructions or attempts to move.
Mutism: Lack of speech.
Verbigeration: Repetitive speech of words or phrases.
Mannerisms: Stereotyped movements or postures.
Posturing: Maintaining an unusual posture for extended periods.
Catalepsy: Waxy flexibility with preservation of imposed posture.
Grimacing: Exaggerated facial expressions.
Oculomotor signs: Doll’s eye maneuver (eyes remain fixed in one direction as head is turned) or staring.
Assessment (A):
Diagnosis:
Based on the clinical presentation, including history, mental status exam, and physical exam findings, establish a diagnosis of catatonia, specifying:
Primary catatonia (occurring in the absence of another mental illness)
Secondary catatonia (occurring in the context of another mental illness or medical condition)
Consider using diagnostic criteria from the DSM-5 or ICD-10 for catatonia.
Severity of Catatonia:
Describe the severity of catatonia based on the number and intensity of catatonic symptoms and the BFCRS score (if used).
Differential Diagnosis:
Briefly consider other conditions that might mimic catatonic symptoms (e.g., severe depression with psychomotor retardation, akinetic-rigid parkinsonism, neuroleptic malignant syndrome).
Plan (P):
Treatment:
Address the underlying cause of catatonia if identified (e.g., treating a medical condition, adjusting medication regimen).
Antipsychotics: Low-dose atypical antipsychotics are often the first-line treatment for catatonia, even in the absence of psychosis.
Benzodiazepines: May be used adjunctively to manage agitation or autonomic hyperarousal symptoms.
Electroconvulsive therapy (ECT): Can be a highly effective treatment for severe catatonia, especially if unresponsive to other interventions.
Supportive Care: Ensure adequate hydration, nutrition, and physical therapy to prevent complications of immobility.
Monitoring:
Closely monitor the patient’s response to treatment, including symptom improvement and potential side effects of medications.
Continue monitoring with BFCRS (if used) to track progress.
Safety Considerations:
Assess the risk of self-harm or neglect due to catatonic symptoms and implement appropriate safety measures.
Patient and Family Education:
Educate the patient and family about catatonia, the treatment plan, and the expected course of recovery.
Provide information on support groups or resources available to them.
Additional Notes:
Document any other relevant information, such as communication with consulting psychiatrists, need for additional testing (e.g., laboratory tests, brain imaging), and anticipated long-term management