Focused SOAP Note

Week 5: Psychotic Disorders; Medication-Induced Movement Disorders

Positive and negative symptoms are seen in schizophrenia spectrum and associated psychotic diseases. Positive symptoms include delusions, hallucinations, and repetitive movements. Negative symptoms include difficulties expressing emotions, withdrawal from social relationships, and apathy.

While “positive” symptoms occur in many diseases, not all of them are schizophrenia. When treating schizophrenia and other psychotic diseases, treat both the positive and negative symptoms.

Tremors are a typical symptom of medication-induced movement disorders, which include antipsychotics and antiemetics. These conditions can range from mild to fatal.

This week, you’ll learn about schizophrenic disorders and medication-induced movement problems.
Learning Goals

They will:

Examine patients with schizophrenic, psychotic, and medication-induced
Make a distinction between schizophrenia, other psychotic, and medication-induced movement disorders.
Formulate treatment strategies for patients with schizophrenic, psychotic, and medication-induced
Patients with schizophrenic, psychotic, and medication-induced movement abnormalities should be educated on health promotion


Readings (click to expand/reduce)

Sadock, B. J., V. A. Sadock, & P. (2015). SYNOPSIS OF MENTAL HEALTH (11th ed.). WKL (For review as needed)

Chapter 7: Schizophrenia Spectrum Disorders
Medications-Induced Movement Disorders
“Chapter 29.3: 2-Adrenergic Receptor Agonists, 1-Adrenergic Receptor Antagonists”

Thapar, A., et al (Eds.). (2015). Rutter’s psychiatry (6th ed.). Wiley.

Drug-induced and related disorders (Chapter 43)
“Schizophrenia and Psychosis”

R Zakhari (2021). Exam prep for psychiatric-mental health nurse practitioners. Springer Verlag.

“Psychotic Disorders and Delusions”

Template for Focused SOAP Notes

Focused SOAP Note Example

Media (click to enlarge/reduce)

PsychScene (2017, April 24). Movement problems and antipsychotics [Video] YouTube.

E Vallejo (2020). True-to-life schizophre YouTube.

WU (2021). Sherman Tremaine.


Analyze the following FDA-approved medications for treating schizophrenia and other psychotic disorders:

Psychosis Schizophrenia
adipex (adjunct)
aripiprazole asenapine blonanserin (adjunct)
clonazepam (adjunct) cyamemazine flupenthixol fluphenazine haloperidol iloperidone lamotrigine (adjunct) (adjunct)
loxapine slurasidone mesoridazine smolindone solanzapine spaliperidone
thioridazine thiothixene trifluoperazine valproate (divalproex) (adjunct)
ziprasidone zotepine zuclopenthixol amisulpride asenapine (adjunct)
loxapine lurasidone mesoridazine molindone olanzapine paliperidone
thioridazine thiothixene trifluoperazine valproate (divalproex) (adjuvant) ziprasidone zotepine zuclopenthixol




Extrapyramidal symptoms
amisulpride saripiprazole
carbamazepine (adjunct)
chlorpromazine sclozapine
haloperidol siloperidone
lamotrigon (adjunct)
ammoniac (adjunct)
mesoridazine smolindone solanzapine
paliperidone sperospirone perphenazine
pipothiazine squetiapine
risperidone ssertindole ssulpiride
thioridazine sthiothixene
trifluoperazine valproate (adjunct)
ziprasidone szotepine
quazepam stemazepam
benztropine sdiphenhydramine

Soap Note for Schizophrenia Spectrum Disorders and Medication-Induced Movement Disorders

Psychotic disorders create aberrant thinking and perception. Psychotic patients may have delusions or hallucinations, or show negative symptoms such as apathy or withdrawal from social events or relationships. Medication-induced movement abnormalities can cause tremors, dystonic responses, or serotonin syndrome.

This Assignment requires you to write a focused SOAP note for a patient with schizophrenic, other psychotic, or medication-induced movement condition.
Prepare by reviewing this week’s resources. Assessing, diagnosing, and treating schizophrenic, psychotic, and medication-induced movement abnormalities.

Getty Images/Wavebreak Media

Review the Focused SOAP Note template for this Assignment. A Focused SOAP Note Exemplar is also supplied to help with expectations.
Case Study: Sherman Tremaine This case will be the basis for this Assignment. A Walden faculty member evaluates a pretend patient. The patient will be an avatar on screen.
Consider the patient’s history collection needs.
Consider your interview questions for this patient.

The Task

Create a focused SOAP note that includes your differential diagnosis and critical thinking process. Include the following in your template responses:

Subjective: What information did the patient share about their major complaint and symptoms? How long and how severe are their symptoms? How do their illnesses affect their daily lives?
What did you notice throughout the psychiatric evaluation?
Assessment: Examine the patient’s mental state. What was your differential? Provide three probable diagnoses with evidence, ranked from greatest to lowest priority. Analyze each differential diagnosis’ DSM-5 diagnostic criteria and explain which criteria rule out the differential diagnosis. Explain how you arrived at your primary diagnosis. Include the patient’s specific positives and negatives.
What is your psychotherapeutic plan? Is there any alternative therapy in your treatment plan? Treatments should include pharmacological and nonpharmacological options as well as follow-up criteria and rationale for the treatment strategy. Ajouter 1 hr de promotion de la santé et 1
What would you do differently with this patient if you could do it over? If you can’t follow up with this patient, discuss your next intervention. Be sure to discuss patient variables (such as age, ethnicity, etc. ), PMH, and other risk factors in your reflection (e.g., socioeconomic, cultural background, etc.).
Assist your diagnosis and differential diagnoses with at least three peer-reviewed journal papers or evidence-based guidelines relevant to this patient. Keep them current (no more than 5 years old).

Week 5 Day 7

Entries are now closed.
Focused SOAP Note

Student’s Name
Institutional Affiliation
Professor’s Name

Focused SOAP Note
Patient Information:
S.T, 53, M, White
CC (chief complaint): Forgetfulness, seeing imaginary things and sounds, and losing touch of reality.
HPI: S.T is a 53-year-old patient who is brought to the clinic by the sister due to the worsening symptoms of seeing and hearing imaginary people and sounds. He believes some people are spying his life and he cannot remember the day correctly. The symptoms have been persisting for weeks. He has a history of smoking and taking marijuana. The symptoms have been persisting for weeks.
Current Medications:
No current medication.
Allergies: No known drug allergies.
PMHx: The patient reports he has been hearing imaginary sounds and people for weeks.
Soc and Substance Hx: The patient has a history of smoking and abusing marijuana. He denies history of cocaine.
Fam Hx: Lives with the sister.
Surgical Hx: No history of surgical operations.
Mental Hx: Mother reports a history of suicide. Denies history of suicide.
Violence Hx: The father was rough on the siblings until his death.
Reproductive Hx: No history of children or marriage.
GENERAL: A 53-year-old male who is having imaginary sounds and voices addressing people. He cannot tell the exact day of the week or month.
HEENT: No hearing problems.
SKIN: No lesions or itching.
CARDIOVASCULAR: No chest discomfort or pain.
RESPIRATORY: No shortness of breath of sputum.
GASTROINTESTINAL: No vomiting, diarrhea, or nausea.
GENITOURINARY: No burning on urination.
NEUROLOGICAL: No dizziness, or numbness.
MUSCULOSKELETAL: No muscle pain or stiffness.
HEMATOLOGIC: No bleeding or anemia.
LYMPHATICS: No enlarged lymph nodes.
PSYCHIATRIC: Cannot comprehend exact day or location. The patient sees imaginary people, hearing imaginary sounds. Mother reports a history of suicide. Denies history of suicide.
ALLERGIES: No known drug allergies.
Diagnostic results:
There is no lab test to evaluate for Schizophrenia. An experienced mental health professional will be required to examine the patient’s behavior and medical history. A complete blood count and urine tests are effective in ruling out the conditions that can cause hallucinations and symptoms related to schizophrenia.
Mental Status Examination
The patient is a 53-year-old patient who presents to the clinic under the recommendation of the sister. He is cooperative during the clinic, but he does not have a touch of reality. His memory of time and date is not clear. He sees things that others cannot see and hears voices that other people cannot hear. He has a history of smoking and abusing marijuana. The speech is clear and coherent and answers questions effectively. The recent and remote memory is not intact.
Differential Diagnoses:
F20. 9: Schizophrenia, unspecified
Unspecified schizophrenia spectrum can occur alongside other psychotic disorders. The condition affects the life of an individual until they cannot function normally. The symptoms of schizophrenia include delusions, hallucinations, and abnormal behavior (Archibald et al., 2019). The patient is likely suffering from schizophrenia since he hears voices from people that other people, such as the sister, cannot hear. For instance, she hears loud music that the sister and other people cannot hear (Archibald et al., 2019). The patient may be suffering from schizophrenia, among other co-occurring disorders.
F23: Brief psychotic disorder
The condition involves a display of psychotic behavior that involves delusions and hallucinations. Psychosis involves a lack of touch with reality (Smith et al., 2020). For example, the patient believes some people are after him and have been spent to spy his life. The condition can occur with a possibility of future relapses (Smith et al., 2020). The patient could be suffering from a brief psychotic disorder due to the behavior of losing touch with reality.
F22 Delusional Disorders
Delusion behavior occurs and impairs the cognition of the patients. It affects individuals until they cannot differentiate between the imagined and real-world (Miola et al., 2020). The patient could be suffering from delusional disorders due to the conversations about time and place (Miola et al., 2020). For instance, the person claims that some people are out to get him and harm him.
F31. 2 Bipolar I Disorder with psychotic features
The condition involves a combination of mania, depression, hallucination, lack of touch with reality, and disordered thinking. Individuals with bipolar disorder can experience a hard time due to the hallucinations (Trisha et al., 2018). In some cases, severe mania and depression can lead to dangerous behavior.
The patient should start psychotherapy sessions immediately. The psychotherapists will use cognitive behavior therapy to address the delusions and hallucinations. The psychotherapists can take 10-12 sessions. A session with the sister or a significant member of the family is critical to enhancing family support. A combination of the medication to address the hallucinations and delusions can be recommended depending on the outcome and health of the patient (Trisha et al., 2018). The patient should take therapy sessions each week and homework assignments to be completed at home. It is vital to report every week for review. It is critical to educate the patient to avoid drugs that can trigger hallucinations, such as marijuana.
If I conducted the treatment interview again, I would ask questions about past psychiatric treatment. I would ask the patient about their experience when they take drugs such as marijuana. I would ask the patient about the severity of the hallucinations. I will also seek to interview the sister, who will explain the severity of the condition. The sister will explain any intervention they have made at home and the patient’s behavior at home. I will also order urine tests to examine if the patient is abusing other drugs that could be causing hallucinations.
I will ensure I follow up with the patient to ensure they are making improvements. I would combine both therapy and medication to enhance the positive results.
During the provision of care, I will ensure I observe confidentiality by avoiding sharing information with third parties without the patient’s permission. I will observe veracity by telling the truth, such as the effect of marijuana on hallucinations (Rainer et al., 2018). I will observe justice and fairness by ensuring the patient is treated kindly and professionally without bias. It will be critical to ensure non-maleficence and beneficence to avoid harm (Rainer et al., 2018). The decisions made during therapy and prescription of medication should be made professionally and with caution.
The health promotion activities will encourage the patient to avoid drugs and substances that can affect the brain chemicals (Archibald et al., 2019). For instance, it will be crucial to caution against abusing marijuana and other prescription drugs. I will encourage the patient to observe an environment free of stress and conducive to allowing the brain to function at optimal levels.

Archibald, L., Brunette, M. F., Wallin, D. J., & Green, A. I. (2019). Alcohol use disorder and schizophrenia or schizoaffective disorder. Alcohol research: current reviews, 40(1).
Miola, A., Salvati, B., Sambataro, F., & Toffanin, T. (2020). Aripiprazole for the treatment of delusional disorders: A systematic review. General Hospital Psychiatry, 66, 34-43.
Rainer, J., Schneider, J. K., & Lorenz, R. A. (2018). Ethical dilemmas in nursing: An integrative review. Journal of Clinical Nursing, 27(19-20), 3446-3461.
Smith, C. M., Komisar, J. R., Mourad, A., & Kincaid, B. R. (2020). COVID-19-associated brief psychotic disorder. BMJ Case Reports CP, 13(8), e236940.
Trisha, C., Golnoush, A., Jan-Marie, K., Torres, I. J., & Yatham, L. N. (2018). Cognitive functioning in first episode bipolar I disorder patients with and without history of psychosis. Journal of affective disorders, 227, 109-116.

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