FOCUSED SOAP NOTE FOR SCHIZOPHRENIA SPECTRUM, OTHER PSYCHOTIC, AND MEDICATION-INDUCED MOVEMENT DISORDERS
FOCUSED SOAP NOTE FOR SCHIZOPHRENIA SPECTRUM, OTHER PSYCHOTIC, AND MEDICATION-INDUCED MOVEMENT DISORDERS
FOCUSED SOAP NOTE FOR SCHIZOPHRENIA SPECTRUM, OTHER PSYCHOTIC, AND MEDICATION-INDUCED MOVEMENT DISORDERS
Week 5: Focused SOAP Note for Schizophrenia Spectrum, Other Psychotic, and Medication-Induced Movement Disorders
Subjective:
CC (chief complaint):“My sister made me come in”
HPI: S.T., a 53-year-old Caucasian woman, entered the mental health facility at her sister’s request. The patient said that she often feels as if someone is looking in through the glass at her. She asserts that she can hear them. She said that these encounters had been occurring for many weeks. The patient thinks that the people on television are trying to murder her by poisoning her meals while she watches television. denies using drugs or having had seizures in the past. No reports of suicidal thoughts or self-harming activities were made.
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Past Psychiatric History:
- General Statement: The patient has a history of Psychosis.
- Caregivers (if applicable): lives with her sister after losing their mother.
- Hospitalizations: indicates a history of three mental hospitalizations when the patient was 29 years old.
- Medication trials: The patient had previously used Haldol and Thorazine to treat her mental problems, but she detested them and said they were unsuccessful. On the other side, risperidone caused her breasts to enlarge, which she hates. confirms Seroquel’s excellent efficacy. She does not consistently take the medicine, however.
- Psychotherapy or Previous Psychiatric Diagnosis: None.
Substance Current Use:The patient admits to smoking three packs or more every day. She consumes alcohol as well, roughly 12 bottles every week. But after her mother passed away, she quit using marijuana.
Family Psychiatric/Substance Use History:The patient’s father was identified as having paranoid schizophrenia condition, while the patient’s mother had a history of anxiety problems. She disputes any suicides by family relations.
Psychosocial History: When their mother died around three years ago, the patient moved home with her sister. Her greatest level of schooling is the tenth grade. She denies ever marrying or having children. She is unemployed. She has never been arrested.
Medical History: Diabetes and fatty liver.
- Current Medications:takes 500 mg of metformin orally twice a day to regulate blood sugar.
- Allergies:There were no documented drug, food, or environmental allergies.
- Reproductive Hx:Never married; heterosexual. denies having had STDs or HIV.
ROS:
- GENERAL: denies feeling drained, losing weight, feeling sick, or having a temperature.
- HEENT: Head: denies any evidence of a headache or injury. Ears: denies itching, discharge, discomfort, or tinnitus. Denies tears, vision problems, redness, or itching in the eyes. Nose: denies stuffiness, sinusitis, irritation, or congestion. Denies dental issues, bleeding gums, swallowing issues, or sore throats.
- SKIN: Without any hives, rashes, or itching.
- CARDIOVASCULAR: denies experiencing chest pressure, orthopnea, dyspnea, edema in the lower limbs, palpitations, or syncope.
- RESPIRATORY: denies experiencing chest discomfort, shortness of breath, hemoptysis, cough, or snoring.
- GASTROINTESTINAL: denies experiencing nausea, vomiting, hematemesis, abdominal swelling, diarrhea, constipation, or bloody stools.
- GENITOURINARY: denies having frequent or urgent urination, incontinence, nighttime urination, burning while urinating, or pee that contains blood.
- NEUROLOGICAL: denies experiencing headaches, balance issues, dizziness, weakness, numbness, or abrupt loss of neurological function.
- MUSCULOSKELETAL: denies any joint soreness or stiffness. demonstrates the complete range of motion in all joints.
- HEMATOLOGIC: denies a history of easy bruising, irregular bleeding, or hypercoagulability.
- LYMPHATICS: denies having swollen lymph nodes in the past.
- ENDOCRINOLOGIC: denies tiredness, a weight increase or loss, polyuria, polyphagia, or polydipsia.
Objective:
Diagnostic results:Routine blood examinations such as complete blood count (CBC) and white blood cell count (WBC) were conducted. To eliminate potential physical etiologies underlying the patient’s symptoms, imaging investigations such as MRIs and CT scans were ordered. The Calgary Depression Scale for Schizophrenia, Clinical Global Impression-Schizophrenia (CGI-SCH), Scale for the Assessment of Negative Symptoms (SANS) and Scale for the Assessment of Positive Symptoms (SAPS), and Positive and Negative Syndrome Scale (PANSS) are additional diagnostic tools employed in the evaluation of schizophrenia (Schultze-Lutter et al., 2019).
Assessment:
Mental Status Examination: The patient, who is 53 years old, presents as well-groomed and attired in clothing appropriate for her age. She is well-organized in terms of time, location, and person. She, though, has a dubious air of awkwardness. She cooperates during the interview but has a limited attention span and is quickly distracted. Her cognitive functioning appears to be impaired. The patient exhibits a depressed mood. Demonstrates proficient short-term and long-term memory capabilities. Additionally, she exhibits indications of hallucinations and delirium. The patient negates any indication of suicidal ideation or self-harming conduct.
Diagnostic Impression:
- Schizophrenia Spectrum and Other Psychotic Disorders: Strange behaviors are a defining feature due to the lack of reality awareness (Palomar-Ciria et al., 2019). Hallucinations, delirium, confused speech, thinking, and odd behavior are further symptoms. The DSM-V stipulates that in addition to negative symptoms or catatonic conduct, the patient must exhibit at least two of the aforementioned symptoms. This diagnosis is the most appropriate since the subject in the case study offered demonstrated most of these symptoms and had a history of psychosis.
- Bipolar I Disorder with psychotic features: According to the DSM-V, people with this condition often have manic episodes coupled with psychotic characteristics including hallucinations and delusions (Kesebir et al., 2020). The patient in the case study was solely exhibiting psychotic traits and had no manic episodes, hence this diagnosis was invalid.
- Delusional Disorder: Most mental illnesses have the sign of delusion. The DSM-V, however, designated this as a separate disorder when a patient presented with delusion symptoms for at least one month without any other symptoms that would point to another mental disease (Perrotta, 2020). In addition to delusion, the patient in the case study offered also had several other psychotic symptoms.
Reflections:The PMHNP’s mental assessment was completed correctly and had all the data necessary to provide a medical diagnosis. The practitioner made every effort to speak with the patient in a kind and nonjudgmental manner, which helped the patient feel comfortable discussing her issues. However, since the patient’s ability to think was impaired, her sister had to be contacted to offer further details about her mental health (Schultze-Lutter et al., 2019). To assist the patient take her medications at home, the PMHNP must respect the patient’s privacy and confidentiality while also telling her sister about her diagnosis and treatment.
Case Formulation and Treatment Plan:
Primary diagnosis: Schizophrenia Spectrum and Other Psychotic Disorders
Psychotherapy: Cognitive behavioral therapy (El-Mallakh et al., 2019).
Alternative psychotherapy:Family therapy and coordinated specialty care (CSC).
Pharmacotherapy:She should be started on Extended-release tablets of quetiapine (Rx), 300 mg, orally once a day. To get the optimum amount for a successful result, increase the dosage by 300 mg per week (Maroney, 2020).
Patient Education: To improve the effectiveness of therapy, inform the patient of the significance of taking her medicine as directed (Maroney, 2020).
Health Promotion: In addition to eating a good diet and exercising, the patient has to be advised on quitting smoking (Maroney, 2020).
Follow-up: For dosage adjustments, the patient must return to the clinic every week.
References
El-Mallakh, R. S., Rhodes, T. P., & Dobbins, K. (2019). The case for case management in schizophrenia. Professional Case Management, 24(5), 273-276.DOI: 10.1097/NCM.0000000000000385
Kesebir, S., Koc, M. I., & Yosmaoglu, A. (2020). Bipolar Spectrum Disorder May Be Associated With a Family History of Diseases. Journal of Clinical Medicine Research, 12(4), 251.DOI: 10.14740/jocmr4143
Maroney, M. (2020). An update on current treatment strategies and emerging agents for the management of schizophrenia. Am J Manag Care, 26(3 Suppl), S55-S61.DOI: 10.37765/ajmc.2020.43012
Palomar-Ciria, N., Cegla-Schvartzman, F., Lopez-Morinigo, J. D., Bello, H. J., Ovejero, S., & Baca-Garcia, E. (2019). Diagnostic stability of schizophrenia: a systematic review. Psychiatry Research, 279, 306-314.https://doi.org/10.1016/j.psychres.2019.04.020
Perrotta, G. (2020). Psychotic spectrum disorders: definitions, classifications, neural correlates, and clinical profiles. Annals of Psychiatry and Treatment, 4(1), 070-084. https://doi.org/10.17352/apt.000023
Schultze-Lutter, F., Nenadic, I., & Grant, P. (2019). Psychosis and Schizophrenia-Spectrum Personality Disorders Require Early Detection on Different Symptom Dimensions. Frontiers in Psychiatry, 10. https://doi.org/10.3389/fpsyt.2019.00476
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FOCUSED SOAP NOTE FOR SCHIZOPHRENIA SPECTRUM, OTHER PSYCHOTIC, AND MEDICATION-INDUCED MOVEMENT DISORDERS
Psychotic disorders change one’s sense of reality and cause abnormal thinking and perception. Patients presenting with psychotic disorders may suffer from delusions or hallucinations or may display negative symptoms such as lack of emotion or withdrawal from social situations or relationships. Symptoms of medication-induced movement disorders can be mild or lethal and can include, for example, tremors, dystonic reactions, or serotonin syndrome.
For this Assignment, you will complete a focused SOAP note for a patient in a case study who has either schizophrenia spectrum, other psychotic, or medication-induced movement disorder.
LEARNING RESOURCES
Required Readings
Boland, R. Verdiun, M. L. & Ruiz, P. (2022). Kaplan & Sadock’s synopsis of psychiatry (12th ed.). Wolters Kluwer.
Chapter 2, “Neurodevelopmental Disorders and Other Childhood Disorders”
Section 2.16, “Early-Onset Schizophrenia” (pp. 207-210)
Chapter 5, “Schizophrenia Spectrum and Other Psychotic Disorders”
Thapar, A., Pine, D. S., Leckman, J. F., Scott, S., Snowling, M. J., & Taylor, E. A. (Eds.). (2015). Rutter’s child and adolescent psychiatry (6th ed.). Wiley Blackwell.
Chapter 43, “Pharmacological, Medically-Led and Related Disorders”
Chapter 57, “Schizophrenia and Psychosis”
Zakhari, R. (2021). The psychiatric-mental health nurse practitioner certification review manual. Springer Publishing Company.
Chapter 9, “Psychotic Disorders and Delusions”
Required Media
PsychScene Hub. (2017, April 24). Movement disorders with antipsychotic medicationLinks to an external site. – Conversations with Dr. Stephen Stahl [Video]. YouTube. https://www.youtube.com/watch?v=ipW5AcbFzzE
Vallejo, E. (2020). Realistic schizophrenia simulationLinks to an external site. [Video]. YouTube. https://www.youtube.com/watch?v=63lHuGMbscU
Walden University. (2021). Case study: Sherman Tremaine. Walden University Canvas. https://waldenu.instructure.com
CASE STUDY TRANSCRIPT FOR SHERMAN TREMAINE:
[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 seen 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. 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, do 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 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, and emotional abuse.
SHERMAN TREMAINE:
My dad was rough on us until he died.
DR. MOORE:
OK. So, thank you for answering those questions for me. Now, let’s talk about how I can best help you.
[MUSIC PLAYING]
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TO PREPARE
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
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 rule 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).
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NRNP_6675_Week5_Assignment_Rubric
NRNP_6675_Week5_Assignment_Rubric
Criteria, Rating and Pts
Create documentation in the Focused SOAP Note Template about your assigned patient.
In the Subjective section, provide:
• Chief complaint
• History of present illness (HPI)
• Past psychiatric history
• Medication trials and current medications
• Psychotherapy or previous psychiatric diagnosis
• Pertinent substance use, family psychiatric/substance use, social, and medical history
• Allergies
• ROS
15 to >13.0 pts Excellent 90%–100%
The response throughly and accurately describes the patient’s subjective complaint, history of present illness, past psychiatric history, medication trials and current medications, psychotherapy or previous psychiatric diagnosis, pertinent histories, allergies, and review of all systems that would inform a differential diagnosis.
15 pts
In the Objective section, provide:
• Physical exam documentation of systems pertinent to the chief complaint, HPI, and history
• Diagnostic results, including any labs, imaging, or other assessments needed to develop the differential diagnoses
15 to >13.0 pts Excellent 90%–100%
The response thoroughly and accurately documents the patient’s physical exam for pertinent systems. Diagnostic tests and their results are thoroughly and accurately documented.
15 pts
In the Assessment section, provide:
• Results of the mental status examination, presented in paragraph form
• At least three differentials with supporting evidence. List them from top priority to least priority. Compare the DSM-5 diagnostic criteria for each differential diagnosis and explain what DSM-5 criteria rule 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.
20 to >17.0 pts Excellent 90%–100%
The response thoroughly and accurately documents the results of the mental status exam…. Response lists at least three distinctly different and detailed possible disorders in order of priority for a differential diagnosis of the patient in the assigned case study, and it provides a thorough, accurate, and detailed justification for each of the disorders selected.
20 pts
In the Plan section, provide:
• Your plan for psychotherapy
• 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.
• Incorporate one health promotion activity and one patient education strategy.
25 to >22.0 pts Excellent 90%–100%
The response provides an evidence-based, detailed, and appropriate plan for psychotherapy for the patient…. The response provides an evidence-based, detailed, and appropriate plan for treatment and management, including pharmacologic and nonpharmacologic treatments, alternative therapies, and follow-up parameters. A strong rationale for the plan is provided that demonstrates critical thinking and content understanding…. The response includes at least one evidence-based health promotion activity and one evidence-based patient education strategy.
25 pts
Discussion:
In the discussion include what may be done differently with this patient if the student conducted the session again.
Discussed the next intervention if you could follow up with this patient.
The discussion was related to legal/ethical considerations (demonstrated critical thinking beyond confidentiality and consent for treatment!), social determinates of health, health promotion, and disease prevention that take into consideration patient factors (such as age, ethnic group, etc.), PMH, and other risk factors (e.g., socioeconomic, cultural background, etc.).
5 to >4.0 pts Excellent 90%–100%
Reflections are thorough, and thoughtful, and demonstrate critical thinking. Reflections contain a discussion of all elements described within assignment directions.
5 pts
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).
10 to >8.0 pts Excellent 90%–100%
The response provides at least three current, evidence-based resources from the literature to support the assessment and diagnosis of the patient in the assigned case study. The resources reflect the latest clinical guidelines and provide strong justification for decision making.
10 pts
Written Expression and Formatting – The paper follows the correct APA format for parenthetical/in-text citations and reference lists.
5 to >4.0 pts
Excellent 90%–100%
Uses correct APA format with no errors
5 pts
Written Expression and Formatting – English Writing Standards: Correct grammar, mechanics, and punctuation
5 to >4.0 pts Excellent 90%–100%
Uses correct grammar, spelling, and punctuation with no errors.
5 pts
Total Points: 100
PLEASE USE THE EXEMPLAR AS A GUIDE
