NRNP 6675 Week 5 Assignment – Focused Soap Note for Schizophrenia Spectrum, other Psychotic and Medication-Induced Movement Disorders Example Subjective:

NRNP 6675 Week 5 Assignment – Focused Soap Note for Schizophrenia Spectrum, other Psychotic and Medication-Induced Movement Disorders Example

Subjective:

CC (chief complaint): “I was living, and not bothering anyone, and those people—those people, they just won’t leave me alone.” “There are some people who do not leave me alone and with this, my sister made me come in today.” The patient also expressed concern about being observed by people outside his window. He asserts that he is able to see and hear shadows of people.

HPI: ST is a 53-year-old male patient who has come to the clinic saying that people are disturbing him and that they are observing him.

His sister coerced him to come for an evaluation. ST reports that he can hear and see individuals troubling him, despite their unawareness. He says that he has not troubled anyone and has been living quietly. He does not understand why some individuals do not want to leave him alone. During the session, he reports that he can hear heavy metal music and that he sees a bird in the surroundings. He reveals that he could put up with his mother, but she died three years ago, so he is living alone. He fears that the government and his sister are planning to meddle with his personal life. He reports that loud voices prevent him from enjoying a good night’s sleep, forcing him to be awake most of the time.

He admits that he abuses alcohol and smokes 3 packs of cigarettes daily. He also used to smoke marijuana, but stopped after his mother passed away three years ago. He says that he does not abuse cocaine or any other narcotics and has not had any seizures or experienced any blackouts. He had been prescribed risperidone, haloperidol, Seroquel, and Thorazine. However, he resisted taking these drugs, terming them as poisonous. He reports that his mother had suffered anxiety and a history of paranoid schizophrenia on his father’s side. He has never had suicidal thoughts, and no one has ever committed suicide in his family. He has diabetes and is managing it using metformin.

Substance Current Use:

The patient had previously abused marijuana but stopped using it three years ago. He currently abuses alcohol and takes 3 packs of cigarettes daily. He consumed alcohol the previous night before coming to the hospital. The length of his smoking period cannot be established.

Medical History:

• Current Medications: ST is treated for his mental disorder with four different drugs. These drugs include Risperidone, Thorazine, Haldol, and Seroquel. ST, however, is not following this recommendation because he believes they are poisonous and partially because of their adverse effects, like gynecomastia. He is also using metformin to control his diabetes.
• Allergies:No known drug for food allergies.
• Social history: TS is the family’s second child. He has one older sister. He formerly resided with his mother, who raised him and his sister together. His mother and father have both died. TS presently lives alone. He thinks his sister conspired with the authorities to meddle in his life. He enjoys drinking alcohol and smoking cigarettes. When he has trouble going to sleep, he watches television.
• Reproductive Hx:He has never been married and has no children.

ROS:

• GENERAL: ST has not reported weight loss, fever, or weariness. He has denied feeling cold, distressed, or hotness in the body.
• HEENT: ST exhibits none of the following symptoms: no visual impairment, no sneezing, no ear discharge or pain, no hearing loss or impairment, no congestion, no running nose, and no sore throat. The patient does not have any nasal blockage or swallowing issues.
• SKIN: There was no mention of any skin rashes or itching. He has not displayed any apparent injuries, scars, or bruises.
• CARDIOVASCULAR: ST shows regular heart activity. No palpitations, chest discomfort, or fatigue-related conditions exist.
• RESPIRATORY: ST did not experience any breathing difficulties, chest discomfort, chest pain, coughing, or tachypnea. Additionally, there is no sputum production, cough, or shortness of breath.
• GASTROINTESTINAL: No reports of vomiting, diarrhea, or anorexia were made, nor were any reports of abdominal pain or blood.
• GENITOURINARY: There are no reports of hematuria, abdominal pains, discomfort, or pain with urination, or urethral discharge.
• NEUROLOGICAL: No reports of paralysis, limb tingling, blurred vision, vertigo, or photophobia. No reports of ataxia, changes in bladder control, headache, syncope, or bowel pr