Soap Note Subjective CC (chief complaint): “I have been feeling very confused lately. I do not know what is happening to me. I need help. HPI: R.H, a 71-year-old White male, presents to the health facility feeling confused and needing help managing his medication

Soap Note Subjective CC (chief complaint): “I have been feeling very confused lately. I do not know what is happening to me. I need help. HPI: R.H, a 71-year-old White male, presents to the health facility feeling confused and needing help managing his medication. He is currently taking antipsychotics and antidepressants. The patient is a new referral to the health facility. However, the patient has been hospitalized before on 01/08/2020. Information is obtained from the patient, staff at the health facility, and medical records. Past Psychiatric History: The patient presented to the health facility feeling confused and was admitted on 01/08/2020. The patient indicates that he has been at the health facility for 3 years and 10 months. The patient has an unclear psychiatric history and denies ever being in a psychiatric hospital. However, the patient reports that he had visual hallucinations in the past and indicates that he saw a deceased family member sitting on the end of his bed. Staff at the health facility do not report any behavioral concerns in the patient. General Statement: Patient R.H indicated that he had been admitted to the health facility for 3 years and 10 months. The patient reports that he is sleeping well and has a good appetite. Also, the patient denies being depressed and indicates that he has adjusted well to being in the health facility.  Caregivers (if applicable): None  Hospitalizations: The patient was admitted to the health facility on 01/08/2022.  Medication trials: The patient has been on antipsychotics and antidepressants.  Psychotherapy or Previous Psychiatric Diagnosis: None Substance Current Use and History: The patient denies a history of alcohol use, smoking tobacco, opiates, cocaine, methamphetamine, and hallucinogens. Family Psychiatric/Substance Use History: The patient's father had a history of schizophrenia. The patient's mother had a history of major depressive disorder. Patient R. Hs brother had panic disorder. Her sister does not have a history of any mental illness. Social History: The patient is divorced and indicates that he was a logger in his past occupation. NRNP/PRAC 6635 Comprehensive Psychiatric Evaluation Template © 2021 Walden University Page 2 of 7 Also, the patient has attained a general educational diploma (GED) and reports his religion as “Mine.” Medical History: Patient R.H has a medical history including retention of urine, Hemiplegia, and Hemiparesis, cerebrovascular accident (CVA), vitamin deficiency, chronic ulcer of skin, obesity, history of malignant neoplasm, hypertension, dysphagia, type 2 diabetes, diabetic neuropathy, atherosclerotic cardiovascular disease (ASCVD), hyperlipidemia, hyperthyroidism, Gastroesophageal reflux disease (GERD), orthostatic hypotension, repeated falls, and muscle weakness.  Current Medications: The patient is currently on antipsychotics and antidepressants. The patient is currently on Cymbalta 20 mg 1 PO daily and Seroquel 125 mg BID. No side effects associated with the medication have been noted in the patient.  Allergies: The patient has no food or drug allergies. He has no history of asthma, hives, eczema, or rhinitis.  Reproductive Hx: The patient has no history of sexually transmitted diseases. ROS:  GENERAL: Reports feeling confused.  HEENT: Head: Denies headache and dizziness. Eyes: Normal eye coloring noted. Denies visual blurring: Ears: Denies any loss of hearing, pain, or discharge. In addition, the patient denies any form of illness in her throat, nose, and mouth.  Skin: The patient showed no signs of any skin infections or coloring. The patient denies having frequent sore throats, changes in voice, bleeding, and swelling of gums. He denies having mouth ulcers.  Cardiovascular: The patient denies having any cardiovascular disease or chest-related problems. No palpitations or edema.  Respiratory: No shortness of breath, cough, or sputum.  Gastrointestinal: The patient denies having any abdominal pain.  Genitourinary: The patient denies having a urinary tract infection.  Neurological: The patient’s nerves seem normal.  Musculoskeletal: The patient denies having fatigue, or back pain. He denies having joint pain or stiffness. No swollen abdomen or legs was reported.  Hematologic: No anemia, bleeding, or bruising. NRNP/PRAC 6635 Comprehensive Psychiatric Evaluation Template © 2021 Walden University Page 3 of 7  Lymphatics: No enlarged nodes. No history of splenectomy.  Endocrinologic: No reports of sweating, cold, or heat intolerance. No polyuria or polydipsia. Objective Physical exam: Weight: 76 Height: 5’3 BP: 125/86 Temp: 97.6 Pulse: 100 RR: 20 General: Confused. HEENT: Normocephalic/atraumatic, pupils reactive. Neck: No nodules were present. Chest: Lungs clear to auscultation bilaterally. Heart: No rubs, murmurs, or gallops. The heart rate is within the normal range. Integumentary: Warm and dry Neurological: No syncope, seizures, weakne