NRNP 6675 Week 5 Assignment; Focused SOAP Note and Patient Case Presentation
- $20.00
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CC: “My sister made me come in.”
HPI: S.T. is a 54 yo M here for a psychiatric intake evaluation. The patient was brought in by his sister to be evaluated for auditory and visual hallucinations. Patient with a history of inpatient psychiatric hospitalization three times in his 20s. The patient reports seeing shadows outside his window and seeing birds, and hearing heavy metal music. The patient states he has not been sleeping well. He also believes that the government tapped his phone and that his sister is “plotting against him.” Reports last marijuana use was three years ago before his mother passed away. The patient reports being on Haldol, Thorazine, Risperidone, and Seroquel but hated Haldol and Thorazine, and Risperidone gave him “boobs.” The patient states that “all meds are poison.” Reports that his dad was “rough” on them when he was still alive. The highest education is some high school.
Substance Current Use: Drinks beer daily, Marijuana use three years ago, Smokes three packs a day.
Medical History: DM Type 2, Fatty Liver
- Current Medications: Metformin
- Medication Trial: Haldol, Thorazine, Seroquel
- Allergies: Not assessed
- Reproductive Hx: Heterosexual
- Family History: Father had paranoid schizophrenia; Mother had GAD.......... Continue
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