NRNP 6675 Week 5 Assignment; Focused SOAP Note for Schizophrenia Spectrum, Other Psychotic,and Medication-Induced Movement Disorders

Course : Walden

Contributed : Latricia Gill

$20.00

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Patient Information

Name: Sherman Tremaine (ST)

Initial: ST

Gender: Male

Age: 53 Years

Subjective:

CC: "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 further complained that he is being watched by other persons outside his window. He claims that can hear people and see their shadows.

HPI: ST I is a 53-year-old male patient who has come to the clinical complaining that people are bothering him and these people are outcome watching him. It is his sister who made him come to the clinic ST claims that he can hear these people and see them even though they have no knowledge that ST can see them. According to ST, he was living without bothering anyone.

However, some people cannot leave him alone. ST claims that some persons in question usually stay outside his window and watch him. According to ST, the government directed these people to watch over him and this has caused high taxes for him. ST claims that his taxes are so high that the taxes get to the sky. ST explain that he has seen and heard of these people for many weeks. ST also claims that he sees a bird while in the doctor’s office and hears heavy metal music during his session with the healthcare provider. ST explains that he used to put up with his mother, however, the mother later died. Currently, ST lives alone. He is, however, worried that her sister is plotting with the government to interfere with how he lives.

ST further explains he never sleeps well due to the loud voices he hears and thus, making him awake most of the days. Based on his substance use history, ST reports drinking alcohol. He also

reports smoking three packs every day. ST also reported having used marijuana. However, stopped using marijuana following the death of her mother that occurred three years ago. ST denies using cocaine, denies eating things after consuming drugs or drinking alcohol, denies blackouts, and denies any seizures. In terms of current medication, ST was prescribed various medications including Seroquel, Thorazine, Haldol, and Risperidone. However, he refused to take these medications. ST explains that his father's father was suffering from paranoid schizophrenia while his mother had anxiety. ST has never experienced suicidal ideation, there is also no family history of suicide. ST is having diabetes and takes metformin for diabetes. His father was tough on them.......... Continue