NRNP 6675 Week 9 Assignment; Focused Soap Note Grand Rounds

Course : Walden

Contributed : Latricia Gill

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Week 9 Focused Soap Note- Grand Rounds

A 59-year-old male presents by referral from care coordinator for diagnostic assessment and medication intervention. He has a long standing history of mental illness complicated by substance use. He does not believe he is mentally ill, rather that he is immortal. The objective/purpose of this paper is to address diagnoses and course of tx in an individual who is non adherent, determine if he is appropriate for civil commitment, discuss criteria for capacity, and discuss antipsychotic medication options for people with comorbidities.

CC: Initial psychiatric diagnostic assessment

Referring Provider: RN Care Coordinator with pt’s health plan referred pt in collaboration with his PCP.

Reason for Referral: Psychiatric evaluation to determine a diagnosis as well as to present options for medication management. Pt has suffered with mental illness most of his life but has not been followed by psychiatry. He has also used methamphetamine and cannabis.

History of Present Illness: 59-year-old male presents by referral from

his Care Coordinator in collaboration with his PCP for a post discharge

follow up after inpatient mental health hospitalization. Pt has a long

standing history of mental illness although he does not believe he is

mentally ill. He has been evaluated by this provider in the last year and

diagnosed with Schizophrenia but refused medication intervention. He

has a strong conviction that he is immortal and that his body is a

“weapon of mass destruction” to which his bodily fluids can cause

catastrophic world events if not disposed of properly. He often becomes

hyperfocused on being “alpha and omega” and that he has a personal

relationship with Jesus and Buddah. He is interested in finding another

person who is immortal and that he has an ability to turn someone