NRNP 6675 Week 5: Focused SOAP Note and Patient Case Presentation

NRNP 6675 Week 5: Focused SOAP Note and Patient Case Presentation. HPI: When patient was asked " what people?". Patient said " the government sent them to get me because my taxes are high". Suddenly patient asked the provider if she can see the birds or hear any loud noise. The provider responded by redirecting the patient that she does not hear any voice or see anything. When the provider how long he is been hearing the voices or seeing things, patient said " for weeks, weeks and weeks". Patient also said the sister tapped her phone with the government. When asked about sleep, patient said " I have not slept well because the voices keep me up for days. I try to watch the TV, they poison my food on TV, I locked everything down in the fridge". Suddenly patient asked " Can I smoke?". Provider said "no you can't smoke here". Patient admit that he smokes all day about 3 packs a day. Drinks alcohol which his sister purchased for him to last him for weeks. Patient denies use of drugs. Admit to history of marijuana use 3 years ago before the mother passed away. Denies blackout, seizures, collateral or legal issues or DUIs from use of drugs or alcohol. Patient admit that he hates Haldol and Thorazine which he used to take. Calls his medications poison and said he is not going to take it. Substance Use History: Admits to use of alcohol, smokes 3 packs of cigarette per day. Admit history of marijuana 3 years ago Family Psychiatric/Mental/Substance Use History: Patient father paranoid and schizophrenia.