NRNP6675 / NRNP 6675 Focused SOAP Note and Patient Case Presentation, Week 5

Family Psychiatric/Mental/Substance Use History: Patient father paranoid and schizophrenia. Patient’s mother: Anxiety. Sister: unknown Grandfather: unknown. Grandmother: unknown Psychosocial History: Patient lives alone. Mother is deceased. Father is undisclosed. Both parents are Caucasian. Patient is presently does not have friends. Educational Level: 10th grade. Legal history: patient denies any history but said the police told him they would because patient calls 911 on people outside. Psychiatric History: Mood disorder unspecified Medical History/Surgical History: Diabetes Birth and Developmental history: Vagina birth, denies any disclosed complication and all developmental millstones was met on time. Current Medications: Haldol and Thorazine (all discontinued), Metformin Allergies: NKDA or seasonal allergies Reproductive Hx: Patient denies sexual history or abuse APPEARANCE: Appeared disheveled HEENT: No vision problem. Ears normal shape with no discharges. Nose normal shape; no deviation or drainage. No sore throat or swelling around the neck. CV: no cardiovascular abnormality PULMO: Lungs sounds clear and no adventitious lung sounds ABDOMEN: All bowel sounds on all four quadrant GENITOURINARY: No disorder or problem with this system EXTREM: All extremities is moveable; some tremors noted in upper extremities NEURO: alert and oriented to person, place, time, and situation but very unrest SKIN: Skin intact and appropriate; no rash or lesion noted Physical exam: Vital Signs: none at this time Weight: 196 Ibs Height: 5'9ft Objective: