lOMoAR cPSD| 66549320
Week (5): (FOCUSED SOAP NOTE FOR SCHIZOPHRENIA SPECTRUM, OTHER
PSYCHOTIC, AND MEDICATION-INDUCED MOVEMENT DISORDERS
Kenisha Watson
College of Nursing-PMHNP, Walden University
NRNP 6675: PMHNP Care Across the Lifespan II
Dr. Essex
October, 2023
Subjective:
, lOMoAR cPSD| 66549320
CC ("Well, my sister made me come in "):
HPI: Mr. S.T. is a 55-year-old African-American male who presents for a psychiatric evaluation.
He is here today because his sister encouraged him to see a psychiatrist. He has been
experiencing auditory and visual hallucinations; he claimed the government sent people to spy
on him. They watch him through the television screen and outside his room; he claims that he
hears them talking and sees their shadows, but he believes they don't know and realizes they are
there. He believes they poison his food and keeps the refrigerator locked to keep them out. He
avoids going to public places such as grocery stores because he thinks he is being watched.
During the interview, he stated that birds were present and heavy metal music was playing. The
patient voiced that he has been experiencing these symptoms for weeks. He has difficulty
sleeping because voices keep him up for days. He denied seizures and blackouts. He stated that
his sister is working with the government to prevent him from living alone, and they also tapped
his phone. The patient voiced that he had been calling the police and was told to stop or he would
be arrested.
Substance Current Use:
Smoking: The patient smokes three packs of cigarettes a day,
Alcohol: The patient stated that a 12-pack of alcohol usually lasts until the next grocery run; his
last use was yesterday.
Cannabis: The patient stated that he smoked marijuana three years ago.
Cocaine: denied cocaine or illicit drug use.
Medical History: The patient has a history of Diabetes and Fatty liver.
Hospitalization: The patient was hospitalized three times in his 20s.
Psychiatric History: The patient has a diagnosis of schizophrenia. He reported that his dad was
also diagnosed with schizophrenia and was hospitalized at the state hospital in the past, and his
Week (5): (FOCUSED SOAP NOTE FOR SCHIZOPHRENIA SPECTRUM, OTHER
PSYCHOTIC, AND MEDICATION-INDUCED MOVEMENT DISORDERS
Kenisha Watson
College of Nursing-PMHNP, Walden University
NRNP 6675: PMHNP Care Across the Lifespan II
Dr. Essex
October, 2023
Subjective:
, lOMoAR cPSD| 66549320
CC ("Well, my sister made me come in "):
HPI: Mr. S.T. is a 55-year-old African-American male who presents for a psychiatric evaluation.
He is here today because his sister encouraged him to see a psychiatrist. He has been
experiencing auditory and visual hallucinations; he claimed the government sent people to spy
on him. They watch him through the television screen and outside his room; he claims that he
hears them talking and sees their shadows, but he believes they don't know and realizes they are
there. He believes they poison his food and keeps the refrigerator locked to keep them out. He
avoids going to public places such as grocery stores because he thinks he is being watched.
During the interview, he stated that birds were present and heavy metal music was playing. The
patient voiced that he has been experiencing these symptoms for weeks. He has difficulty
sleeping because voices keep him up for days. He denied seizures and blackouts. He stated that
his sister is working with the government to prevent him from living alone, and they also tapped
his phone. The patient voiced that he had been calling the police and was told to stop or he would
be arrested.
Substance Current Use:
Smoking: The patient smokes three packs of cigarettes a day,
Alcohol: The patient stated that a 12-pack of alcohol usually lasts until the next grocery run; his
last use was yesterday.
Cannabis: The patient stated that he smoked marijuana three years ago.
Cocaine: denied cocaine or illicit drug use.
Medical History: The patient has a history of Diabetes and Fatty liver.
Hospitalization: The patient was hospitalized three times in his 20s.
Psychiatric History: The patient has a diagnosis of schizophrenia. He reported that his dad was
also diagnosed with schizophrenia and was hospitalized at the state hospital in the past, and his
