Focused SOAP Note for Schizophrenia Spectrum, Other Psychotic, and MedicationInduced Movement Disorders Subjective CC (chief complaint): “My sister encouraged me to come to the clinic for psychiatric evaluation” HPI: S.T is a 53 year old African American man who reports to the clinic for psychiatric evaluation. He notes that he sees people from the window who he thinks that they are watching him. He sees shadows and thinks that the people are taking to him. He has had the hallucinations for several weeks. He hears heavy metal music that cannot be heard by others. Additionally, he also sees as if there are birds that are flying. He hears voices that are too loud and they make it difficult for him to sleep. He stays awake for many days. He has always had fears that his food is poisoned by individuals that he cannot see. This has made him lock all his food in the refrigerator. He fears going to the store as he fears that others are following him. He has not received any medications because he thinks that they are a poison to him. He considers his sister to be a government operative who is plotting against him and has tapped his phone to listen to their conversations. He has made several 911 calls to report people he thinks are following him. Past Psychiatric History: The patient has been previously hospitalized for schizophrenia General Statement: The patient believes that his sister has negative intentions against him Hospitalizations: He has been hospitalized three times Medical trials: Risperidone and did not have any side effects of gynecomastia. The patient never experienced the side effects brought about by Haldol and Thorazine. He also noted that Seroquel benefitted him
Focused-SOAP-Note-for-Schizophrenia-Spectrumdocx/ 3 Substance Current Use and History: Smokes three packets of every day. Drinks a beer each day. He used to smoke marijuana before the passing on of his mother three years ago Family Psychiatric/Substance Use History: His mother had anxiety. His father had paranoid schizophrenia Psychosocial History: The patient lives with his sister. He notes that he previously lived with his mother who passed on three years ago. He is not employed and schooled up to grade 10. He had experienced emotional and verbal abuse from his father when he was young. Medical History: Diabetes and fatty liver disease Current Medications: Metformin Allergies: No known allergies Reproductive history: Not married and does not have children General: No weight loss, fever, fatigue, chills or weakness HEENT: Head: No headaches. Eyes: No loss of vision, double vision or blurred vision. Ears: No hearing loss, discharge or pains. Nose: No mucus or discharge. Throat: No sore throat or pain when swallowing Skin: The skin is intact without breakages, rashes, or itching. Cardiovascular: No edema, chest pains, palpations and orthopnea. Respiratory: No breathing and respiratory difficulties. Gastrointestinal: Regular bowel movement. No nausea, vomiting and diarrhea. Genitourinary: No burning while urinating. Urine is clear and yellow Neurological: No dizziness, loss of balance or coordination concerns Musculoskeletal: No muscular and joint pains or swelling Hematologic: No anemia or bleeding.
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