SOAP for Schizophrenia and Psychotic Disorders (Case Study Sample)

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Student Name
College of Nursing-PMHNP,
NRNP 6675: PMHNP Care Across the Lifespan II
Faculty Name
Assignment Due Date
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Subjective:
CC (chief complaint): “Well, my sister made me come in. I was living with my mom,
and she died. I was living, and not bothering anyone, and those people-- those people, they just won't leave me alone.”
HPI: S.T. is a 52-year-old Caucasian male presenting for evaluation of psychosis. Previous prescriptions include Haldol, Thorazine, Risperidone, and Seroquel. He says he is not going to take Haldol and Thorazine because he hates them. Risperidone gave him boobs but Seroquel is okay. The patient also reports that all the drugs are poison and he will not take them. He is complaining that the government sent people to spy on him outside his window. The patient says he can hear and see their shadows. “They think I don't see them, but I do.” He has been hearing and seeing these people watching him “for weeks, weeks and weeks and weeks.” The patient keeps calling the 911 about the people outside the window but the 911 does not find anyone. He avoids going to the store since the people follow him there and he hears loud heavy metal music in the store He also experiences visual hallucinations by seeing birds and auditory hallucinations by hearing music during the interview.
He reports he does not sleep for days, as the voices are loud. They watch him through the TV when he tries to watch. He also says they come to the house and poison his food. He reports he tricked those people by locking everything in the fridge. He reports that the sister is plotting with the government and tapping his phone to stop the patient from living alone.
Past Psychiatric History:
General Statement: Began treatment at 20 when he was hospitalized to receive treatment for psychosis.
Caregivers (if applicable): His sister.
Hospitalizations: The patient was hospitalized three times when he was 20. He denies