*NURSING > SOAP NOTE > Week 5: Focused SOAP Note for Schizophrenia Spectrum, Other Psychotic, and Medication-Induced Moveme (All)
College of Nursing-PMHNP, Walden University NRNP 6675: PMHNP Care Across the Lifespan II Summer 2025/26. Week 5: Focused SOAP Note for Schizophrenia Spectrum, Other Psychotic, and Medication-Induce... d Movement Disorders Patient Information Name: Sherman Tremaine (ST) Gender: Male Age: 53 years CC (chief complaint): The patient's sister urged him to visit the medical facility to get mental assessment since he was experiencing responses to stimulus from within. HPI: ST is a 53-year-old African American male seeking a mental assessment. He claims to observe individuals beyond his window observing him. He perceives the sound of their conversation as well as observes their shadows, however he remains skeptical of their ability to perceive his presence. He claimed to have experienced these delusions for an extended period of time, specifically "several weeks". He perceives strong metal music that others can't hear as well as observes a bird in flight. He expresses dissatisfaction with the excessive volume of the voices, which is causing him difficulty in maintaining sleep, resulting in several consecutive days of wakefulness. He has the belief that his meals has been contaminated by unidentified individuals and as a precautionary measure, he safeguarded every item of food within his fridge. He stays away from going to his store due to the presence of mysterious individuals who would trail him to that location. He avoids from taking drugs of any kind due to his belief that they are toxic to his body. He has the belief that his sister has affiliations with the federal authorities and she is conspiring against him. He suspects that his cellphone has been subjected to surveillance. He has subsequently contacted emergency services (911) to notify them of the presence of unidentified individuals who are pursuing him. [Show More]
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