Schizophrenia - Psychiatry Case Presentation

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Psychiatry Case Presentation Candice Reyes, MS III Pacific Hospital of Long Beach

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Week 5: Focused SOAP Note and Patient Case Presentation College of Nursing-PMHNP, Walden University NRNP 6675: PMHNP Care Across the Lifespan 2 Practicum Introduction Psychosis is a mental condition in which a person's ideas and perceptions are disrupted, and the individual may have difficulty distinguishing between what is real and what is not. A health condition, medications, or drug usage can all contribute to psychosis. Delusions, hallucinations, incomprehensible speech, and agitation are all possible signs; the patient has incorrect beliefs and sees or hears things that others do not see or hear. The person suffering from the disease is usually unaware of his or her actions. Medication, psychotherapy, peer support, family support and education, and talk therapy are all options for treatment. More or less every mental intervention is backed by evidence accumulated during the patient's initial interview; each patient's therapy begins with a thorough medical and mental health evaluation, the incorporation of trust, and a discussion of past mental health history, substance misuse history, family mental health history, and so on. In this example, the patient's evaluation was documented, and a diagnosis was made based on the information collected from the patient during the evaluation. When the case was being developed, a therapeutic approach was designed. The patient is a 53- year-old Caucasian male who was scheduled for an initial screening for a psychotic disorder after his sister recommended a visit to the psychiatrist because patient's behavior changed since the mother passed away. Patient Initial: S.T Age: 53 Gender: Male Subjective Data: CC: "I was brought here by my sister because since my mother passed away, I was living on my own and not bothering anyone. Those people outside my window they are after me. They just want me dead". HPI: When patient was asked " what people?". Patient said " the government sent them to get me because my taxes are high". Suddenly patient asked the provider if she can see the birds or hear any loud noise. The provider responded by redirecting the patient that she does not hear any voice or see anything. When the provider how long he is been hearing the voices or seeing things, patient said " for weeks, weeks and weeks". Patient also said the sister tapped her phone with the government. When asked about sleep, patient said " I have not slept well because the voices keep me up for days. I try to watch the TV, they poison my food on TV, I locked everything down in the fridge". Suddenly patient asked " Can I smoke?". Provider said "no you can't smoke here". Patient admit that he smokes all day about 3 packs a day. Drinks alcohol which his sister purchased for him to last him for weeks. Patient denies use of drugs. Admit to history of marijuana use 3 years ago before the m ...

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