Focused SOAP Note for Schizophrenia Spectrum, Other Psychotic, and Medication- Induced Movement Disorders Chief Complaint

Focused SOAP Note for Schizophrenia Spectrum, Other Psychotic, and Medication- Induced Movement Disorders Chief Complaint

Patient was encouraged by his sister to come to the clinic for a psychiatric evaluation due to responding to internal stimuli. History of Present Illness:Sh.T.is a 53 years old African American male who presents for a psychiatric evaluation. He states that he sees people outside the window watching him. He hears them talking and sees shadows of them and he doesn`t believe that they see him. He stated that he had these hallucinations for “weeks and weeks and weeks”. He hears heavy metal music that other don`t hear and is sees a flying bird. He complains that the voices are so loud that he has troubles staying asleep and he has been awake for many days. He believes that his food is poisoned by the unseen others and he has locked all the food in the refrigerator. He doesn`t go to the store because the unseen others would follow him there. He has not been taking any medications because he believes that they are poison to him. He believes that his sister is connected with the government and plotting against him and that they tapped his phone. Has made calls to 911 to report the unseen others that are following him. Past Psychiatric History:Hospitalized for schizophrenia in the past. General Statement:He believes that his sister is connected with the government and plotting against him and that they tapped his phone. Hospitalizations: Three times during his 20`s Medication trials: Risperidone but didn`t like the side effects of gynecomastia. Did not like the effects of Haldol and Thorazine. Seroquel was beneficial to him