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
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
