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10119 NeurolCognitive - Alert active. Unable to assess orientation. Speech is
1900 clear and easily understood. Appears pressured
Respiratory: Breathing regular, even, unlabored. No evidence of
respiratory distress
Skin: Scratch marks noted to bilateral arms. The client regularly
scratches his amms and rubs them
Psychosocial: Visual hallucinations per client statements of seeing giant
beetles all over the floor. The client frequently giggles to himself. Having
persecutory delusions: “They put a chipin my arm, I'm trying to get it out
1 need to get to the celestial city. | cantgo with the chip. The chip has to
0
gl otwer
1019 1500 Medical History.
« Schizophrenia
- PTSD
Depression
« Anxiety
Sleep termors
1019 1500 Home Medication List
« Chiorpromazine 200 mg by mouth daily
« Clazapine 100 mg by mouth twice daily
« Risperidone 4 mg by mouth daily
- Benztropine 4 mg by mouth daily
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