SOAP Note for Schizophrenia Disorder

Schizophrenia SOAP Note
Student's Name
University Affiliation
Professor's Name
Course Title
Due Date
Subjective
Chief Complaint: “I would like to see my lawyer right now.”
HPI: Alena is a 33-year-old female. She was brought to the hospital by the police for her initial admission. She had caused an altercation at a local fast-food joint. She argued that the food joint belonged to her, prompting management to call the police. She presents with some deep-lying illusions and delusions about her identity and those around her. She believes that there are some people who secretly sneak into her room every night and leave some ants to torment her. Additionally, she believes that some funny creatures are in her stomach that makes her uncomfortable. She also has some unique ideations that are out of reality. For instance, she believes that she owns a vault consisting of precious metals and that she is an extremely wealthy person. Her speech is somewhat inconsistent and incoherent. 
History: Alena denies any previous form of hospital admission. She argues that she is not a member of her family. She adds that she is not sure who her family is or where they are. She claims that she was raped severally in the last two months, but she has no documentation or proof of the same. She denies using alcohol or any other drugs (medicinal or otherwise). 
ROS: She complains that she has consistent upset of the gastrointestinal tract. Particularly, she complains of recurring stomach upset. She believes that there are some funny creatures in her stomach that are on the mission of tormenting her. 
Objective
Vital Signs/ BMI:  Alena’s respiratory rate is 17. Her body temperature is 37.1 degrees Celsius. Her pulse rate is 80. She has a weight of 85kg and a height of 152cm. Her BMI is 36.8, which places her in class II of obesity. 
Physical Examination and Diagnostic Results: some scratches are observable on both her hands. Lab tests reveal that her neutrophils are at 67%, monocytes at 7% and lymphocytes at 25%. Her cholesterol levels are 208, while her phosphate levels are at 5.1. Urine analysis for pregnancy gives negative results. Most other measures are within normal limits. Mental state examination shows some signs of psychological disorder. Her hair is unkempt and unwashed. Her mood is greatly euphoric, and she boasts of owning things that she does not have. Her thought process is obviously illogical and delusional. Additionally, her judgment and insight are significantly impaired. 
Assessment/ Plan
Differential List and Rationale for Final/ Working Diagnosis: The list of possible problems, in this case, includes schizophrenia, the paranoid type and obesity. The rationale for diagnosing schizophrenia would be through the use DSM 5 manual. According to the provisions of the manual, the client is presenting with five symptoms used in diagnosing schizophrenia. She is having incoherent speech, delusions and inconsistent behavior. Additionally, she is presenting with negative symptoms, as evidenced by her mental state examination. While it may not be clear whether the patient has had these symptoms for at least six months, it is clear that it h...