Pmhnp

History of present illness continued

He reports AH/HV, and increased paranoia. The hallucinations are something he has lived with for many years and is accustom to, however, reports they are “louder and clearer” at this time. He has had numerous delusions in the past few weeks that have affected his daily life, including thinking he was miniature and went outside urinating in the road because he thought he was small and no one could see him. He recently thought he could run at “warp speed” and thought he could fly. He did not act on the thoughts of flying because “something told me it was dangerous”. He reports he has periods were he cannot tell what is “real or make believe”. There are times when these thoughts interfere with his family life. He has become increasingly paranoid and thought his mother was in a cult until recently, when the oral Risperdal was started.

His mood is “good”, but reports frustration over the increased hallucinations and paranoia. Report energy and motivation levels as good. Appetite good. No sleep disturbances. Endorses getting upset easily and feels overwhelmed frequently. Denies SI/HI. Reports occasional episodes of depression and his personal hygiene suffers. He has a history of trauma that includes years of physical and emotional abuse by step father.