Assignment: Assessing and Diagnosing Patients With Schizophrenia, Other Psychotic Disorders, and Medication-Induced Movement Disorders

 

Subjective:

CC (chief complaint): “Well, you know there is a pain in my neck, it aches, it spreads to my back; I think there is a lump there. I am really worried.” “And it’s slowly killing me, and it’s all because of them and Eric’s obsession with me”.

HPI: Ms. Fatima is a 28-years-old lady presenting with the chief complaint of being worried about being fired by her boss. She has been referred to a psychiatrist by her boss due to having difficulties at work. According to her boss, she has not made any sales for the last three weeks. She claims the boss wants to fire her from work because he feels threatened by the fact that the supervisor wants her. “They have ganged up to fire me because they don’t want me to get in their way; I’m probably a distraction.” She claims it wouldn’t be bad if they fired her because all these problems worsened her health. She complains of pain, suffering, and a broken heart. “Well, you know there is a pain in my neck, it aches, it spreads to my back; I think there is a lump there Assignment: Assessing and Diagnosing Patients With Schizophrenia, Other Psychotic Disorders, and Medication-Induced Movement Disorders. I am really worried.” Although she has not seen a doctor, she thinks it’s cancer. “And it’s slowly killing me, and it’s all because of them and Eric’s obsession with me.

 

Past Psychiatric History:

• General Statement: Lives alone and denies any past psychiatric history and family mental illness issues.
• Caregivers (if applicable): Lives alone.
• Hospitalizations: No known hospitalizations.
• Medication trials: No known medication trials.
• Psychotherapy or Previous Psychiatric Diagnosis: Denies to discuss.

Substance Current Use and History: No known history or current substance use.

Family Psychiatric/Substance Use History: The patient denied any family mental health issues.

Psychosocial History: Ms. Fatima was raised by her parents and lives alone in Coronado, CA. She is the only child. She has a hospitality degree but works as an administrative assistant in car sales.

Medical History: Has a medical history of Scoliosis and is currently treated with chiropractic care.

Assignment: Assessing and Diagnosing Patients With Schizophrenia, Other Psychotic Disorders, and Medication-Induced Movement Disorders

 

• Current Medications: Has a scoliosis history and is undergoing chiropractic treatment at the moment.
• Allergies: The patient is allergic to latex.

• Reproductive Hx: Receives regular menses and uses no birth control pills.

ROS:

• GENERAL: The client denies losing or gaining weight; however, she reports neck pain stretching to her back and a broken heart.
• HEENT: The patient denies dizziness, headache, or ear or eye ache signs. She also denies dysphagia, nasal discharge, and blurred vision.
• SKIN: reports no bruises or abnormal skin rashes.
• CARDIOVASCULAR: Denies chest pain, chest tightness, and shortness of breath.
• RESPIRATORY: the patient reports no dyspnea, cough, or nocturnal dyspnea.
• GASTROINTESTINAL: Reports no signs of stomach cramps, vomiting, stomach upset, or diarrhea.
• GENITOURINARY: The patient reports no signs of urinary frequency, urgency, or pain when urinating.
• NEUROLOGICAL: The patient denies numbness or ataxia
• MUSCULOSKELETAL: The client denies joint or muscle pain.
• HEMATOLOGIC: No signs of bruising or abnormal bleeding
• LYMPHATICS: Reports no painful or swollen lymph nodes
• ENDOCRINOLOGIC: The client reports zero signs of hypothyroidism

Objective:

Vitals; T- 98.4 P- 82 R 18 124/74 Ht 5’0 Wt 118lbs

Diagnostic results: Urine and drug tested negative

Assessment:

Mental Status Examination: Ms. Fatima is a 28-year-old female who has been referred for psychiatric assessment by her boss. She is well groomed for the interview and well-oriented X4. She appears at her stated age and maintains good eye contact throughout the interview. She has pressured speech and is spontaneous. She looks confused with delusional thoughts. No signs of abnormal psychomotor movements. She denies auditory or visual hallucinations. No suicida