Schizophrenia Results

Category Scored Items Experts selected these topics as essential components of a strong, thorough interview with this patient. Patient Data Not Scored A combination of open and closed questions will yie better patient data. The following details are facts o patient's case. Chief Complaint Established chief complaint Reports hallucinations Has paranoid thoughts History of Present Illness Asked about onset and duration of symptoms Reports hearing voices for the past 7 days Reports voices have increased over the last week Reports that voices are currently constant Asked about characteristics of symptoms Describes voices as sometimes male, sometimes female Denies visual hallucinations Denies gustatory hallucinations Denies olfactory hallucinations Denies tactile hallucinations Followed up on content of hallucinations Reports command hallucinations Reports resisting doing what the voice say Asked about aggravating factors of symptoms Reports that voices are more disturbing in quiet environments (when unable to be distracted) Asked about coping strategies Reports music as a coping strategy Past Medical History Asked about existing health conditions Denies general health conditions Asked about history of mental health Reports diagnosis of schizophrenia Reports occasional insomnia Denies past history of depression Denies past history of anxiety Denies past history of bipolar disorder Followed up on schizophrenia diagnosis Diagnosed age 23 Followed up on insomnia Reports frequent insomnia Reports difficulty falling asleep Reports recent insomnia has increased Reports sleeping 2 - 3 hours per night Reports frequent awakening Reports occasional nightmares Asked about previous psychiatric hospitalizations Reports previous psychiatric hospitalizations Followed up on previous hospitalizations Reports 3 previous hospitalizations All 3 hospitalizations were psychiatric admissions Reports first hospitalization was age 23 Reports second hospitalization was age 25 Reports third hospitalization was age 26 Asked about suicidal ideation and self-harm Reports command hallucinations telling him to take a bottle of pills Home Medications Asked about past suicide attempts Reports one past suicide attempt Followed up on suicide planning Denies intent to act on the command Asked about homicidal ideation Denies homicidal ideation Asked about home medications and treatment of symptoms Reports that he typically takes a prescribed medication for diagnosed schizophrenia Reports medication for insomnia Denies OTC medications Denies supplements or herbal formulas Denies vitamins Asked about medication regimen adherence Reports missing doses of medication for schizophrenia Reports being unsure of last dose of medication Reports that he was unable to continue take it because he tried to get it refilled, and insurance coverage wouldn't cover his usual prescription Reports that his mother was trying to help him get his usual prescription covered Followed up on last dose of home medications Reports not remembering his last dose of medication Followed up on medication for schizophrenia Medication name is Risperdal Denies remembering Risperdal dosage Takes medication twice a day Reports that medication typically is effective Followed up on medication for insomnia Medication name is trazodone Denies remembering trazodone dosage Takes medication as prescribed once daily at HS Reports that medication is typically effective when taken. Social History Asked about drug use Denies drug use Asked about alcohol use Reports some alcohol use Followed up on alcohol use Denies current alcohol in system Reports drinking 0 - 2 beers a week Denies binge drinking Asked about tobacco and nicotine use Reports smoking cigarettes Followed up on tobacco and nicotine use Reports smoking 1 PPD Reports smoking since age 16 Denies interest in quitting smoking Asked about occupation and education Reports currently working in a grocery store Reports working 20 - 30 hours / week Reports some college Currently in college working toward Audio Engineer degree Asked about living situation, safety, and support system Lives with mother Has no children Never married, in a relationship Reports not feeling safe at home Asked about activities of daily living Reports not bathing in the last week Reports not changing clothes in the last week Reports not being able to work in the last week Reports not being able to go to school in the last week Asked about appetite Reports loss of appetite Reports unable to finish a meal Reports skipping meals Reports loss of appetite has gone on for the past week Reports not knowing when or what his last meal was Review of Systems Asked about general symptoms Denies fever Denies chills Denies night sweats Denies fatigue Reports weight loss Asked about review of systems for respiratory Denies cough Denies shortness of breath Denies dyspnea on exertion Denies wheezing Asked about review of systems for gastrointestinal Denies abdominal pain Denies difficulty swallowing Denies nausea Denies vomiting Denies constipation Denies diarrhea Denies changes in stool or bowel patterns Asked about review of systems for neurological Denies weakness Denies frequent headaches Denies numbness or tingling Denies syncope, dizziness, fainting, or vertigo Denies changes in coordination Denies changes in memory Denies recent falls Asked about dental status Denies dentures Denies loss of teeth Denies problems with teeth Reports last dentist visit was several years ago Asked about awareness of involuntary movements Denies abnormal involuntary movements Asked if involuntary movements interfere with daily life Denies abnormal involuntary movements interfering with life