SH__Eric_Ford__Schizophrenia.TRANSCRIPT

Chief Complaint Finding: Established chief complaint Finding: Reports hallucinations (Found) Pro Tip: A pt's chief complaint establishes any illnesses or concerns they are presenting. Asking about the chief complaint will allow the pt to voice any concerns or symptoms the pt may have. Example Question:Do you ever hear things that others do not hear? Finding: Has paranoid thoughts (Found) Pro Tip: A pt's chief complaint establishes any illnesses or concerns they are presenting. Asking about the chief complaint will allow the pt to voice any concerns or symptoms the pt may have. Example Question: Do you ever think people are trying to harm you? HX of Present Illness? Finding:Asked about onset and duration of symptoms Finding:Reports hearing voices for the past 7 days (Found) Pro Tip: Asking a pt about the length of their current health issues solicits information relevant to the HX of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing. Example Question: When did your symptoms start? Finding: Reports voices have increased over the last week (Found) Pro Tip: Asking a pt about the length of their current health issues solicits information relevant to the HX of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing. Example Question: Did the hallucinations start gradually? Finding: Reports that voices are currently constant (Available) Pro Tip: Asking a pt about the length of their current health issues solicits information relevant to the HX of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing. Example Question: Are your hallucinations constant? Finding: Asked about characteristics of symptoms Finding: Describes voices as sometimes male, sometimes female (Found) Pro Tip: Asking a pt about the length of their current health issues solicits information relevant to the HX of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing. Example Question: Can you describe your hallucinations? Finding: Denies visual hallucinations (Found) Pro Tip: Asking a pt about the length of their current health issues solicits information relevant to the HX of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing. Example Question: Do you ever see things that are not there? Finding: Denies gustatory hallucinations (Available) Pro Tip: Asking a pt about the length of their current health issues solicits information relevant to the HX of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing. Example Question: Do you taste things that are not there? Finding: Denies olfactory hallucinations (Found) Pro Tip: Asking a pt about the length of their current health issues solicits information relevant to the HX of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing. Example Question: Do you smell things that are not there? Finding: Denies tactile hallucinations (Available) Pro Tip: Asking a pt about the length of their current health issues solicits information relevant to the HX of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing. Example Question: Do you feel things that are not there? Finding: Followed up on content of hallucinations Finding: Reports command hallucinations (Found) Pro Tip: Asking a pt about the length of their current health issues solicits information relevant to the HX of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing. Example Question: Do the voices tell you to do anything? Finding: Reports resisting doing what the voice say (Available) Pro Tip: Asking a pt about the length of their current health issues solicits information relevant to the HX of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing. Example Question: Do you do what the voices say? Finding: Asked about aggravating factors of symptoms Finding: Reports that voices are more disturbing in quiet environments (when unable to be distracted) (Found) Pro Tip: Asking a pt about the length of their current health issues solicits information relevant to the HX of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing. Example Question: What makes your symptoms worse? Finding: Asked about coping strategies Finding: Reports music as a coping strategy (Found) Pro Tip: Asking a pt about the length of their current health issues solicits information relevant to the HX of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing. Example Question: How do you cope with your hallucinations? Past Medical HX Finding: Asked about existing health conditions Finding: Denies general health conditions (Found) Pro Tip: Inquiring into the pt's relevant HX can reveal past diagnoses and previous conditions or concerns. Information about the pt's existing health conditions, a timeline of diagnosis, symptoms, and allergies can indicate where you should follow-up for further care and treatment. Example Question: What health issues do you have? Finding: Asked about HX of mental health Finding: Reports diagnosis of schizophrenia (Found) Pro Tip: Inquiring into the pt's relevant HX can reveal past diagnoses and previous conditions or concerns. Information about the pt's existing health conditions, a timeline of diagnosis, symptoms, and allergies can indicate where you should follow-up for further care and treatment. Example Question: Have you been diagnosed with schizophrenia? Finding: Reports occasional insomnia (Found) Pro Tip: Inquiring into the pt's relevant HX can reveal past diagnoses and previous conditions or concerns. Information about the pt's existing health conditions, a timeline of diagnosis, symptoms, and allergies can indicate where you should follow-up for further care and treatment. Example Question: Do you have insomnia? Finding: Denies past HX of depression (Available) Pro Tip: Inquiring into the pt's relevant HX can reveal past diagnoses and previous conditions or concerns. Information about the pt's existing health conditions, a timeline of diagnosis, symptoms, and allergies can indicate where you should follow-up for further care and treatment. Example Question: Do you have a HX of depression? Finding: Denies past HX of anxiety (Found) Pro Tip: Inquiring into the pt's relevant HX can reveal past diagnoses and previous conditions or concerns. Information about the pt's existing health conditions, a timeline of diagnosis, symptoms, and allergies can indicate where you should follow-up for further care and treatment. Example Question: Do you have generalized anxiety disorder? Finding: Denies past HX of bipolar disorder (Available) Pro Tip: Inquiring into the pt's relevant HX can reveal past diagnoses and previous conditions or concerns. Information about the pt's existing health conditions, a timeline of diagnosis, symptoms, and allergies can indicate where you should follow-up for further care and treatment. Example Question: Have you been diagnosed with bipolar disorder? Finding: Followed up on schizophrenia diagnosis Finding: Diagnosed age 23 (Found) Pro Tip: Inquiring into the pt's relevant HX can reveal past diagnoses and previous conditions or concerns. Information about the pt's existing health conditions, a timeline of diagnosis, symptoms, and allergies can indicate where you should follow-up for further care and treatment. Example Question: At what age did you get schizophrenia? Finding: Followed up on insomnia Finding: Reports frequent insomnia (Available) Pro Tip: Inquiring into the pt's relevant HX can reveal past diagnoses and previous conditions or concerns. Information about the pt's existing health conditions, a timeline of diagnosis, symptoms, and allergies can indicate where you should follow-up for further care and treatment. Example Question: How often have you had trouble falling asleep? Finding: Reports difficulty falling asleep (Available) Pro Tip: Inquiring into the pt's relevant HX can reveal past diagnoses and previous conditions or concerns. Information about the pt's existing health conditions, a timeline of diagnosis, symptoms, and allergies can indicate where you should follow-up for further care and treatment. Example Question: Have you had trouble falling asleep before? Finding: Reports recent insomnia has increased (Available) Pro Tip: Inquiring into the pt's relevant HX can reveal past diagnoses and previous conditions or concerns. Information about the pt's existing health conditions, a timeline of diagnosis, symptoms, and allergies can indicate where you should follow-up for further care and treatment. Example Question: Can you tell me more about your sleep? Finding: Reports sleeping 2 - 3 hours per night (Available) Pro Tip: Inquiring into the pt's relevant HX can reveal past diagnoses and previous conditions or concerns. Information about the pt's existing health conditions, a timeline of diagnosis, symptoms, and allergies can indicate where you should follow-up for further care and treatment. Example Question: How many hours a night do you sleep? Finding: Reports frequent awakening (Available) Pro Tip: Inquiring into the pt's relevant HX can reveal past diagnoses and previous conditions or concerns. Information about the pt's existing health conditions, a timeline of diagnosis, symptoms, and allergies can indicate where you should follow-up for further care and treatment. Example Question: How often do you wake up during the night? Finding: Reports occasional nightmares (Available) Pro Tip: Inquiring into the pt's relevant HX can reveal past diagnoses and previous conditions or concerns. Information about the pt's existing health conditions, a timeline of diagnosis, symptoms, and allergies can indicate where you should follow-up for further care and treatment. Example Question: Does anything make it harder to sleep? Finding: Asked about previous psychiatric hospitalizations Finding: Reports previous psychiatric hospitalizations (Found) Pro Tip: Inquiring into the pt's relevant HX can reveal past diagnoses and previous conditions or concerns. Information about the pt's existing health conditions, a timeline of diagnosis, symptoms, and allergies can indicate where you should follow-up for further care and treatment. Example Question: Have you had to go to the hospital for a psychiatric disorder? Finding: Followed up on previous hospitalizations Finding: Reports 3 previous hospitalizations (Found) Pro Tip: Inquiring into the pt's relevant HX can reveal past diagnoses and previous conditions or concerns. Information about the pt's existing health conditions, a timeline of diagnosis, symptoms, and allergies can indicate where you should follow-up for further care and treatment. Example Question: Have you been hospitalized as an adult Finding: All 3 hospitalizations were psychiatric admissions (Found) Pro Tip: Inquiring into the pt's relevant HX can reveal past diagnoses and previous conditions or concerns. Information about the pt's existing health conditions, a timeline of diagnosis, symptoms, and allergies can indicate where you should follow-up for further care and treatment. Example Question: Why were you previously admitted to the hospital? Finding: Reports first hospitalization was age 23 (Available) Pro Tip: Inquiring into the pt's relevant HX can reveal past diagnoses and previous conditions or concerns. Information about the pt's existing health conditions, a timeline of diagnosis, symptoms, and allergies can indicate where you should follow-up for further care and treatment. Example Question: Can you tell me about your HX of psychiatric treatment? Finding: Reports second hospitalization was age 25 (Available) Pro Tip: Inquiring into the pt's relevant HX can reveal past diagnoses and previous conditions or concerns. Information about the pt's existing health conditions, a timeline of diagnosis, symptoms, and allergies can indicate where you should follow-up for further care and treatment. Example Question: Can you tell me about your HX of psychiatric treatment? Finding: Reports third hospitalization was age 26 (Available) Pro Tip: Inquiring into the pt's relevant HX can reveal past diagnoses and previous conditions or concerns. Information about the pt's existing health conditions, a timeline of diagnosis, symptoms, and allergies can indicate where you should follow-up for further care and treatment. Example Question: Can you tell me about your HX of psychiatric treatment? Finding: Asked about suicidal ideation and self-harm Finding: Reports command hallucinations telling him to take a bottle of pills (Available) Pro Tip: Inquiring into the pt's relevant HX can reveal past diagnoses and previous conditions or concerns. Information about the pt's existing health conditions, a timeline of diagnosis, symptoms, and allergies can indicate where you should follow-up for further care and treatment. Example Question: Can you tell me what the voices command you to do?