NRNP 6635 Assignment: Assessing and Diagnosing Patients With Schizophrenia, Other Psychotic Disorders, and Medication-Induced Movement Disorders

 

Subjective:

CC (chief complaint): ‘I have problems in my workplace.’

HPI: Ms. Branning is a Twenty Five yearold woman who came to the clinic after Mr. Nehring her boss, suggested she should go for a Psychiatric evaluation. Ms. Branning reports having problems in her workplace. According to her, Mr. Nehring, her supervisor wants to fire her because Eric is in love with her. Eric is her supervisor who she feels is attracted to her. Ms. Branning is not in a relationship with Eric but believes that she is beautiful and people, including Eric are attracted to her. Ms. Branning feels that Nehring is jealous of her, as she thinks she  could replace him in a couple of years. According to her, she has mental problems that have been worsening over time. She reports having pain in the neck and broken heart, which are probably attributed to cancer.

Past Psychiatric History:

  • General Statement: ‘I have problems in my workplace.’
  • Caregivers (if applicable): self
  • Hospitalizations: no index of hospitalizations
  • Medication trials: no index of medication trials
  • Psychotherapy or Previous Psychiatric Diagnosis: no indication of previous psychotherapy or psychiatric diagnosis.

Substance Current Use and History: None indicated.

Family Psychiatric/Substance Use History: Mrs. Branning denied any history of psychiatric conditions or substance use in her family.

Psychosocial History: The client is single and in a relationship. She lives with her family. She has two brothers who are alive. She is a Christian. She reports to seek support from her family members in times of hardships.

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Medical History: Mrs. Branning denied any history of hospitalization, surgery or blood transfusion.

 

  • Current Medications: Levothyroxine daily
  • Allergies: Medical Tape
  • Reproductive Hx: Mrs. Branning reported that her last menstrual period was 3/10/2021. She has regularmenstrual cycle of 28 days lasting for four days. She is currently on a contraceptive method. She denied history of sexually transmitted infections. She also denied history of multiple sex partners. She does not have any history of pregnancy loss.

ROS:

GENERAL: The client appears appropriately dressed for the occasion. There is the absence of observable fatigue or evidence of weight loss.

HEENT: Eyes: she denies visual loss, blurred vision, double vision, or eye drainage.

Ears, Nose, Throat: She denies hearing loss, ear drainage, sneezing, congestion, runny nose, or sore throat.

SKIN: She denies rash or itching.

CARDIOVASCULAR: She denies chest pain, chest pressure, or chest discomfort. No palpitations and presence of lower limbs edema

RESPIRATORY: She denies shortness of breath, cough, or sputum.

GASTROINTESTINAL: She denies anorexia, nausea, vomiting, or diarrhea. No abdominal pain or passage of blood stained stool

GENITOURINARY: She denies burning on urination, urgency, hesitancy, odor, odd color

NEUROLOGICAL: She denies headache, denies dizziness, syncope, paralysis, ataxia, numbness, or tingling in the extremities. No change in bowel or bladder control

MUSCULOSKELETAL: She denies joint pains and edema

HEMATOLOGIC: She denies changes in skin color due to bleeding under skin

LYMPHATICS: She denies enlarged nodes. No history of splenectomy.

ENDOCRINOLOGIC: She denies reports of sweating, cold, or heat intolerance. No polyuria or polydipsia.

Objective:

Physical exam:

Temp 98.4F RR 18 HR 80 BP 127/68 SPO2 98% Weight 52 kgs Height 152 cm BMI 22.5

GENERAL: She is well groomed for the clinical visit, with no evidences fatigue nor weight loss

HEENT: Eyes: Normal vision acuity and accommodation, absence of double vision, and jaundice or eye drainage.

Ears, Nose, Throat: Normal air and bone conductivity, absence of nasal flaring, ear discharge, loss of balance, rhinorrhea, or deviation of nasal septum

SKIN: Absence of petechie, cyanosis and skin ras

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