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

Subjective:

Chief Complaint: “Mr. Nehring suggested you see me. He said you are having some issues at work ”

History of Presenting Illness: F.B is a 27-year-old Caucasian female presenting for a psychiatric evaluation as recommended by her supervisor following allegations of issues at her workplace. She has a medical history of scoliosis and is currently under chiropractic care. She currently works as an administrative assistant in car sales. She lives alone and is an only child. She has had issues at her workplace. She has not been able to make any sales in three weeks. She feels that her supervisor is in love with her even though he has not done anything inappropriate. The supervisor has a girlfriend. F.B feels like her boss and her supervisor are ganging up against her to persecute her by firing her. She also believes that her boss is threatened by her being a strong woman who may replace him in his position. She also reports feeling pain in her neck that radiates to her back and thinks there is a lump on her back. She thinks this could be cancer. She believes that the ‘cancer’ is slowly killing her due to her supervisor’s obsession with her. She declines consultation with parents for collaborative history.

Past Psychiatric History: F.B’s past psychiatric history is unknown as she has declined to discuss her past psychiatric history and she also declined to consult with patients for a collaborative history.

Substance Current Use and History: FB reports no history of alcohol use or any substance abuse.

Family History: There is no mention of any history of psychiatric illness in the family. F.B’s family history is unclear as she has not disclosed much information about her family. There is no mention of a family history of diabetes, hypertension, cancer, or mental illness.

Social History: F.B was raised by her parents. She is an only child. She lives in Coronado. She lives alone. She has a Bachelor’s degree in hospitality. works as an administrative assistant in car sales. There is no reported history of trauma or violence in her life.

Medical History:

She has a medical history of scoliosis under treatment with chiropractic care.

  • Current Medications: F.B has no current medications. She is only under chiropractic care for managing scoliosis.
  • Allergies: She reports being allergic to latex, and no food or drug allergies were reported.
  • Reproductive History: F.B does not mention if she has borne any children, she has regular menses, she has no history of the use of contraceptives, and she has no history of treatment for any STIs. She practices vaginal intercourse.

ROS:

GENERAL: no weight loss reported, no fever, and no feeling of lethargy

  • HEENT: The head is of normal size, no obvious masses, normal hair distribution, no headache, the eyes are placed normally, no visual disturbances, no eye pain, no scleral jaundice, no conjunctival pallor, the ears are anatomically normal, no cerumen impaction, no auditory disturbances, No neck masses, no nasal congestion, or sore throat reported
  • Skin: No skin color changes, no swellings, no striae.
  • Cardiovascular: there is no edema of the extremities, no awareness of heartbeat, no dyspnea on exertion or orthopnea, there is no distention of the neck veins.
  • Respiratory: there is mild on and off cough, no shortness of breath, chest pain, hemoptysis, or chest tightness reported
  • Gastrointestinal: there is no reported vomiting, abdominal pain, change in bowel habits, diminished appetite, or bloody stool.
  • Genitourinary: there are no changes in urinary frequency, no burning sensation or pain during urination or coitus, no perineal itchiness or genital warts, and no perineal pain or ulcerations.
  • Neurological: there is no limb weakness or paralysis.
  • Musculoskeletal: There is no swelling, pain, change in color, or restricted range of motion in any of the joints.
  • Hematologic: there is no easy fatiguability or bleeding tendencies reported.
  • Lymphatics: There are no enlarged lymph nodes or spleen, and there is no unilateral leg swelling.
  • Endocrinologic: no changes in skin pigmentation, no heat intolerance, there is some level of unexplained lethargy, and there is emotional disturbances manifested as restlessness reported.

Objective:

Physical exam: vital signs: Temperature- 98.4, Pulse rate- 82, Respiratory rate 18, Blood Pressure 124/74mmHg  Height 5’0 Weigh

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