Comprehensive Psychiatric Evaluation Note and Patient Case Presentation
Catherine2
NRNP6645PRACWEEK7COMPREHENSIVEASSESSMENTDOCUMENTATION.docxChief Complaint: The patient stated, “I started hearing voices 2 weeks ago saying you are dead, you are dead".
VITAL
Height: 5’11”
Weight: 174 lbs.
BP: 129/88
Temperature: 97.3
Pulse: 72
Respiratory rate: 18
O2 Saturation: 97%
Pain: Denied pain
Diagnoses: Schizophrenia
Allergies:
Patient has no known drug allergies
No food allergies recorded
No environmental allergies recorded
Medications
Quetiapine Fumarate (Seroquel) 100 mg by mouth 1 tablet daily at bedtime
Smoking Status
Non-smoker 06/10/2020
GENDER IDENTITY
MALE
SEXUAL ORIENTATION
Straight or heterosexual
SOCIAL HISTORY
Works in a Grocery store as a Stalker. Lives with 2 siblings. Completed High school diploma.
ONGOING HEALTH PROBLEM
Not getting enough sleep
FAMILY HEALTH HISTORY: No Psychiatric problem verbalized
SOCIAL HISTORY
Works in a Grocery store as a Stalker. Lives with 2 siblings. Completed High school diploma.
DEVELOPMENTAL HISTORY
Grew up with both Parents. Denies physical and sexual abuse
SUBJECTIVE
The patient is a 44 years old African American male who was seen today in the facility with consent obtained, with diagnosis of Schizophrenia. He reports that he started hearing voices 2 weeks ago saying "he is dead, he is dead". he was involved in a violent altercation with his neighbor that involved calling police but charges were not pressed. He voluntarily checked himself too the ER and was transferred to psychiatric hospital for weeks. He voiced that this is the first time he is hearing voices. Prior to the hospitalization he reports sleeping for about 2 - 3 hour a day.
OBJECTIVE
The patient is alert and oriented x 3, verbally responsive with intact memories. He denies suicidal/homicidal ideation, reports hearing voices telling him, “You are dead, you are dead", he denies seeing things that are not present. Further evaluation of mental status reveals the following:
C-SSRS (LIFETIME)
1. WISH TO BE DEAD; no.
have you wished you were dead or wish you could go to sleep and not wake up?
2. NON-SPECIFIC ACTIVE SUICIDAL THOUGHTS: In the past, not now.
have you had any thoughts of killing yourself? No, but in the past
3. ACTIVE SUICIDAL IDEATIONS WITH ANY METHODS (NOT PLAN) WITHOUT INTENT TO ACT
have you been thinking about how you might do this? No
4. ACTIVE SUICIDAL IDEATIONS WITH SOME INTENTS TO ACT, WITHOUT SPECIFIC
have you had these thoughts and had some intentions of acting on them? No
5.ACTIVE SUICIDAL IDEATIONS WITH SPECIFIC PLAN AND INTENT: No
have you start to work out or worked out the details of how to kill yourself?
MENTAL STATUS EXAMINATION
general appearance: Appropriate, calm and cooperative with poor eye contact
Attitude: Good
Behavior: normal
Speech: Normal
Mood: Anxious
Affect: Labile
Thought Process: Goal directed
Thought Content: Normal
perceptions: Fair
insight: Fair
judgment: Fair
cognition: Good
Memory: Intact
ASSESSMENT
The patient is a 44 years old African American male who was admitted to the facility with diagnosis of Schizophrenia. He reports that he started hearing voices 2 weeks ago saying "you are dead, you are dead". He also voiced that the voice triggered him to his neighbor whom he had an encounter with before he voluntarily checked himself too the ER of a hospital and was transferred to psychiatric hospital for 2 weeks. He voiced that this is the first time he is hearing voices. He had a normal delivery, lives with both parents. He had never been abused or harassed all his life. No known drug allergies.
Plan of care:
The goal is to decrease aggressive behavior and hearing within 90 days.
Continue on Seroquel 300 mg PO QHS
Call 911 if feeling suicidal or homicidal ideation
Follow up with therapist in 2 weeks
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