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Eric Ford- Schizophrenia
Chief Complaint Finding: Established chief complaint Finding: Reports hallucinations (Found) Pro Tip: A patient's chief complaint establishes any illnesses or concerns they are presenting. Asking about the chief complaint will allow the patient to voice any concerns or symptoms the patient may have. Example Question: Do you ever hear things that others do not hear? Finding: Has paranoid thoughts (Found) Pro Tip: A patient's chief complaint establishes any illnesses or concerns they are presenting. Asking about the chief complaint will allow the patient to voice any concerns or symptoms the patient may have.
Example Question: Do you ever think people are trying to harm you? History 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 patient about the length of their current health issues solicits information relevant to the history 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 patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you
Finding: Denies visual hallucinations (Found) Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history 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 patient about the length of their current health issues solicits information relevant to the history 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 patient about the length of their current health issues solicits information relevant to the history 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 patient about the length of their current health issues solicits information relevant to the history 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 patient about the length of their current health issues solicits information relevant to the history 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
(Found) Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history 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 History Finding: Asked about existing health conditions Finding: Denies general health conditions (Found) Pro Tip: Inquiring into the patient's relevant history can reveal past diagnoses and previous conditions or concerns. Information about the patient'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 history of mental health Finding: Reports diagnosis of schizophrenia (Found)
Pro Tip: Inquiring into the patient's relevant history can reveal past diagnoses and previous conditions or concerns. Information about the patient'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 patient's relevant history can reveal past diagnoses and previous conditions or concerns. Information about the patient'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 history of depression (Available) Pro Tip: Inquiring into the patient's relevant history can reveal past diagnoses and previous conditions or concerns. Information about the patient'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 history of depression?
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 patient's relevant history can reveal past diagnoses and previous conditions or concerns. Information about the patient'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 patient's relevant history can reveal past diagnoses and previous conditions or concerns. Information about the patient'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 patient's relevant history can reveal past diagnoses and previous conditions or concerns. Information about the patient'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 patient's relevant history can reveal past diagnoses and previous conditions or concerns. Information about the patient'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 patient's relevant history can reveal past diagnoses and previous conditions or concerns. Information about the patient'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?
Followed up on previous hospitalizations Finding: Reports 3 previous hospitalizations (Found) Pro Tip: Inquiring into the patient's relevant history can reveal past diagnoses and previous conditions or concerns. Information about the patient'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 patient's relevant history can reveal past diagnoses and previous conditions or concerns. Information about the patient'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 patient's relevant history can reveal past diagnoses and previous conditions or concerns. Information about the patient'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 history of psychiatric treatment? Finding: Reports second hospitalization was age 25 (Available) Pro Tip: Inquiring into the patient's relevant history can reveal past diagnoses and previous conditions or concerns. Information about the patient'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 history of psychiatric treatment? Finding: Reports third hospitalization was age 26 (Available) Pro Tip: Inquiring into the patient's relevant history can reveal past diagnoses and previous conditions or concerns. Information about the patient'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 history of psychiatric treatment? Finding: Asked about suicidal ideation and self-harm
(Found) Pro Tip: Inquiring into the patient's relevant history can reveal past diagnoses and previous conditions or concerns. Information about the patient'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 ever wished that you were dead? Finding: Asked about homicidal ideation Finding: Denies homicidal ideation (Found) Pro Tip: Inquiring into the patient's relevant history can reveal past diagnoses and previous conditions or concerns. Information about the patient'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 the voices ever told you to hurt someone? Home Medications Finding: Asked about home medications and treatment of symptoms Finding: Reports that he typically takes a prescribed medication for diagnosed schizophrenia
(Found) Pro Tip: A patient's home medications can provide insight into the patient's current treatment and its effacacy. Inquiring into medication history, dosage, and frequency will help you understand the patient's background and how it may affect their current situation. Example Question: Are you on any prescription medication? Finding: Reports medication for insomnia (Found) Pro Tip: A patient's home medications can provide insight into the patient's current treatment and its effacacy. Inquiring into medication history, dosage, and frequency will help you understand the patient's background and how it may affect their current situation. Example Question: Are you on any prescription medication? Finding: Denies OTC medications (Available) Pro Tip: A patient's home medications can provide insight into the patient's current treatment and its effacacy. Inquiring into medication history, dosage, and frequency will help you understand the patient's background and how it may affect their current situation. Example Question: Do you take a medication you can buy at the store? Finding: Denies supplements or herbal formulas (Available)
Finding: Reports being unsure of last dose of medication (Found) Pro Tip: A patient's home medications can provide insight into the patient's current treatment and its effacacy. Inquiring into medication history, dosage, and frequency will help you understand the patient's background and how it may affect their current situation. Example Question: When was the last time you took any medications? Finding: 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 (Found) Pro Tip: A patient's home medications can provide insight into the patient's current treatment and its effacacy. Inquiring into medication history, dosage, and frequency will help you understand the patient's background and how it may affect their current situation. Example Question: Why have you been missing doses of your medication? Finding: Reports that his mother was trying to help him get his usual prescription covered (Found) Pro Tip: A patient's home medications can provide insight into the patient's current treatment and its effacacy. Inquiring into medication history, dosage, and frequency will help you understand the patient's background and how it may affect their current situation. Example Question: Do you have difficulty obtaining medication?
Finding: Followed up on last dose of home medications Finding: Reports not remembering his last dose of medication (Found) Pro Tip: A patient's home medications can provide insight into the patient's current treatment and its effacacy. Inquiring into medication history, dosage, and frequency will help you understand the patient's background and how it may affect their current situation. Example Question: What medications have you taken recently? Finding: Followed up on medication for schizophrenia Finding: Medication name is Risperdal (Found) Pro Tip: A patient's home medications can provide insight into the patient's current treatment and its effacacy. Inquiring into medication history, dosage, and frequency will help you understand the patient's background and how it may affect their current situation. Example Question: What schizophrenia medication do you take? Finding: Denies remembering Risperdal dosage (Available)
