Schizophrenia and Other Psychotic Disorders; Medication-Induced Movement Disorders

Please use continue with what is below. I completed this assignment yesterday Unfortunately lost everything when my laptop went off. I got frustrated and went to bed. I will attach school exemplar format to follow. 

NRNP/PRAC 6635 Comprehensive Psychiatric Evaluation Template

CC (chief complaint): The patient reports increase mood swings, insomnia, and fear of COVID-19 new outbreak.

Name:  Ms. MB

Gender: Female

Age: 57 years old

HPI: Mrs. MS is a 57-year Spanish female who presents to the clinic with complaints of increased mood swings, insomnia, and fear of COVID-19 new outbreak, limits her outdoor activities unless its medical appointments. Vaccinated for COVID-19 but appears paranoid /fears the unknown of getting infected with the new variants strain. The patient reported she has had a gain of 15 Ibs over the last 12 months. The patient was diagnosed with schizoaffective disorder twenty years ago and has utilized different psychiatrists and medications management. Currently, been with this psychiatrist for the past twenty years with the improvement of symptoms. Patient reports stop working as a registered nurse since April 2021 and on disability. The patient reports stable housing, denied suicidal thoughts, self-injurious behavior, hallucination, and delusions. No history of drug or substance abuse. The patient AxOx3, appears neat, with a congruent mood, and cooperative during medication management and further mood stabilization assessment. The patient lives in Boston, MA alone middle child raised by both parents with two brothers. The patient reports being safe at home, medications compliant, and denied any side effects. Her medications were refilled with two months follow-up. She works as a registered nurse with a bachelor’s degree in sciences 25 years ago from Northeastern University in MA. At age 14 she was first diagnosed with ADHD/ anxiety disorder.  However, ten years later diagnosis with major depressive disorder, schizoaffective disorder, and insomnia. Not married, currently reports having a boyfriend, no kids. The patient reports a father with a history of bipolar disorder and generalized anxiety disorder. Her mother with no psychiatric diagnosis. Both of her brothers are healthy with no psychiatric disorder history and substances abuse. Denied any history of sexual abuse. The patient worked upright with no assistive device denied pain.

Past Psychiatric History: At age 14 she was first diagnosed with ADHD/ anxiety disorder.  However, ten years later diagnosis with major depressive disorder, schizoaffective disorder, and insomnia. Not married, currently reports having a boyfriend, no kids. The patient reports a father with a history of bipolar disorder and generalized anxiety disorder. Her mother with no psychiatric diagnosis. Both of her brothers are healthy with no psychiatric disorder history and substances abuse.

•           General Statement:

•           Caregivers (if applicable): None

•           Hospitalizations: Two hospitalizations with the psychiatric episode at age 14 were diagnosed with ADHD/generalized anxiety disorder. Second hospitalization at age 28 diagnosis with major depressive disorder, schizoaffective disorder, and insomnia.

•           Medication trials: No trials medication.

Current psychotropic medications:

•           Wellbutrin SR 200 mg tablet 12 hours sustained release by mouth twice daily

•           Trazodone 150 mg tablet PO at bedtime

•           Hydroxyzine HCL 50 mg tablet by mouth twice daily

•           Mirtazapine 30 mg tablet by mouth daily before bedtime.

•           Buspirone 10 mg tablet three times daily

•           Aripiprazole 30 mg tablet by mouth daily.

•           Fluphenazine 5 mg tablet by mouth twice daily

•           Divalproex 500 mg tablet, delayed-release by mouth twice daily.

•           Psychotherapy or Previous Psychiatric Diagnosis:

Substance Current Use and History: None

Family Psychiatric/Substance Use History:

Psychosocial History:

Medical History:

 

•           Current Medications:

•           Allergies: Strawberry reaction rash.

•           Reproductive Hx:

ROS:

•           GENERAL:

•           HEENT:

•           SKIN:

•           CARDIOVASCULAR:

•           RESPIRATORY:

•           GASTROINTESTINAL:

•           GENITOURINARY:

•           NEUROLOGICAL:

•           MUSCULOSKELETAL:

•           HEMATOLOGIC:

•           LYMPHATICS:

•           ENDOCRINOLOGIC:

Physical exam: Temperature: 98.4, Pulse: 80,  Respiration: 18, unlabored, Blood pressure: 128/76,  Height: 5’0 and weight: 120lbs. The patient is AxOx3 ambulatory without difficulty.

 

Diagnostic results:

Assessment

Mental Status Examination:

Differential Diagnoses:

Reflections:

References

 

 

 

                                                                                                                 

 

      

 

 

 

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