Verify Patient
Name:Willie
DOB: 67years old (specifice date not provided).
Minor: NA
Accompanied by: self
Demographic: NA
Gender Identifier Note:Male
CC: “I hear voices in my head telling me to do bad things, and I have trouble distinguishing what’s real and what’s not. I also feel very sad and hopeless most of the time, and I’ve lost interest in things I used to enjoy”.
HPI: Willie a 67years old male presents with a history of auditory hallucinations and delusions. He reports hearing multiple voices in his head that tell him to harm himself and others. He also has difficulty distinguishing these voices from reality. Additionally, he reports feeling sad and hopeless most of the time, with decreased appetite and difficulty sleeping. He also reports to have lost interest in activities he previously enjoyed. The patient has been previously diagnosed with schizophrenia and pschizoaffective disorder, but his symptoms have not improved with previous treatment. The patient’s symptoms have been present all along and have gradually worsened over the time
Patient has been hallucinating. The patient has nomal thought process.
SI/ HI/ AV: patient shows signs of suicidal ideation.
Allergies: NKDFA.
(medication & food)
Past Medical Hx: adherence
Medical history: Denies cardiac, respiratory, endocrine and neurological issues, including history head injury.
Patient denies history of chronic infection, including MRSA, TB, HIV and Hep C.
Surgical history no surgical history reported
Past Psychiatric Hx:
Previous psychiatric diagnoses: schizophrenia and pschizoaffective disorder
Describes stable course of illness.
Previous medication trials: not reported
Safety concerns:
History of Violence to Self:suicidal
History of Violence t o Others: none reported
Auditory Hallucinations:reported
Mental health treatment history discussed:
History of outpatient treatment: reported
Previous psychiatric hospitalizations: reported
Priorsubstance abuse treatment: not reported
Trauma history: Client reveals no history of traumatic experiences (such as abuse, domestic violence, or exposure to upsetting events).
Substance Use: not reported
Client does report abuse of or dependence on alcohol.
Current Medications: Benztropine
(Contraceptives):
Supplements:
Past Psych Med Trials: schizophrenia
Family Medical Hx: not reported
Family Psychiatric Hx: not reported
Substance use –NKDA
Suicides-not reported
Psychiatric diagnoses/hospitalization-not reported
Developmental diagnoses
Social History:
Occupational History: currently unemployed.
Military service History:Denies previous military hx.
Education history: completed HS and vocational certificate
Developmental History: no significant details reported.
(Childhood History include in utero if available)
Legal History: no reported/known legal issues,no reported/known conservator or guardian.
Spiritual/Cultural Considerations: none reported.
ROS:
Constitutional: no fever reported.
Eyes: No report of acute vision changes or eye pain.
ENT: No report of hearing changes or difficulty swallowing.
Cardiac: No report of chest pain, edema or orthopnea.
Respiratory: Denies dyspnea, cough or wheeze.
GI: reports abdominal pain.
GU: No report of dysuria or hematuria.
Musculoskeletal: No report of joint pain or swelling.
Skin: No report of rash, lesion, abrasions.
Neurologic: No report of seizures, blackout, numbness or focal weakness.
Endocrine: No report of polyuria or polydipsia.
Hematologic: No report of blood clots or easy bleeding.
Allergy: No report of hives or allergic reaction.
Reproductive: No report of significant issues. (females: GYN hx; abortions, miscarriages, pregnancies, hysterectomy, PCOS, etc…)