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

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

Medical History: Mrs. Branning denied any history of hospitalization, surgery or blood transfusion.

• Current Medications: Levothyroxine daily
• Allergies: Medical Tape

• Reproductive Hx: Mrs. Branning reported that her last menstrual period was 3/10/2021. She has regularmenstrual cycle of 28 days lasting for four days. She is currently on a contraceptive method. She denied history of sexually transmitted infections. She also denied history of multiple sex partners. She does not have any history of pregnancy loss.

ROS:

GENERAL: The client appears appropriately dressed for the occasion. There is the absence of observable fatigue or evidence of weight loss.

HEENT: Eyes: she denies visual loss, blurred vision, double vision, or eye drainage.

Ears, Nose, Throat: She denies hearing loss, ear drainage, sneezing, congestion, runny nose, or sore throat.

SKIN: She denies rash or itching.

CARDIOVASCULAR: She denies chest pain, chest pressure, or chest discomfort. No palpitations and presence of lower limbs edema

RESPIRATORY: She denies shortness of breath, cough, or sputum.

GASTROINTESTINAL: She denies anorexia, nausea, vomiting, or diarrhea. No abdominal pain or passage of blood stained stool

GENITOURINARY: She denies burning on urination, urgency, hesitancy, odor, odd color

NEUROLOGICAL: She denies headache, denies dizziness, syncope, paralysis, ataxia, numbness, or tingling in the extremities. No change in bowel or bladder control

MUSCULOSKELETAL: She denies joint pains and edema

HEMATOLOGIC: She denies changes in skin color due to bleeding under skin

LYMPHATICS: She denies enlarged nodes. No history of splenectomy.

ENDOCRINOLOGIC: She denies reports of sweating, cold, or heat intolerance. No polyuria or polydipsia.

Objective:

Physical exam:

Temp 98.4F RR 18 HR 80 BP 127/68 SPO2 98% Weight 52 kgs Height 152 cm BMI 22.5

GENERAL: She is well groomed for the clinical visit, with no evidences fatigue nor weight loss

HEENT: Eyes: Normal vision acuity and accommodation, absence of double vision, and jaundice or eye drainage.

Ears, Nose, Throat: Normal air and bone conductivity, absence of nasal flaring, ear discharge, loss of balance, rhinorrhea, or deviation of nasal septum

SKIN: Absence of petechie, cyanosis and skin rashes

CARDIOVASCULAR: Absence of adventitious sounds on palpation and breathing using accessory muscles and chest in drawing

RESPIRATORY: Absence of cough, sneezing, sputum, and adventitious sounds on auscultation

GASTROINTESTINAL: Absence of abdominal masses, scars, and abnormal bowel sounds

GENITOURINARY: Not examined

NEUROLOGICAL: Absence of paralysis, ataxia, numbness, or tingling in the extremities, changes in bowel and bladder control and level of consciousness.

MUSCULOSKELETAL: Absence of joint pains, edema, and restricted movement in a range of motions

HEMATOLOGIC: Absence of  bleeding and anemia

LYMPHATICS: No enlarged nodes

Diagnostic results: The complaints that Ms. Branning do not require any diagnostic investigations. History taking and physical examination can provide data for use in making an accurate diagnosis to guide the treatment. However, blood tests can be performed to determine if the patient has other underlying conditions such as an infection. Besides, chest x-ray may be ordered to determine if the client has chest or respiratory problems causing the symptoms.

Assessment:

Mental Status Examination: Ms. Branning is appropriately dressed for the occasion. She does not show any signs and symptoms of fatigue or weight loss. She is oriented to self, place, time and events. Her insight is normal. She reports delusional behaviors. She denies illusions and delusions. She denies suicidal thoughts, attempts and plans. Her thought content is future oriented.

Differential Diagnoses:

Erotomania with somatic disorder: The primary diagnosis for Ms. Branning is erotomania with somatic disorder. Erotomania is a mental disorder where a patient believes that another individual is in love with them. The individual is always someone who is famous or important. The patient may engage in behaviors such as stalking and trying to contact the delusional object to satisfy their needs. Patients with somatic disorder believe that they have a chronic condition or physical defect. The believe is false, as medical and diagnostic tests are always normal (Coltheart & Langdon, 2019; Faden et al., 2017). Ms. B