| Subjective | Objective |
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Patient’s Chief Complaints: “ I am hearing voices ” History of Present Illness MM states she believes her boyfriend is cheating on her, which her boyfriend denies. She states she can hear two women talking about her boyfriend and her, how they have sex with her boyfriend and how KB isn’t good enough for him. This has been occurring for a few weeks now and the voices mock her daily. Her boyfriend has been caught cheating in the past and she is now wondering if the women she hears talking about her boyfriend are real or not. She has not asked anyone else if they can hear the women talking because what they have to say is so negative. She hears these women talking mostly at home with her boyfriend, especially at night, but sometimes she hears them when she is out too, especially when she is out in public with her boyfriend. Past psychiatric history: None Past Medical History: Occasional headaches, treated with OTC pain relievers. Family History · Father is alive, has hypertension. · Mother is alive, has history of depression · One brother, healthy · one son age 4, alive and well Social History · Lives with fiancé and their 4-year-old son · does not have any friends · unemployed since her son was born · High school graduate · Nonsmoker · Drinks socially, 1-2 times a week · Several gasses of coke or sweet tea during the day · vapes CBD occasionally, 1-2 times a week. · no formal exercise · no hobbies
Review of Systems · occasional headache, relieved with acetaminophen · appetite poor, weight stable · sleeps 4-5 hours at night Allergies: NKDA |
Physical Examination: General
Alert, appropriately dressed Caucasian female in no apparent distress. She appears older than her stated age. Vital Signs: BP-120/80, T-98.6F, P-88, RR-20, SpO2: 98% Wt 110 lbs, Ht 5’6” |
| Mental status exam:
•Cranial nerves II-VIII intact •Gait steady •Denies headache and dizziness Appearance: appropriate dress for age and situation, well nourished, eye contact poor, No apparent distress Alertness and Orientation: fully oriented to person‚ place‚ time‚ and situation, Alert Behavior: cooperative Speech: soft, flat Mood: euthymic Affect: constricted, congruent Thought Process: logical‚ linear Thought content: No thoughts of suicide‚ self-harm‚ or passive death wish Perceptions: No evidence of psychosis, no response to internal stimuli noted during interview, reports auditory hallucinations. Memory: Recent and remote WNL Judgement/Insight: Insight is fair, Judgement is poor Attention and observed intellectual functioning: Attention intact for purpose of assessment. Fund of knowledge: Good general fund of knowledge and vocabulary Musculoskeletal: normal gait and station |
Mental status exam:
•Cranial nerves II-VIII intact
•Gait steady
•Denies headache and dizziness
Appearance: appropriate dress for age and situation, well nourished, eye contact poor, No apparent distress
Alertness and Orientation: fully oriented to person‚ place‚ time‚ and situation, Alert
Behavior: cooperative Speech: soft, flat Mood: euthymic
Affect: constricted, congruent Thought Process: logical‚ linear
Thought content: No thoughts of suicide‚ self-harm‚ or passive death wish
Perceptions: No evidence of psychosis, not responding to internal stimuli, reports auditory hallucinations.
Memory: Recent and remote WNL Judgement/Insight: Insight is fair, Judgement is fair
Attention and observed intellectual functioning: Attention intact for purpose of assessment.
Fund of knowledge: Good general fund of knowledge and vocabulary
Musculoskeletal: normal gait and station