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3-2 PATIENT NOTE: HALLUCINATIONS HISTORY: Describe the history you just obtained from this patient.

Include only information (pertinent positives and negatives) relevant to this patients problem(s). HPI: 17-YEAR-OLD MALE BROUGHT IN BY HIS PARENTS, WITH PARENTS PERMISSION TO BE SEEN, REPORTS AUDITORY HALLUCINATION. STARTED A MONTH AGO, AT LEAST TWO TIMES A DAY IN THE MORNING AND PRIOR TO GOING TO SLEEP, LAST APPROXIMATELY 10 MIN. PATIENT STATES, HE HEARS VOICES TELLING HIM HE IS A FAILURE AND WILL NOT GRADUATE FROM COLLEGE. DENIES TACTILE OR VISUAL HALLUCINATIONS. PATIENT REPORTS DEPRESSION, AGITATION, TESTLESNESS, LOSS OF INTEREST. DECREASE CONCENTRATION AT SCHOOL AND WORK, SLEEP IS DISTRUBED BY EARLY RISING. DENIES NIGHTMARES, SNORING, OR FATIGUE. PATIENT REPORTS STRESS DUE TO ACADEMIC RESPONSIBILITIES, ENERGY LEVELS CHANGE THROUGHOUT THE DAY, +RACING THOUGHTS. +HAIR LOSS, +DRYSKIN, +COLD INTOLERANCE. ROS: NEGATIVE EXCEPT AS NOTED ABOVE ALLERGIES: NKDA MEDICATIONS: NONE PMH: NO PREVIOUS EPISODES, NO HISTORY OF MENTAL ILLNESS PSH: NONE FH: PARENTS ALIVE AND WELL, NO HISTORY OF MENTAL ILLNESS SH: DENIES TOBACCO, ETOH, USES MARIJUANA OCCASIONALLY, COLLEGE STUDENT LIVES AT SCHOOL WORKS IN HOME REPAIR, IS NOT SEXUALLY ACTIVE. PHYSICAL EXAM: Describe any positive and negative findings relevant to this patients problem(s). Be careful to include only those parts of examination you performed in this encounter. HE IS IN NO ACUTE DISTRESS BUT STARING AT THE GROUND DURING THE PHYSICAL EXAM. HIS VITALS ARE WITHIN NORMAL LIMITS. PATIENT IS ALERT AND ORIENTED TO TIME, PLACE AND PERSON. HE APPEARED DEPRESSED WITH DECREASED ENERGY. HE IS DELUSIONAL FROM HEARING THE VOICES BUT DENIES SUICIDAL IDEATIONS. HIS HEAD, NOSE, EYES APPEAR NORMAL AND ATRAUMATIC. HIS NECK IS SUPPLE WITHOUT LYMPHADENOPATHY AND THYROID IS WITHIN NORMAL LIMITS. HIS BREATH SOUNDS ARE CLEAR BILATERALLY. HIS HEART SOUNDS ARE NORMAL WITHOUT RUBS, GALLOPS, MURMURS. HIS ABDOMEN IS NONDISTENDED AND NONTENDER WITH BOWEL SOUNDS PRESENT. HIS NEUROLOGICAL EXAM IS NORMAL WITH INTACT 2-12 CRANIAL NERVES. HIS MUSCLE STRENGTH IS 5/5 BILATERALLY AND REFLEXES 2/4 BILATERALLY. HIS SENSATION TO DULL AND SHARP IS INTACT BILATERALLY. ROMBERG SIGN IS WITHIN NORMAL LIMITS. DATA INTERPRETATION: Based on what you have learned from the history and physical examination, list up to 3 diagnoses that might explain this patients complaint(s). List your diagnoses from most to least likely. For some cases. Fewer than 3 diagnoses will be appropriate. Then, enter the positive or negative findings from the history and physical

examination (if present) that support each diagnosis. Lastly, list initial diagnostic studies (if any) you would order for each listed diagnosis (e.g. restricted physical exam maneuvers, laboratory tests, imaging, ECG, etc. Diagnosis #1: Schizophrenia HISTORY FINDING(S) PHYSICAL EXAM FINDING(S) - AUDITORY HALLUCINATIONS -LOSS OF HAIR, DRY SKIN - DEPRESSION, LOSS ON INTEREST - IN ACUTE DISTRESS - H/O MARIJUANA USE - STARING AT THE GROUND DURING PHYSICAL EXAM Diagnosis #2: Bipolar with psychosis HISTORY FINDING(S) PHYSICAL EXAM FINDING(S) - AUDITORY HALLUCINATIONS - IN ACUTE DISTRESS -DEPRESSION, DECREASED INTEREST - STARING AT THE GROUND - H/O MARIJUANA USE -LOSS OF HAIR, DRY SKIN Diagnosis #3: Psychosis secondary to drug abuse HISTORY FINDING(S) PHYSICAL EXAM FINDING(S) - H/O MARIJUANA USE - IN ACUTE DISTRESS - AUDITORY HALLUCINATIONS - STARING AT THE GROUND - DEPRESSION - LOSS OF HAIR, DRY SKIN Diagnostic Studies -CBC -TSH -DRUG SCREEN -BUN, CR., CA, GLUCOSE