Chief complaint: Paranoia
Demographic data: K.P is a 20-year-old Caucasian female in her second year of college at Alabama State University.
HPI: K.P and her father present to the clinic for CC of paranoia. She reports being dismissed last week from the university due to her erratic behaviors. Recently she has been found wandering at night dressed in inappropriate clothing, disturbing students at the campus library yelling out profanities. She reports loss of interest in her studies, missing classes, and grades started to drop. She lost 15lbs in one month because she fears her roommate is trying to kill her by poisoning her meals. K.P strongly believes that she is a nun and says that she wants to join a local religious group. She continuously picks at her nose as she believes she has stigmata there. She also thinks that she wears a crown of thorns. Her father states that his daughter thought process is all over the place, and often looking over her shoulders as though someone is trying to harm her.
Past Medical History: Hypothyroidism
Past Surgical History: Strabismus surgery
Medications: Multivitamin and Levothyroxine 125mcg daily
Social History: K.P last attended Alabama State University in her second year, now she lives back home with her father, Larry, and older brother Tommy. Her mother died from breast cancer when she was nine years old. She is currently unemployed; last employment was six months ago at the campus bookstore. She walked off the job after threatening a customer for looking at her the wrong way. Her father is supporting financially. The patient reports she smokes marijuana occasionally at her friend’s house. She denies using tobacco and drinks alcohol five times a month when partying with friends on the weekends. She gets max fours of sleep due to staying up all night. She is sexually active with her current boyfriend and reports using condoms sometimes.
Review of System:
Constitutional symptoms- Report weight loss of 15lbs within a month and trouble sleeping. Denies fever, chills, and weakness.
HEENT- Denies visual issues. No glasses or corrective lenses. Denies throat or swallowing issues. Denies hearing changes, nasal congestion.
Neurologic-Denies lightheadedness, headache, numbness, tingling, and sensation changes.
Cardiovascular- Denies Chest pain, palpitation, Hx of murmurs, activity intolerance.
Respiratory- Denies coughing up blood, Shortness of breath, and wheezing.
Gastrointestinal-Decreased appetite in fear of someone poisoning her food. Denies heartburn, bloating, nausea/vomiting, diarrhea, constipation, epigastric pain, and change in bowel habits.
Genitourinary- Denies difficulty or burning in urination, frequent urination at night, and blood in urine.
Musculoskeletal- Denies pain, stiffness, swelling, crepitus, and limited range of motion.
Integumentary- Denies rashes, itching, and changes in hair or nails.
Endocrine: Reported intermittent cold intolerance due to hypothyroidism. Denies increased appetite, thirst, urine production, and excessive sweating.
Psychiatric: Reported increasing anxiety and nervousness, mood swings, trouble concentrating, sleeping problem- sleep for 4 hours each night. Denies depression and suicidal/Homicidal Ideation.
Vital signs: BP 113/65, T 96.5, P 100, R 18 Sao2 99% on room air
General: 20-year-old Caucasian female appears stated age appears anxious. Alert, oriented, and cooperative. Able to speak in full sentences and does not appear in distress.
Skin: Skin warm, dry, and intact. Skin color is pale pink, no cyanosis or pallor.
HEENT: Head normocephalic. Hair thin and distribution even throughout scalp. Mild red sclera. Conjunctiva: white, PERRLA, EOMs intact. Tympanic membranes gray and intact with light reflex noted. Pinna and tragus non-tender Nares patent with thin white exudate noted. No deviated septum noted. Sinuses non-tender to palpation. Oropharynx pink, moist, no lesions, or exudate. Teeth in good repair, four cavities noted. Tongue smooth, pink, no lesions, protrudes in midline. Neck supple. No cervical lymphadenopathy or tenderness noted. Thyroid midline, small and firm without palpable masses.
Respiratory: Lungs clear to auscultation bilaterally. Respirations unlabored. No wheezes or rales noted.
Cardiovascular: S1 and S2 noted, no murmurs noted, peripheral pulses equal bilaterally, no peripheral edema
Gastrointestinal: Abdomen round, soft, bowel sounds noted in all four quadrants. No organomegaly noted.
Musculoskeletal: Full range of motion to bilateral upper and lower extremities. No tenderness to palpation.
Mental Status Exam:
Appearance and behavior: K.P is a young Caucasian woman dressed appropriately for a visit with good eye contact. Repetitive scratching of her nose was noted during the examination. Speech: normal rate and rhythm. Thought form: No, abnormality. Thought content: The patient is noted to have delusional thought content, as mentioned in the history. She does not have suicidal ideations. Mood: K.P is anxious about her future regarding joining a religious group. Perception: experiences delusions during the interview relating herself to a nun that wears a crown of thorns and believes she is subconsciously connected to the Archbishop of Italy. Cognitive function: Patient is oriented to person, place, and time. She is noted to have good attention and concentration. No abnormalities of memory and average intellect. Insight: K.P has no insight into her current mental health issues.