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

CC (chief complaint): Potential substance use

HPI: The patient is a 48-year-old Asian who presents to the clinic due to alcohol abuse complaints by parents, students, and colleagues. The principal requested this session since the patient had been late to classes for twenty-two days. She denies these statements and is clearly agitated by the accusations. After being pressed further, she states that there was a party at Darrel’s house where everyone drank much and not just her. She wonders why Darrel was not brought up for questioning. She also states that she got angry since Darrel did not wake her up the day after, making her late for class. She denies being drunk while teaching and is agitated by the same complaints. The complaints included sleeping in class while students were writing notes. She further claims that it is Alexis who is saying things about her. After being told that the administration required her cooperation, she agrees that she drank a lot the previous night and admits that she drinks every night. She drinks alone at home. She began drinking heavily in her freshman and less during her college years.

Past Psychiatric History:

General Statement: The patient has a history of substance abuse but has never been committed to an institution.

Caregivers (if applicable): None

Hospitalizations: None

Medication trials: None

Psychotherapy or Previous Psychiatric Diagnosis: None

Substance Current Use and History: The patient has a history of drinking alcohol during her college days. She currently drinks alcohol every day, causing her issues at work.

Family Psychiatric/Substance Use History: Her father had an alcohol use disorder. He went to Alcoholics Anonymous and got sober.

Psychosocial History: The patient is an only child, and both parents were raised in San Francisco, California. She has a master’s degree in high school education and a Ph.D. in biology. She lives alone, single, without any children. She is currently in a new relationship after breaking up with her ex-boyfriend, Ryan. She drinks a couple of glasses of alcohol alone in her free time. She occasionally goes to social events with her friends. She is a high school teacher but does not currently enjoy her job. She denies any current or history of legal issues.

Medical History:

Current Medications: Unknown

Allergies: Unknown

Reproductive Hx: Heterosexual and sexually active. Not pregnant or lactating.

ROS:

GENERAL: Denies weight loss, fatigue, chills or fever

HEENT: Denies visual loss, blurred visions or yellow sclerae. Denies runny nose, nasal congestion, throat pain, hearing loss or sneezing.

SKIN: No itching or rash

CARDIOVASCULAR: Denies chest pain or chest discomfort. Denies peripheral edema or palpitations.

RESPIRATORY: Denies dyspnea, cough, or sputum

GASTROINTESTINAL: Denies appetite loss, nausea, vomiting or abdominal pain

GENITOURINARY: Denies urinary urgency, incontinence, or burning sensation on urination

NEUROLOGICAL: Denies syncope, ataxia, dizziness, numbness, paralysis, or headache.

MUSCULOSKELETAL: Denies muscle pain, joint pain, or back pain.

HEMATOLOGIC: Denies anemia or easy bruising

LYMPHATICS: Denies swollen lymph nodes.

ENDOCRINOLOGIC: Denies heat/cold intolerance, polyuria, polyphagia, or polydipsia

Physical exam:

Constitutional: The patient is A & O X3. She is appropriately dressed for the weather. She is not cooperative.

HEENT: Head is atraumatic and normocephalic. Eyes: Visual acuity: 20/20. PERRLA. Ears: Tympanic membrane is grey and intact. Nose: Nasal nares are patent. Throat: Oral mucosa is moist and pink

Cardiovascular: S1, S2 heard. Chest expansion is equal bilaterally. Capillary refill is less than three seconds.

Respiratory: No wheezes, crackles, or labored breathing noted.

Abdominal: Normal bowel sounds on auscultation. No masses were noted.

Lymphatics: No lymphadenopathy on palpation.

Skin: Skin is warm and moist to the touch. No tattoos noted.

Genitourinary: Deferred

Brest: Deferred

Diagnostic results:

The usual laboratory testing for alcohol in clinical settings is the blood alcohol content (BAC). BAC is estimated using a breathalyzer machine (Marienfeld, 2020). Other tests should also be conducted to rule ou