Schizophrenia Eric Ford Shadow health Subjective Data Collection
Chief Complaint:
– Eric reports experiencing hallucinations, which are perceptions of things that aren’t really there.
– He also mentions having paranoid thoughts, feeling like others may want to harm him.
Table of Contents
History of Present Illness:
– Eric has been hearing voices for the past week, and these auditory hallucinations have been increasing in frequency.
– Currently, he hears these voices constantly and describes them as sometimes male and sometimes female.
– He denies experiencing visual, taste-related, smell-related, or touch-related hallucinations.
– Eric reports experiencing command hallucinations, where the voices tell him to do things, but he resists following their instructions.
– He finds that his hallucinations are more disturbing when he’s in quiet environments and unable to distract himself.
– To cope with his symptoms, Eric listens to music.
Past Medical History:
– Eric denies any general health conditions but acknowledges a diagnosis of schizophrenia, which he received at the age of 23.
– He also reports occasional insomnia, with recent episodes of increased difficulty falling asleep. He typically sleeps for only 2 to 3 hours per night, experiences frequent awakenings, and occasionally has nightmares.
By gathering this information, healthcare providers can better understand Eric’s current condition, his experiences with schizophrenia, and his coping mechanisms. This helps in formulating an appropriate treatment plan tailored to his needs.
Infant Well Visit Zachary LaFontaine Shadow health Transcript
Schizophrenia Eric Ford Shadow health Subjective Data Collection
Hover over the Patient Data items below to reveal important information, including Pro Tips and Example Questions.
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Found:
Indicates an item that you found.
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Available:
Indicates an item that is available to be found.
Category
Scored Items
Experts selected these topics as essential components of a strong, thorough interview with this patient.
Patient Data
Not Scored
A combination of open and closed questions will yield better patient data. The following details are facts of the patient’s case.
Chief Complaint
- Finding:Established chief complaint
- Finding:Reports hallucinations
(Found)
Pro Tip: A patient’s chief complaint establishes any illnesses or concerns they are presenting. Asking about the chief complaint will allow the patient to voice any concerns or symptoms the patient may have.Example Question:
Do you ever hear things that others do not hear? - Finding:Has paranoid thoughts
(Found)
Pro Tip: A patient’s chief complaint establishes any illnesses or concerns they are presenting. Asking about the chief complaint will allow the patient to voice any concerns or symptoms the patient may have.Example Question:
Do you ever think people are trying to harm you?
History of Present Illness
- Finding:Asked about onset and duration of symptoms
- Finding:Reports hearing voices for the past 7 days
(Found)
Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.Example Question:
When did your symptoms start? - Finding:Reports voices have increased over the last week
(Found)
Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.Example Question:
Did the hallucinations start gradually?
Finding:
Reports that voices are currently constant
(Available)
Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.Example Question:
Are your hallucinations constant?
Finding:
Asked about characteristics of symptoms
Finding:
Describes voices as sometimes male, sometimes female
(Found)
Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.Example Question:
Can you describe your hallucinations?
Finding:
Denies visual hallucinations
(Available)
Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.Example Question:
Do you ever see things that are not there?
Finding:
Denies gustatory hallucinations
(Available)
Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.Example Question:
Do you taste things that are not there?
Finding:
Denies olfactory hallucinations
(Available)
Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.Example Question:
Do you smell things that are not there?
Finding:
Denies tactile hallucinations
(Available)
Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.Example Question:
Do you feel things that are not there?
Finding:
Followed up on content of hallucinations
Finding:
Reports command hallucinations
(Found)
Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.Example Question:
Do the voices tell you to do anything?
Finding:
Reports resisting doing what the voices say
(Available)
Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing. Schizophrenia Eric Ford Shadow health Subjective Data CollectionExample Question:
Do you do what the voices say?
Finding:
Asked about aggravating factors of symptoms
Finding:
Reports that voices are more disturbing in quiet environments (when unable to be distracted)
(Found)
Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.Example Question:
What makes your symptoms worse?
Finding:
Asked about coping strategies
Finding:
Reports music as a coping strategy
(Found) Schizophrenia Eric Ford Shadow health Subjective Data Collection
Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.Example Question:
How do you cope with your hallucinations?
Schizophrenia Eric Ford Shadow health Subjective Data Collection Past Medical History
Finding:
Asked about existing health conditions
Finding:
Denies general health conditions
(Found)
Pro Tip: Inquiring into the patient’s relevant history can reveal past diagnoses and previous conditions or concerns. Information about the patient’s existing health conditions, a timeline of diagnosis, symptoms, and allergies can indicate where you should follow-up for further care and treatment.Example Question:
What health issues do you have?
Finding:
Asked about history of mental health
Finding:
Reports diagnosis of schizophrenia
(Found)
Pro Tip: Inquiring into the patient’s relevant history can reveal past diagnoses and previous conditions or concerns. Information about the patient’s existing health conditions, a timeline of diagnosis, symptoms, and allergies can indicate where you should follow-up for further care and treatment.Example Question:
Have you been diagnosed with schizophrenia?
Finding:
Reports occasional insomnia
(Found)
Pro Tip: Inquiring into the patient’s relevant history can reveal past diagnoses and previous conditions or concerns. Information about the patient’s existing health conditions, a timeline of diagnosis, symptoms, and allergies can indicate where you should follow-up for further care and treatment. Schizophrenia Eric Ford Shadow health Subjective Data CollectionExample Question:
Do you have insomnia?
Finding:
Denies past history of depression
(Available)
Pro Tip: Inquiring into the patient’s relevant history can reveal past diagnoses and previous conditions or concerns. Information about the patient’s existing health conditions, a timeline of diagnosis, symptoms, and allergies can indicate where you should follow-up for further care and treatment.Example Question:
Do you have a history of depression?
Finding:
Denies past history of anxiety
(Available)
Pro Tip: Inquiring into the patient’s relevant history can reveal past diagnoses and previous conditions or concerns. Information about the patient’s existing health conditions, a timeline of diagnosis, symptoms, and allergies can indicate where you should follow-up for further care and treatment.Example Question:
Do you have generalized anxiety disorder?
Finding:
Denies past history of bipolar disorder
(Available)
Pro Tip: Inquiring into the patient’s relevant history can reveal past diagnoses and previous conditions or concerns. Information about the patient’s existing health conditions, a timeline of diagnosis, symptoms, and allergies can indicate where you should follow-up for further care and treatment. Schizophrenia Eric Ford Shadow health Subjective Data CollectionExample Question:
Have you been diagnosed with bipolar disorder?
Finding:
Followed up on schizophrenia diagnosis
Finding:
Diagnosed age 23
(Found)
Pro Tip: Inquiring into the patient’s relevant history can reveal past diagnoses and previous conditions or concerns. Information about the patient’s existing health conditions, a timeline of diagnosis, symptoms, and allergies can indicate where you should follow-up for further care and treatment.Example Question:
At what age did you get schizophrenia?
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Finding:
Followed up on insomnia
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Finding:
Reports frequent insomnia
(Available)
Pro Tip: Inquiring into the patient’s relevant history can reveal past diagnoses and previous conditions or concerns. Information about the patient’s existing health conditions, a timeline of diagnosis, symptoms, and allergies can indicate where you should follow-up for further care and treatment.Example Question:
How often have you had trouble falling asleep? -
Finding:
Reports difficulty falling asleep
(Found)
Pro Tip: Inquiring into the patient’s relevant history can reveal past diagnoses and previous conditions or concerns. Information about the patient’s existing health conditions, a timeline of diagnosis, symptoms, and allergies can indicate where you should follow-up for further care and treatment.Example Question:
Have you had trouble falling asleep before? -
Finding:
Reports recent insomnia has increased
(Found)
Pro Tip: Inquiring into the patient’s relevant history can reveal past diagnoses and previous conditions or concerns. Information about the patient’s existing health conditions, a timeline of diagnosis, symptoms, and allergies can indicate where you should follow-up for further care and treatment.Example Question:
Can you tell me more about your sleep? -
Finding:
Reports sleeping 2 – 3 hours per night
(Available)
Pro Tip: Inquiring into the patient’s relevant history can reveal past diagnoses and previous conditions or concerns. Information about the patient’s existing health conditions, a timeline of diagnosis, symptoms, and allergies can indicate where you should follow-up for further care and treatment.Example Question:
How many hours a night do you sleep? -
Finding:
Reports frequent awakening
(Found)
Pro Tip: Inquiring into the patient’s relevant history can reveal past diagnoses and previous conditions or concerns. Information about the patient’s existing health conditions, a timeline of diagnosis, symptoms, and allergies can indicate where you should follow-up for further care and treatment.Example Question:
How often do you wake up during the night? -
Finding:
Reports occasional nightmares Schizophrenia Eric Ford Shadow health Subjective Data Collection
