Review of Systems (ROS):
GENERAL: Denies any fever or chills. Reports eating excessively and recent weight gain of 20 lbs.
HEENT: Denies any complaint of headache, no sore throat or difficulty swalowing
SKIN: No lesions or open wound
CARDIOVASCULAR: no chest pain or chest discomfort
RESPIRATORY: No difficulty breathing or shortness of breath
GASTROINTESTINAL: No nausea, vomiting or diahrrea os stomach pain
GENITOURINARY: No burning urination or bladder discomfort
NEUROLOGICAL: No involuntary movements or motor tics
MUSCULOSKELETAL: No joint stiffness, moves all extremities.
HEMATOLOGIC: No bleeding problems or disorders
LYMPHATICS: No enlarged lymph nodes
ENDOCRINOLOGIC: Denies heat or cold intolerance
Psychitric ROS
· Mood; Client reports feeling sad, + low self-esteem and has self-doubts.
· Anxiety; + sensations of shortness of breath, shaking, flushing, and fear of dying. He worries, restless, has difficulty concentrating, his mind goes blank, and he feels on edge.
· Sleep; + sleeping difficulties.
· Psychotic symptoms; Client has no history of manic or hypomanic episodes, reports one psychotic episode two years ago, and has no suicidal or homicidal ideations.
· Appetite; + increased appetite, and he severely feels hungry
· Behavioral; He reports Hx of being impulsive, talking a lot, nervous twitching, and making poor decisions.
· Trauma; Divorce is the major contributing event. No history of abuse.
Objective:
Physical exam: Unable to assess
Diagnostic results:
Wt- 220 lbs, Ht- 70 in
Diagnostic reports are not available on the patient’s chart. To determine other possible underlying medical conditions, obtaining lab tests should be included in a psychiatric work up. I would recommend checking CBC, CMP, Thyroid panel, Vitamin D level, and liver enzymes.
Last Physical was in 2019 – Recommend referral to PCP for physical
Recommend Rheumatologist order MRI scan of the spine for further monitoring and management of the ankylosing spondylitis. Also, assess patient for possible eligibility for disability due to this condition.
Screening tools: Both GAD-7 and PHQ-9 screening tools results are pending completion.