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Physical Examination
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Poor eye contact and limited engagement during interactions
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Minimal spontaneous movement
Negative Symptoms
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Alogia
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Apathy
Cognitive Symptoms:
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Concentration difficulties
Inpatient Observations:
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Max slept an average of 14 hours per day.
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He demonstrated poor insight, insisting he was well and ready to go home, while questioning the need for hospitalization.
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Verbal aggression was noted, including threats toward staff, raising safety concerns.
Mood Symptoms:
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Depression
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Anxiety
Suicidality risk:
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Low. Denied any ideation or behaviors of self-harm
Treatment During Hospitalization:
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Max was initiated on an oral antipsychotic, but he reported excessive fatigue as a side effect.
Vital Signs
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Height: 70 inches (1.78 m)
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Weight: 195 lb (88 kg)
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Body Mass Index: 28 kg/m
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Heart Rate: 82 bpm
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Respiration: 17 breaths/min
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Blood Pressure: 138/85 mm Hg
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Diagnosis
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After a thorough evaluation, Max was diagnosed with schizophrenia.