Grand Rounds Discussion: Complex Case Study Presentation

Caroline E Sam

College of Nursing-PMHNP, Walden University

PRAC 6675: Grand Rounds Discussion Complex Case Study Presentation 07/27/2022

Subjective:

CHIEF COMPLAINT: ''Attempted suicide because the voices told me to do so."

HPI: C.P is a 55-year-old African-American male with a reported history of schizophrenia depression type that presents to the hospital for psychiatric assessment due to increased suicidal ideation and auditory hallucinations. The patient reports that one time he attempted suicide by cutting his wrist because he was hearing voices telling him to do so. C.P further reports that he has always struggled with medication compliance and in other cases, he has also had difficulty refilling his prescription due to lack of funding. He mentions being off his medications for 2 weeks. The patient further reports feeling lonely after his only sister left home for college and he was unable to take his medication refilled. He started experiencing visions and sounds that he could not understand (visual and auditory hallucinations). The patient reported experiencing poor sleep patterns. C.P further notes high levels of anxiety, depressed mood, anhedonia, low energy, and increased suicidal ideation. The patient also reports attempting to burn the family house after his sister abandoned him for college because he could not stand living there alone.

Past Psychiatric History:

· General Statement: The patient experienced his first symptoms of mental illness at the age of 26 years, was hospitalized on three occasions, and received treatment. Factors that contributed to his hospitalization include feelings of paranoia and impulsiveness regarding thoughts of harm to others and self.

· Caregivers (if applicable): None

· Hospitalizations: Hospitalized on three occasions.

· Medication trials: Depakote, Zyprexa, trazodone, Haldol, and Lithium.

· Psychotherapy or Previous Psychiatric Diagnosis: Schizophrenia

Substance Current Use and History: None

Family Psychiatric/Substance Use History: C. P's mother had psychiatric problems and his father had alcohol and substance use issues.

Psychosocial History: The patient has never been married and has no children. He was in special education all through his primary and secondary school. She lived with his sisters before she left for college.

Medical History: Hypertension

· Current Medications: Lisinopril

· Allergies: None

· Reproductive Hx: Not sexually active

ROS:

· GENERAL: The patient reports fatigue and weight loss, and denies weakness, chills, or fever.

· HEENT: Eyes: Denies yellow sclera, double vision, blurred vision, and visual loss. Ears, Nose, Throat: Denies sore throat, runny nose, congestion, sneezing, or hearing loss.

· SKIN: No itching or rash.

· CARDIOVASCULAR: No edema or palpitations. No chest discomfort, chest pressure, or chest pain.

· RESPIRATORY: No sputum, cough, or shortness of breath.

· GASTROINTESTINAL: No abdominal pain or blood. No diarrhea, vomiting, nausea, or anorexia.

· GENITOURINARY: No odd color, odor, hesitancy, urgency, or burning sensation on urination

· NEUROLOGICAL: No change of bladder or bowel control. No syncope, dizziness, headache, numbness, ataxia, paralysis, or tingling in the extremities.

· MUSCULOSKELETAL: No joint pain, back pain, or muscle pain/stiffness.

· HEMATOLOGIC: No bruising, bleeding, or anemia.

· LYMPHATICS: No splenectomy history. No enlarged nodes

· ENDOCRINOLOGIC: no report of polydipsia or polyuria. No reports of heat intolerance, cold, or sweating.

Objective:

Physical exam:

Vital Signs: Temperature 98.7, respiration 18, blood pressure 120/80lying down, Pulse 96 regular.

Generally, a well-developed, normal-weight African-American man

HEENT; Normal.

Neck: Normal, no masses, thyroid not palpable.

Nodes: no adenopathy.

Chest: Breast-no masses or discharges, non-tender. Lungs: No dullness. Diaphragm moves well with respiration. No wheezes, rubs, or rhonchi.

Heart; regular rhythm.

Spine: non tender, no costovertebral tenderness.

Abdomen: soft, flat, bowel sounds present, no bruits. Non tender to palpation.

Extremities: skin warm and smooth, no edema, no clubbing nor cyanosis

Neurological; Awake, alert, and fully oriented.

Diagnostic results: Routine lab exams were performed. Liver and kidney function, routine blood tests, computed tomography (CT) of the head, and electrocardiograph (ECG) were normal.

Assessment:

Mental Status Examination: C.P is a 55-year-old African-American male with a reported history of schizophrenia depression type that presents to the hospital for psychiatric assessment due to increased suicidal ideation and auditory hallucinations. The patient's appearance is unkempt. The attitude is cooperative. His gait is steady and appropriate for his age. His mood is depressed and his affect is constricted. The speech is normal in rate, volume, and tone. The patient's language is intact. His thought processes are disorganized. His thought content is paranoia. The patient reports suicidal and homicidal ideation with a plan. The patient reports auditory and visual hallucinations. He is alert and oriented to place, person, situation, and time. The patient's insight is fair and judgment is poor. The patient attention and concentration are poor. His fund of

knowledge is grossly intact. He is calm, cooperative, and has good eye contact. His short-term and long-term memory is intact.

Differential Diagnosis

DSM-5 295.70 (F25.1) Schizoaffective disorder, depressive type

According to Parker (2019), Schizoaffective disorder is characterized by the co­ occurrence of psychotic and mood disorders (mania or depression) as well as the persistence of psychotic features for at least a week after experiencing mood symptoms At least three of the following psychotic symptoms should be present: delusions, hallucinations, disorganized speech, grossly disorganized or catatonic behavior, and negative symptoms (Wy & Saadabadi, 2019). The bipolar type includes episodes of mania and sometimes major depression while the depressive type only includes depressive episodes. According to Beckmann et al. (2020), the patient also has to present with delusions or hallucinations for a minimum of two weeks, major mood symptoms, and the impairment in daily functioning is not due to the effects of substance use or another underlying medical condition. Schizoaffective disorder with depression is the most probable diagnosis in this case because the patient presents with psychotic features such as hallucinations, delusions, and disorganization as well as mood symptoms such as depressed mood, anhedonia, and poor sleep. Psychotic symptoms are co-occurring with a depressed mood; hence, Schizoaffective disorder, depressed type is the most likely diagnosis.

DSM-V 295.90 (F20.9) Schizophrenia

According to Stepnicki et al. (2018), schizophrenia is characterized by a range of cognitive, behavioral, and emotional impairments. The key symptoms of schizophrenia include hallucinations, delusions, disorganized speech, catatonic behaviors, and negative emotions such as decreased motivation and diminished expressiveness. According to Mccutcheon et al., 2020),

patient also presents with cognitive deficits affecting their memory, speed of mental processing, and executive functions. Schizophrenia also impairs the patient's level of functioning in fundamental areas such as work, interpersonal relations, and self-care. While schizophrenia is a consideration in this case due to the patient's psychotic features, it will be disregarded because the patient also presents with key depressive symptoms such as anhedonia and poor sleep.

DSM 296.20 (F32.9) Major depressive disorder, single episode, unspecified.

According to Hasin et al. (2018), major depressive disorder (MDD) is diagnosed when a patient present with at least two weeks of persistent anhedonia, depressed mood, and hopelessness as well as feelings of guilt, increased disturbances in sleep and appetite, and suicide ideation or attempt. Mullen (2018) also notes that MDD is characterized by weight loss/gain, lack of energy, restlessness or slowness, and difficulty concentrating on indecisiveness. MDD is a consideration in this case because the patient presents with depressive symptoms such as low mood, anhedonia, and poor sleep patterns. However, it will be disregarded because these symptoms also co-occur with psychotic features that cannot be ignored.

Case Formulation and Treatment Plan:

The patient is not safe to leave the hospital. The patient is not on multiple antipsychotics. Non­ adherence is suspected to lead to exacerbation in symptoms. According to Schnitzer et al. (2020), antipsychotic treatment is the mainstay of pharmacotherapy for conditions included in the schizophrenia spectrum including both bipolar and depressive subtypes of schizoaffective disorder. Therefore, I will start the previously effective Zyprexa/Depakote and make dose adjustments as indicated. The plan is;

· Start Zyprexa 10 mg Qhs for psychosis

· Start Depakote 500 mg BID for mood

· Obtain Dep lvl on 3/29

If required, further adjustments will be made to the medications pending new lab results. The therapist will coordinate with the social worker to assess outpatient support follow-up along with gathering collateral information. The therapist will follow internal med recs regarding medical concerns. The risks and benefits of all the above medications/treatments are discussed with the patient and the patient voices understanding and agree to continue with the plan unless otherwise specified.

Reflection: This is a case of schizoaffective disorder with is a condition whereby the patient presents with symptoms of both schizophrenia and mood disorders. However, the symptoms are insufficient to meet the diagnostic criteria of either a mood disorder or schizophrenia. In the future, I would explore the mood and schizophrenia symptoms further to establish whether the patient meets the criteria of any of these conditions. Patient education should also emphasize medication adherence which is a major concern in psychosis. The issue of poor insight and the patient not being of sound mind also introduces ethical and legal issues that should be considered such as informed consent.

Questions

1. What are the key symptoms of schizoaffective disorder?

2. What is the mainstay of pharmacotherapy for schizoaffective disorder, depressive type?

3. What are some of the reasons that people with schizoaffective disorder are more at risk of medication non adherence?

References

Beckmann, D., Schnitzer, K., & Freudenreich, 0. (2020). Approach to the diagnosis of schizoaffective disorder. Psychiatric Annals, 50(5), 195-199. https://doi.org/10.3928/00485713-20200408-01

Hasin, D. S., Sarvet, A. L., Meyers, J. L., Saha, T. D., Ruan, W. J., Stohl, M., & Grant, B. F. (2018). Epidemiology of adult DSM-5 major depressive disorder and its specifiers in the United States. JAMA psychiatry, 75(4), 336-346. doi:10.1001/jamapsychiatry.2017.4602

McCutcheon, R. A., Marques, T. R., & Howes, 0. D. (2020). Schizophrenia-an

overview. JAMA Psychiatry, 77(2), 201-210. doi:10.1001/jamapsychiatry.2019.3360

Mullen, S. (2018). Major depressive disorder in children and adolescents. Mental Health Clinician, 8(6), 275-283. DOI: 10.9740/mhc.2018.11.275

Parker, G. (2019). How well does the DSM-5 capture schizoaffective disorder? The Canadian

Journal of Psychiatry, 64(9), 607-610. https:ljdoi.org/10.ll 77/0706743719856845

Schnitzer, K., Beckmann, D., & Freudenreich, 0. (2020). Schizoaffective disorder: treatment considerations. Psychiatric Annals, 50(5), 200-204. https://doi.org/10.3928/00485713-

20200409-01

St pnicki, P., Kondej, M., & Kaczor, A. A. (2018). Current concepts and treatments of schizophrenia. Molecules, 23(8), 2087. doi:10.3390/molecules23082087

Wy, T. J.P., & Saadabadi, A. (2019). Schizoaffective Disorder. StatPearls [Internet]

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Week (9): (Ground Rounds Discussion: Complex Case Study Presentation)

Judith Uwazuruonye

College of Nursing-PMHNP, Walden University

NRNP 6675: PMHNP Care Across the Lifespan II

DR Ishkova

July 27, 2022

Presentation Objectives

i. To perform a comprehensive psychiatric patient evaluation on the patient.

ii. To develop a differential diagnosis based on the subjective and objective data obtained.

iii. To determine the most reasonable diagnosis based on the patient’s symptoms.

iv. To develop a patient-centered treatment plan for the patient.

Subjective:

CC (chief complaint): “Anxiety on going out.”

HPI: L.L. is a 65 years old African American patient seeking help in managing anxiety. The patient admits to feeling anxiety when going to the stores and driving from her comfort zone. She struggles with overwhelming anxiety and avoidance of the anxiety. The onset of her anxiety was gradual following an incident in the early 2000s when she experienced an episode of encopresis before she could make it to the bathroom. Since the event, she has been avoiding going to stores and gradually grew anxious when driving due to the fear of getting lost and losing control. Since her retirement, the fear has increased significantly, and this has kept her away from seeing her family, going to physician appointments alone, and engaging in recreational activities. She has few friends, is widowed, and is not in a relationship. She lives with her children in a rented apartment. Her medical history is positive for irritable bowel syndrome and glaucoma. She denies a history of military service, legal issues, or drug or substance abuse. Her medication list includes Buspar 2.5mg P.O. in the evening. She was previously on Zoloft 25mg daily, but this was discontinued due to the feeling of drowsiness. She feels depressed due to the fear of leaving her house. She is allergic to Biaxin. L.L. reports not being compliant with her medications and requiring the withdrawal of the current medications.

Substance Current Use: Denies

Medical History:

· Current Medications: None

· Allergies: Biaxil. Unknown reaction

· Reproductive Hx: Post-menopausal. Has 3 children. Not sexually active. Widowed.

· Surgery: No past surgery

Family history

Mother- generalized anxiety disorder

Father- Alcohol use disorder

Children- No remarkable health issues

Social history

The patient lives in a rented apartment with her children. She is widowed and is not currently in a relationship. She is retired. She denies a history of drug or substance use, legal issues, or military history. The patient denies a history of abuse or trauma when growing up and in her adulthood, except for the loss of her husband. She maintains few friends and reports feeling anxious when going out. She is afraid of driving from her comfort zone due to the fear of losing control or getting lost.

ROS:

· GENERAL: The patient reports increased anxiety and non-compliance to medications. She denies any unexplained changes in weight or appetite.

· HEENT: Head: No history of trauma, headache, or hair pulling. Eyes: No vision challenges, use of vision aids, or pain. Ears: No history of ear infections, hearing problems, or pain. Nose: No blockage or wheezing. Throat: No swollen tonsils, swallowing problems, or pain.

· SKIN: No cuts, rashes, bruises, or wounds.

· CARDIOVASCULAR: No pain, congestion, or pressure in the chest. No changes in heart rate. No palpitations.

· RESPIRATORY: No breathing difficulties, shortness of breath, or pain, congestion, or pressure in the chest.

· GASTROINTESTINAL: Has a history of irritable bowel syndrome. No changes in weight or appetite.

· GENITOURINARY: No incontinence, enuresis, or increased frequency. Denies pain, burning sensation, or irritation during urination.

· NEUROLOGICAL: No history of falls, blackouts, syncope, or tremors.

· MUSCULOSKELETAL: No history of broken bones. Denies pain or weakness on any muscle, joint, or bone.

· HEMATOLOGIC: No easy bruising or bleeding. No history of anemia.

· LYMPHATICS: No unusual sweating or chills. No swollen lymph nodes.

· ENDOCRINOLOGIC: No hunger, thirst, hunger, urination, or bowel movement, or urination.

Objective:

· GENERAL: The patient is alert and oriented to all four spheres during the interview. She is a good historian and the primary source of health information. Her concentration and attention are adequate and she does not demonstrate pressure, agitation, or unusual mannerisms.

· HEENT: Head: Normocephalic and atraumatic head. Norma hair pattern and color for a 65 years old African American female. Eyes: PERRLA. No jaundice. Has glaucoma. Ears: Gray tympanic membranes. Nose: No running nose. Throat: No hoarse voice, odor, or inflammation.

· SKIN: No bruises, cuts, dyspigmentation, or burns.

· VITAL SIGNS: H, 5’5”. W, 139lbs. BMI 23.1. T 990F. RR 18. BP 124/80mmHg left arm cuff while seated.

· CARDIOVASCULAR: No gallops or murmurs.

· RESPIRATORY: All lung fields are clear to auscultation.

· GASTROINTESTINAL: Hyperactive bowel sounds.

· GENITOURINARY: Not assessed.

· NEUROLOGICAL: No tremors or coordination problems noted. No syncope or dizziness. No ambulation difficulties.

· MUSCULOSKELETAL: No bone fractures, or ambulation difficulties.

· HEMATOLOGIC: No bleeding problems. No bruises or cuts, jaundice, or scarring.

· LYMPHATICS: No hair loss, baldness, or swollen lymph nodes.

· ENDOCRINOLOGIC: No chills or sweating.

Diagnostic results:

CBC- Normal

Urine drug tests- Alcohol, marijuana, cocaine, heroin- Within normal limits

Assessment:

Mental Status Examination: L.L. is a 65 years old African American woman appearing to be of the stated age. The patient is fully awake, alert, and oriented x4. She is appropriately dressed and well groomed. She is cooperative and maintains good eye contact with the practitioner. Speech is normal, mood is euthymic, and affect is congruent. Thought processes are goal-directed, organized, and logical, thought content is future-oriented and without suicidal, homicidal, or self-harm intentions. Her insight, judgement, long-term, and short-term memory are intact. Attention and concentration are adequate for the session, language (naming and repeating phrases) is intact, and her fund of knowledge is average.

Diagnostic Impression:

Agoraphobia

The DSM-5 defines agoraphobia as anxiety of being in situations or places where one might be embarrassed and not be able to escape (Roest et al., 2019). It is the fear of being in places where help may not be readily available in case of an undesired event. The patient admits fearing going out and driving from her comfort zone. Her fear is related to an encopresis incidence experienced in the early 2000s. She states that she observes precautions such as asking where the bathrooms are whenever she is outside. According to the DSM-5 criteria, agoraphobia is characterized by marked fear of being in open spaces, standing in line, outside home alone, using public transportation, or being in enclosed spaces (Roest et al., 2019). In addition, she actively avoids traveling to these places. These situations provoke anxiety in the patient, and this is often out of proportion to the actual danger posed by the situation. The anxiety has been persistent and has increased gradually over the last 20 years. The patient meets the criteria for two of these symptoms, making it a positive diagnosis.

Social Anxiety Disorder

According to the DSM-5 criteria, social anxiety disorder (SAD) is characterized by marked fear of being in social situations (Park & Kim, 2020). Often, patients experience significant fear when expecting to be in social situations such as family gatherings, meetings, or in crowded places. L.L. admits having significant fear of being in public places and leaving her house. Specific symptoms of SAD include feeling distressed due to social interactions, fear of specific social settings, fear of social rejection due to anxiety, avoidance of social interactions, and the fear is not related to underlying health issue, drug abuse, or substance use. The patient’s fear is attributed to bowel problems and the associated encopresis incident experiences about 20 years ago. She fears being lost and losing control.

Major Depressive Disorder 

Patients with major depressive disorder (MDD) exhibit significant distress and declined interest in things they used to enjoy (Tolentino & Schmidt, 2018). The patient reports feeling distressed due to the inability to leave her home. She is also unable to enjoy going out and traveling as she used to when she was younger. Other symptoms of MDD described in the DSM-5 include diminished concentration and attention, weight changes, appetite changes, suicidal ideations, anhedonia, hopelessness and worthless, guilt, and irritability. The patient does not demonstrate the (at least) five symptoms as required in the DSM-5 criteria for a positive MDD diagnosis.

Reflections:

If the patient were to be assessed again, it would be essential to evaluate the impact of the identified stressors, including the loss of her husband, on her life. The loss of a loved one often causes significant distress, leading to disorders such as major depression (Magill et al., 2022). Major changes in her life, including menopause and retirement, also increase the risk for psychological health issues. Asking probing questions related to these issues can help identify how they affect her wellness and develop coping strategies to reduce the risk of complications.

The patient reports not be adherent to the treatment plan. It is essential to assess the reasons for non-compliance and collaborate with her to develop measures to optimize compliance. During follow-up, practitioners should consider changes in the patient's symptoms towards achieving recovery and side effects experienced from the medications (Tasca et al., 2019). In addition, the practitioner should collaborate with the patient to develop strategies to promote compliance, including adjusting the treatment plan. 

Case Formulation and Treatment Plan: 

Pharmacotherapy. Her medications were withdrawn from her treatment plan due to non-compliance related to adverse side effects. Her PCP also advised her to withdraw the medications.

Psychotherapy, psychoeducation, and health promotion: 

Cognitive behavioral therapy is recommended for the management of agoraphobia. Patients require 6-8 sessions over a treatment course lasting about 12 weeks (Andrews et al., 2018). The practitioner helps the patient analyze her fear and develop cognitive and behavioral techniques to address the anxiety during CBT. Collaborative, the therapist and the patient identify and implement approaches that may work best for them.

Psychoeducation on treatment adherence is essential for this patient based on her history of non-compliance to treatment. This should include issues such as treatment tolerance and the risk for complications. The practitioner should encourage the patient to consult professional help when she feels ready to take medications.

Health promotion should include patient education on the benefits of regular physical activities and heart-healthy dieting in protecting against chronic health issues (Rivera-Torres et al., 2019). Due to her advanced age, regular physical activity can improve her cardiovascular health and lower the risk for the problems such as heart failure, heart attack, stroke, and diabetes. Exercises can also improve her physical wellness. Healthy dieting can improve weight management and protect against cardiometabolic health issues.

Reflection Questions

1. What strategies can be implemented in this patient to promote treatment compliance?

2. Based on the patient’s symptoms, what is the most relevant DSM-5 diagnosis?

3. Discuss different risk factors to the agoraphia and social anxety disorder.

References

Andrews, G., Bell, C., Boyce, P., Gale, C., Lampe, L., Marwat, O., … & Wilkins, G. (2018). Royal Australian and New Zealand College of Psychiatrists clinical practice guidelines for the treatment of panic disorder, social anxiety disorder and generalised anxiety disorder. Australian & New Zealand Journal of Psychiatry, 52(12), 1109-1172. https://doi.org/10.1177%2F0004867418799453

Magill, N., Walker, J., Symeonides, S., Gourley, C., Hobbs, H., Rosenstein, D., … & Sharpe, M. (2022). Depression and anxiety during the year before death from cancer. Journal of Psychosomatic Research, 158, 110922. https://doi.org/10.1016/j.jpsychores.2022.110922

Park, S. C., & Kim, Y. K. (2020). Anxiety Disorders in the DSM-5: Changes, controversies, and future directions. Anxiety Disorders, 187-196. https://doi.org/10.1007/978-981-32-9705-0_12

Rivera-Torres, S., Fahey, T. D., & Rivera, M. A. (2019). Adherence to exercise programs in older adults: informative report. Gerontology and Geriatric Medicine, 5, 2333721418823604. https://doi.org/10.1177%2F2333721418823604

Roest, A. M., de Vries, Y. A., Lim, C. C., Wittchen, H. U., Stein, D. J., Adamowski, T., … & WHO World Mental Health Survey Collaborators. (2019). A comparison of DSM‐5 and DSM‐IV agoraphobia in the World Mental Health Surveys. Depression and Anxiety, 36(6), 499-510. https://doi.org/10.1002/da.22885

Tasca, G. A., Angus, L., Bonli, R., Drapeau, M., Fitzpatrick, M., Hunsley, J., & Knoll, M. (2019). Outcome and progress monitoring in psychotherapy: Report of a Canadian Psychological Association Task Force. Canadian Psychology, 60(3), 165-177. https://psycnet.apa.org/doi/10.1037/cap0000181

Tolentino, J. C., & Schmidt, S. L. (2018). DSM-5 criteria and depression severity: implications for clinical practice. Frontiers in Psychiatry, 9, 450. https://doi.org/10.3389/fpsyt.2018.00450

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Week 9: Grand Rounds Discussion: Complex Case Study Presentation

Sherie Reed

College of Nursing-PMHNP, Walden University

NRNP 6675: PMHNP Care Across the Lifespan II

Dr. Nataliya Ishkova- Volovets

June 28, 2022

Subjective:

CC (chief complaint): "I'm starting to hear voices again."

HPI

           A.B. is a 37-year-old male with a history of Schizophrenia. The client is single with no children and resides with his parents in New Jersey. He lives in the finished basement of his parent's home that they fixed up for him. His highest level of education is two years of community college. The patient is currently unemployed and on disability for his mental health issues. The client was going to a mental health professional that retired two years ago and hasn't seen anyone since. He participates in therapy on and off with a therapist he has been visiting since he was 25. The patient was hospitalized when he was 24, and that is when he was diagnosed with Schizophrenia. His psychiatrist prescribed him Abilify, but he hasn't taken it in the past year and a half due to his psychiatrist retiring. The patient has reported auditory and visual hallucinations since he stops taking Abilify. His parents helped him find this facility to start a treatment regimen.

           

Substance Current Use: The patient denies any substance use. 

Medical History: The patient denies any medical or surgical history. 

 

·     Current Medications: The patient denies taking any medications. 

·     Allergies: No known drug or food allergies.

· Reproductive History: The client does not have any children. 

ROS: 

· GENERAL: Patient denies fevers, chills, sweats, or weight changes.

· HEENT: The patient denies any difficulty hearing and no symptoms of rhinitis or sore throat. 

· SKIN: The patient denies any rashes or skin changes. 

· CARDIOVASCULAR: The patient denies having chest pain or palpitations.

· RESPIRATORY: The patient denies dyspnea on exertion and no wheezing or cough. 

· GASTROINTESTINAL: The patient denies nausea, vomiting, diarrhea, constipation, or stomach aches.

· GENITOURINARY: The patient denies any genitourinary issues. 

· NEUROLOGICAL: The patient denies headaches, no seizures, no numbness, no tingling, and no weakness. 

· MUSCULOSKELETAL: The patient denies myalgias or arthralgias.

· HEMATOLOGIC: The patient denies ha

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