NR 546 Week 5 Case Study
Subjective Objective
The client is a 21-year-old Caucasian female who Physical Examination:
presents for a psychiatric evaluation at an
Height: 63″, weight: 112 lb.
outpatient clinic.
General: female appears stated age
Patient’s Chief Complaints:
Mental status exam:
“I always get upset lately. I do not like myself.”
Appearance: appropriate dress for age and situation, hygiene fair,
History of Present Illness eye contact good.
Client reports her friend encouraged her to get Alertness and Orientation: alert, fully oriented to
help. Client has started skipping work because she person‚ place‚ time‚ and situation,
feels angry all the time “for no reason and is crying Behavior: cooperative
“all the time”. ” In the last three to four months has
experienced episodes of increased energy and Speech: normal rate and volume
productivity where she did not sleep much, lasting Mood: irritable at times
4-5 days each time. During these periods she was
shopping impulsively and overspending. She also Affect: constricted, congruent with stated mood
reported her thoughts as “racing,” and having
Thought Process: logical‚ linear
difficulty staying focused. Now she is very sad and
can get really angry at times. She has been getting Thought content: appropriate. No thoughts of suicide‚ self-
into arguments with her roommate which is not like harm‚ or passive death wish
her.
Perceptions: No evidence of psychosis, not responding to internal
Past psychiatric history: The client was treated a stimuli, reports auditory hallucinations.
year ago by a psychiatrist for complaints of “anxiety,
Memory: Recent and remote WNL
depression, obsessive–compulsive disorder, and
attention deficit disorder.” Has a history of passive Judgement/Insight: Insight is fair, Judgement is fair
suicidal thoughts thinking “What if I were dead?”
Attention and observed intellectual functioning: Attention intact
Was prescribed Fluoxetine which helped a little, but
for purpose of assessment. Able to follow questioning.
she stopped taking the medication 4 months age
when she felt better. No hospitalizations. Fund of knowledge: Good general fund of knowledge and
vocabulary
Past Medical History: Overall healthy, reports some
food allergies. Current medications: birth control Musculoskeletal: normal gait
pill (does not remember the name).
Family History
Father is alive and well.
Mother is alive, has anxiety and depression
has 2 sisters, both healthy, one has ADHD
Social History
This study source was downloaded by 100000884024057 from CourseHero.com on 11-30-2024 02:26:14 GMT -06:00
7.22
https://www.coursehero.com/file/163294228/NR546-wk-5-case-study-July-22-docx/
Subjective Objective
The client is a 21-year-old Caucasian female who Physical Examination:
presents for a psychiatric evaluation at an
Height: 63″, weight: 112 lb.
outpatient clinic.
General: female appears stated age
Patient’s Chief Complaints:
Mental status exam:
“I always get upset lately. I do not like myself.”
Appearance: appropriate dress for age and situation, hygiene fair,
History of Present Illness eye contact good.
Client reports her friend encouraged her to get Alertness and Orientation: alert, fully oriented to
help. Client has started skipping work because she person‚ place‚ time‚ and situation,
feels angry all the time “for no reason and is crying Behavior: cooperative
“all the time”. ” In the last three to four months has
experienced episodes of increased energy and Speech: normal rate and volume
productivity where she did not sleep much, lasting Mood: irritable at times
4-5 days each time. During these periods she was
shopping impulsively and overspending. She also Affect: constricted, congruent with stated mood
reported her thoughts as “racing,” and having
Thought Process: logical‚ linear
difficulty staying focused. Now she is very sad and
can get really angry at times. She has been getting Thought content: appropriate. No thoughts of suicide‚ self-
into arguments with her roommate which is not like harm‚ or passive death wish
her.
Perceptions: No evidence of psychosis, not responding to internal
Past psychiatric history: The client was treated a stimuli, reports auditory hallucinations.
year ago by a psychiatrist for complaints of “anxiety,
Memory: Recent and remote WNL
depression, obsessive–compulsive disorder, and
attention deficit disorder.” Has a history of passive Judgement/Insight: Insight is fair, Judgement is fair
suicidal thoughts thinking “What if I were dead?”
Attention and observed intellectual functioning: Attention intact
Was prescribed Fluoxetine which helped a little, but
for purpose of assessment. Able to follow questioning.
she stopped taking the medication 4 months age
when she felt better. No hospitalizations. Fund of knowledge: Good general fund of knowledge and
vocabulary
Past Medical History: Overall healthy, reports some
food allergies. Current medications: birth control Musculoskeletal: normal gait
pill (does not remember the name).
Family History
Father is alive and well.
Mother is alive, has anxiety and depression
has 2 sisters, both healthy, one has ADHD
Social History
This study source was downloaded by 100000884024057 from CourseHero.com on 11-30-2024 02:26:14 GMT -06:00
7.22
https://www.coursehero.com/file/163294228/NR546-wk-5-case-study-July-22-docx/
