NR 546 WEEK 3 CASE STUDY AND NR 546 WEEK 3 DISCUSSION UPDATED 2023
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Course
NR 546
Institution
NR 546
NR 546 WEEK 3 CASE STUDY AND NR 546 WEEK 3 DISCUSSION
UPDATED 2023
CASE STUDY
Subjective Objective
Patient’s Chief Complaints:
“I think I am hearing voices”
History of Present Illness
LM states she believes her boyfriend is cheating on
her, which her boyfriend denies. She states she c...
NR 546 WEEK 3 CASE STUDY AND NR 546 WEEK 3 DISCUSSION UPDATED 2023 CASE STUDY Subjective Objective Patient’s Chief Complaints: “I think I am hearing voices” History of Present Illness LM states she believes her boyfriend is cheating on her, which her boyfriend denies. She states she can hear two women talking about her boyfriend and her, how they have sex with her boyfriend and how LM isn’t good enough for him. This has been occurring for a few weeks. Her boyfriend has been caught cheating in the past and she is now wondering if the women she hears talking about her boyfriend are real or not. She has not asked anyone else if they can hear the women talking because what they have to say is so negative. She hears these women taking mostly at home with her boyfriend but sometimes she hears them when she is out too, especially when she is out in public with her boyfriend. Physical Examination: General Alert appropriately dressed Caucasian female in no apparent distress. She appears older than her stated age. Vital Signs: BP-116/76, T-98.6F, P-86, RR-20, SpO2: 100% Wgt 170 lbs., Ht 5’6” Past psychiatric history: None Past Medical History: Occasional headaches, overweight Family History • Father is deceased, died by suicide • Mother is alive and well • One brother has history of substance abuse Social History • Lives with boyfriend and his son • States she does not have any friends • unemployed • High school graduate • Nonsmoker • Drinks socially, 1-2 times a week • Several cups of coke or sweet tea during the day • vapes CBD 1-2 times a week. • no formal exercise Review of Systems • occasional headache, relieved with acetaminophen • appetite good, weight stable • sleeps 7-9 hours at night Allergies: NKDA Mental status exam: • Cranial nerves II-VIII intact • Gait steady • Denies headache and dizziness Appearance: appropriate dress for age and situation, well nourished, eye contact poor, No apparent distress Alertness and Orientation: fully oriented to person‚ place‚ time‚ and situation, Alert Behavior: cooperative Speech: soft, flat Mood: euthymic Affect: constricted, congruent Thought Process: logical‚ linear Thought content: No thoughts of suicide‚ self-harm‚ or passive death wish Perceptions: No evidence of psychosis, not responding to internal stimuli, reports auditory hallucinations. Memory: Recent and remote WNL Judgement/Insight: Insight is fair, Judgement is fair Attention and observed intellectual functioning: Attention intact for purpose of assessment. Fund of knowledge: Good general fund of knowledge and vocabulary Musculoskeletal: normal gait and station Diagnosis: F20.9 Schizophrenia, unspecified Psychopharmacology Questions: see the assignment rubric
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