Nursing Case Studies
#1 Chief Complaint: Anxiety and substance dependence
History of Present Illness
AB is a 22 year old college student ina local college. He lives on campus, sharing a room with two other male students. He is supported by his parents, who live out of state. AB has presented at the clinic with complaining of anxiety, insomnia, suicidal thoughts, and lack of appetite. He feels stressed out due to his inability to manage his finances, as he operates on a slim stipend provided by his parents. He is asking for an intervention that will enable him deal with the anxiety, and also help him overcome his dependency on substance use.
Psychiatric History
No hospitalization. He has attempted to self medicate with anti-anxiety medicine (Prozac).
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Family History
AB’s family is not nearby, meaning that he generally has to fend for himself. He is not in an intimate relationship at the moment, but broke up with his girlfriend recently. He is an introvert who prefers his own company. No family history of mental illness.
Alcohol/Substance Abuse/ Dependence (History and Current)
Has admitted to limited marijuana and alcohol use. He is also a smoker.
Medical History
None
Medications/Herbal/OTC:
Prozac 20 mg po daily
Allergies
NKA
Problem List:
296.32 (F33.1) -Major depressive disorder, recurrent, moderate
Temp: 98.9 F (oral)
BP: 134/81
HR: 81
RR: 20
WT: 172 Lbs.
HT: 5ft 10”
Mental/Functional:
Normal
Mental Status Exam:
Appearance: Attire was appropriate , good hygiene
Behavior: cooperative/ calm
Speech: RRR
Eye contact: fair
Attention span: distracted
Mood: "I am stressed out"
Affect: congruent with mood
Thought content: Denies si/hi/hallucinations or delusions
Thought process: linear
Motor: normal
Good insight, cooperative and good judgement
Orientation: Oriented to person, place, time, event/s
Treatment Plan
•Continue with fluoxetine (Prozac) 20 mg po daily.
•Continue psychotherapy
•The patient was recommended for rehabilitation services to curb substance dependence.
•Risk and benefits Alternative to medication discussed.
•AB is accepting of treatment and has verbalized understanding.
•Steps will be done by the patient, with the nurse’s support, to contact his parents more regularly for emotional support.
•AB acknowledged understanding of emergency resources such as going to ER or dialing 911if experiencing suicidal/homicide ideation.
•Will return to clinic in two weeks or as needed for a follow up on medication regimen, assess for suicidality and side effects.
#2 Chief Complaint: “My friends and workmates are constantly criticizing me"
History of Present Illness
DJ is a white female. She presented to clinic stating that she feels under siege from society. She feels people are up to no good, scheming to make her lose her job in a local retail store, constantly tearing into her for poor personal hygiene, and failing to understand her personality. She has not been taking any medication, since she does not consider herself sick. She just feels the need to talk to someone to vent her frustrations.
Psychiatric History
Has not had a previous Schizophrenia diagnosis. She however reveals she has been in her present condition for around 1 year.
Family History
Father has Schizophrenia
Social/Developmental History
She lives with her parents, and works in a local store.
She has been in numerous altercations with her colleagues in recent weeks. No previous arrests.
Alcohol/Substance Abuse/ Dependence (History and Current)
Denies drug, alcohol and tobacco use.
Medical History
Denies previous medical interventions to manage her condition
Medications/Herbal/OTC:
None
Allergies
None
Temp: 98.9 F (oral)
BP: 118/72
HR: 86
RR: 18
WT: 135Lbs.
HT: 5ft 6"
Diagnosis:
Schizophrenia 293.82 (F06.0)
Mental Status Examination
Alertand Oriented: x4
Appearance: haggard and unkempt appearance
Behavior: calm & cooperative.
Eyecontact: Fair.
Psychomotoractivity: No EPS.
Speech: normal rate, rhythm, tone.
Thought form:Disorganized loose associations
Thought Content: AH present, denies VH.
Mood: paranoid, highly sensitive to negative remarks about her appearance or conduct
Affect: reactive odd.
Perception: regular hallucinations.
Suicidal Ideation: none present.
Homicidal Ideation: none
Insight/ Judgement: poor
Memory: Intact
Attention/ Concentration: Intact
Fund of Knowledge: average
Treatment Plan
•Prescription given for Invega Sustenna IM 156mg monthly
quetiapine 400mg po qhs
•Referal to psychotherapy.Stress reduction through exercise, meditation therapy, biofeedback and mindfulness cognitive behavioral therapy (CBT).
•Encouraged to report any side effects, possible weight gain discussed.
•Verbal and written education on schizophrenia and medication was provided.
•Risk and benefits Alternative to medication discussed.
•Patient is accepting of treatment and has verbalized understanding.
•Safety plan discussed.
•Acknowledged understanding of emergency resources such as going to ER or dialing 911if experiencing suicidal/homicide ideation.
•Will agrees return to clinic in one month or as needed for a follow up on medication regimen, assess for suicidality and side effects.
##3 Chief Complaint: ‘’I am able to attend my children's school concerts and take them to the movies without having panic attacks '’
History of present Illness
Jim is a married 29-year-old black male. He is an army veteran, serving for several years in Afghanistan. He referred by his primary care provider for anxiety 8 weeks ago.
The patient has talked of various traumatic experiences he went through during his years of service. He survived numerous explosions, an attempted kidnapping, and several gunfights. After returning, he has been having severe nightmares, and episodes of severe anxiety. His wife is highly stressed by this issue, which has compromised their relationship. He is on his first visit to the clinic.
Psychiatric History
The patient has never been hospitalized for the condition.
He is currently attending therapy. Pt has been on Paxil 10mg po daily for 8 weeks and feels it helps with his panic disorder
Family History
Received an honorable discharge after serving the country. His relationship with his family is amicable. He is immensely proud of his service, and holds strong views about the need to take care of veterans.
Alcohol/Substance Abuse/ Dependence (History and Current)
Claims to be a social drinker, but is addicted to tobacco.
Medical History
The only intervention so far has been Paxil, which he feels is working.
Medications/Herbal/OTC:
Paxil po 10 mg daily
Allergies
NKA
Problem List:
PTSD - 309.81 (F43.10) Panic disorder (episodic paroxysmal anxiety)
Temp: 98.2 F(oral)
BP: 132/84
HR: 62
RR: 18
WT: 80 kg.
HT: 6ft 3”
Mental/Functional:
Normal
Mental Status Exam
Appearance: Good hygiene and well groomed
Behavior: cooperative
Speech: regular unimpaired
Eye contact: normal
Attention span: non distracted
Mood: anxious
Affect: content process appropriate
Thought content: has periodic hallucinations or delusions
Thought process: linear
Motor: calm
Good insight, cooperative and good judgement
Orientation: Oriented to person, place, time, event/s
Treatment Plan
•Will continue Paxil 10mg po daily.
•Continue psychotherapy/ exercise
•Reinforcement of verbal and written education on panic disorder and medication was provided.
•Risk and benefits Alternative to medication discussed.
•Pt is accepting of treatment and has verbalized understanding.
•Safety plan discussed.
•Pt acknowledged understanding of emergency resources such as going to ER or dialing 911 if experiencing suicidal/homicide ideation.
•Will return to clinic in one month or as needed for a follow up on medication regimen, assess for suicidality and side effects.
#4 Chief Complaint: “I cant stop worrying about my baby’s wellbeing.”
History of Present Illness
Anne is a 25 year old black female who has recently given birth. She presents to the clinic for her first visit since giving birth 2 weeks ago. She intimates that she cannot stop worrying about her baby, since she claims to have been under so much stress when she was pregnant and after, having lost her job in the current pandemic. She can barely sleep. She is ever sad or anxious, and feels sorry for being incapable of caring for the baby properly.
Psychiatric History
She has no prior psychiatric diagnoses.
Family History
Mother: Alive, with no history of depression
Father: Alive, with no history of depression.
Alcohol/Substance Abuse/ Dependence (History and Current)
Denies
Medical History
None that is relevant to depression
Medications/Herbal/OTC:
She has been self-medicating with Selective serotonin reuptake inhibitors.
Allergies
NKA
Mental Status Exam/Cognitive History
Pt is orientated to time, place, person and situation
Appearance is well groomed
Mood is "I feel I am letting my baby down”
Speech is normal, volume is normal
Intellectual functioning is unimpaired
Eye contact is normal.
Facial expression and general demeanor is anxious.
Has experienced suicidal ideas or intentions, as well as wanting to harm the baby.
Insight into problems appears fair.
Judgment appears fair.
Temp: 98.3 F (oral)
BP: 122/82
HR: 79
RR: 18
WT: 152Lbs.
HT: 5ft 7”
Treatment Plan
•Pt will continue Selective serotonin reuptake inhibitors, do not discontinue medication abruptly.
•Report sore throat, fever, malaise, yellow skin, bleeding, bruising, persistent vomiting or headaches, rapid heart rate, seizures, stiff neck, sexual dysfunction, agitation, tension headache, autonomic changes (dry mouth, sweating, weight changes, nausea, loose BM) and chest pain to physician.
•If having abdominal pain, fever, tachycardia, high blood pressure, delirium, muscle spasms or irritability, (SEROTONIN SYNDROME) Call 911.
•Continus of group therapy/Individual therapy, stress reduction through exercise, meditation therapy, biofeedback and mindfulness cognitive behavioral therapy (CBT) is recommended.
•Verbal and written medication education reinforced.
•Risk and benefits Alternative to medication discussed.
•Pt continues acceptance of treatment.
•Safety plan discussed.
•Pt acknowledged understanding of emergency resources such as going to ER or dialing 911if experiencing suicidal/homicide ideation.
•Will return to clinic in 2 weeks or as needed for a follow up on medication regimen, assess for suicidality and side effects
#5 Chief Complaint: “Rose just can’t eat. She is obsessed about her body weight.”
HPI :Jane is a 16-year-old white female. She was brought into initial clinic visit by her mother and father for consultation. Her mother reports that Jane does not eat more than a meal a day, which is usually way below the portions she would be expected to take. She has severe mood swings, and engages in exercise that the parents consider to be excessive. She has been exhibiting impulsive behavior, such as disappearing from school, and spending too much time online on weight loss video channels. Jane also says she feel alone, unloved, and misunderstood by her friends.
Psychiatric History
Denies psychiatric hx and hospitalizations.
No family hx
Alcohol/Substance Abuse/ Dependence (History and Current)
Denies
Medical History
Denies
Medication
Denies
Social/ Developmental History
Lives with mother and father in Pasadena CA. She is the only child.
Alert and Oriented: x4
Appearance: Appropriately dressed/well groomed.
Attitude: cooperative but irritable.
Eye contact: avoidant, intentionally rolling eyes.
Psychomotor activity: agitation.
Speech: loud, angry and emotional.
Thought process: circumstantial and tangential.
Thought Content: Denies suicidal or homicidal ideas
Mood: angry.
Affect: congruent with mood.
Perception: No Hallucinations.
Insight: fair.
Judgement: fair
Diagnosis
F50.0 Anorexia nervosa unspecified.
Temp: 98.2 F (oral)
BP: 118/79
HR: 81
RR: 18
WT: 104 Lbs.
HT: 5ft 4”
Treatment Plan
•recommended antidepressant medications for two weeks.
•Refer group and individual psychotherapy/ dialectical behavioral therapy (DBT)
•Alternative to therapy discussed- parents declined at this time.
•Pt and parents are accepting of therapy.
•Safety plan discussed.
•Pt acknowledged understanding of emergency resources such as going to ER or dialing 911if experiencing suicidal/homicide ideation.
•Will return to clinic in two weeks or as needed for a follow up and reassess for medication and progress
