In this assignment, you will review the Psychosis Interactive Case Study patient scenario and analyze the data to determine the health status of the patient.
Select the Patient Subjective Information tab. Within this tab, you will be able to watch a video to gain more insight regarding the patient as well as view important patient details.
For this assignment, you will
Your case study write up should include specific reference to relevant guidelines and other clinical information. The national guidelines should also be considered within treatment plans.
When you have completed viewing the patient information, download the Comprehensive Case Study Paper Template (Word) from the assignment page in Moodle. Use this document to complete the assignment and then submit it to the assignment drop box. Additionally, there is an Exemplar document for review to help guide your case study write up.
Substance Use: Denies any use of nonprescription medication, denies use of tobacco or ETOH.
Trauma History: Denies any past history of trauma.
Spirituality: Spiritual, no specifics.
Family History of Psychiatric Mental Illness: Unknown
Family History of Suicide: Denied
Last immunization: Flu vaccine, 2 years ago
No recent travel outside the US.
Last Gyn exam and PAP, ASCUS with negative HPV co-testing 8 months ago at Primary Care Provider-f/u pap due in 3 years. Last PCP visit, 8 months ago for possible contraception initiation to aid with PCOS symptoms.
Regularly wears seatbelt when riding as passenger.
No weapons in the home.
Reports usual health as “good.” Denies fever, chills, weight changes.
Denies chest pain, palpitations.
Denies polyuria, polydipsia, and polyphagia. Denies cold-heat intolerance, nervousness, change in appetite, weight gain, or change in skin. Reports hx of PCOS, reports adherence to Metformin therapy but not sure why taking.
Complains of increase in facial hair to chin and at side of face. Also complains of “acne” to cheeks and around nose. Lupus rash was present two years ago, no flare-up since.
Denies coordination problems, numbness, tingling. Denies seizures or frequent headaches. Not aware of memory problem. Denies h/o head injury.
Anhedonia, constricted affect, presence of significant stressors.
Hypersomnia, difficulty getting up in the morning, no middle-night awakening.
Inability to successfully carry out goal-directed behavior, social isolation.
Low self-esteem, anxious in public, lack of motivation, guilt over diagnosis.
No increased energy, feeling fatigued.
Difficulty concentrating when hearing voices.
No increased or decreased appetite.
Audio hallucinations, no command voices, voices are distracting. Sometimes unable to distinguish if hallucination or actual people around her. Afraid co-workers and family members can read her thoughts. Visual and tactile hallucinations now occurring daily—spiders or bugs crawling on arms and legs.
No self-inflicted injuries, no frequent thoughts of death, no suicidal thoughts, no suicidal intent, no past suicide attempts.
No homicidal thoughts, sometimes wants to “kill” the voices and spiders.
Withdrawn, poor work performance, limited interpersonal relationship problems. Stopped taking meds after getting new job and feeling like she was better.
| Ht | 61 inches |
|---|---|
| Wt | 232 lbs. |
| T | 99.9 |
| P | 76 |
| R | 18 |
| BP | 134/80 |
| BMI | calculate at every visit |
General appearance same as stated age, disheveled appearance with fair personal hygiene; no inappropriate clothing, no bizarre personal appearance, no body odor.
Remainder of physical exam deferred during psychiatric mental health assessment.
A&Ox2 (person and place only). Disheveled appearance. No spontaneous speech, but answers questions when asked.
Cooperative, distracted, at times seems to be responding to internal stimuli (voices) by suspiciously looking about the room. No hostile nor disinterested attitude, no heightened startle, no hypervigilance.
No tremors or tics; normal gait and stance; no involuntary movements.
Minimal, slowed speech, normal volume.
Anhedonia, constricted affect, anxiety at times related to suspicions and voices.
Constricted.
No language abnormalities; speech fluent, but minimal, normal sentence structure.
Patient oriented x 2; no disorientation, short-term memory impairment, reduced abstraction ability, some cognitive functioning.
No deficiency on evaluation of connectedness, organized.
Audio hallucinations, paranoid ideations, thought insertion, no suicidal ideation, nor homicidal ideations.
Impaired insight, impaired judgment, poor problem-solving.
***No recent labs on file.