UNFOLDING Clinical Reasoning Case Study
History of Present Problem:
Jeremy Brown is a 30-year-old Caucasian male who was brought to the emergency department (ED) by the police after
being involved in an altercation at work. Jeremy was at work today, and he threw a large piece of metal at a coworker
and began yelling, “Stop following me, I know what you have been up to!” Because Jeremy was very agitated and upset,
and the police were called.
Since arriving in the ED, he has been agitated, displaying rapid pressured speech and repeating the phrases he hears
the police and others in the ED said. Jeremy reported that he recently stopped taking his risperidone and citalopram
because he believed his coworkers have been breaking into his house and poisoning his medications. Jeremy’s manager
reports that he was diagnosed with schizophrenia five years ago.
Personal/Social History:
Jeremy graduated from college with a 4.0 GPA and was in his first year at law school when he
experienced the first episode of acute mental illness and was diagnosed with schizophrenia. He had to drop out of law
school at age 24 and never finished. Jeremy lives at home with his mother and father and recently broke up with his
girlfriend.
Jeremy likes his job at the foundry but feels he is a disappointment because both of his sisters are lawyers, as is his
father. Jeremy has no close friends and only a few acquaintances. Jeremy’s mental health had been stable up until the
last three months. He has been feeling more paranoid the past three months and experienced a dramatic increase in
symptoms when he stopped taking all of his medications one month ago.
What data from the histories are RELEVANT and have clinical significance to the nurse?
RELEVANT Data from Present Problem: Clinical Significance:
Patient was brought into ED by police after Patient was unable to control his paranoia and became
altercation at work, threw a large piece of physical and dangerous to self and others. Patient isn't
metal at coworker and yelled "Stop follwoing
me, I know what you have been up to!"
taking medications making him unstable from baseline.
Seems agitated and upset, rapid pressured Patient was diagnosed 5 years ago, this history will help plan
speach and repeating the phrases he hears. of care and medication recomendation.
Stopped taking medication, paranoid
someone is poisoning his meds. Manager
reports that he was diagnosed with
schozophrenia five years ago.
RELEVANT Data from Social History: Clinical Significance:
Patient was a law student when he first Patient feels disappointed that everyone is a lawyer exept for
experienced an acute mental illness and diagnosed
with schizophrenia. Dropped out of law school. him. Patient lives with parents and recently could be in
Lives at home with his mother and father and distress due to relationship ending. Patient stopped taking
recently broke up with his gf. Feels disapointed medications a month ago creating unstability.
because both his sisters & father is a lawyer.
Stable mental health up to 3 months ago. Stopped
taking medications 1 month ago.
Patient Care Begins:
Current VS: P-Q-R-S-T Pain Assessment:
T: 97.8 F/36.6 C (oral) Provoking/Palliative: Denies pain
P: 100 (regular) Quality:
R: 22 (regular) Region/Radiation:
BP: 130/84 Severity:
O2 sat: 98% room air Timing:
© 2018 Keith Rischer/www.KeithRN.com
, What VS data are RELEVANT and must be interpreted as clinically significant by the nurse?
RELEVANT VS Data: Clinical Significance:
WNL Patients VS are WNL could indicate any other health issues and mental
health status.
Current Assessment:
GENERAL Calm, body relaxed, no grimacing, appears to be resting comfortably
APPEARANCE:
RESP: Breath sounds clear with equal aeration bilaterally ant/post, nonlabored respiratory effort
CARDIAC: Pink, warm & dry, no edema, heart sounds regular with no abnormal beats, pulses strong,
equal to palpation at radial/pedal/post-tibial landmarks, brisk cap refill
NEURO: Alert & oriented to person, place, time, and situation (x4)
GI: Abdomen flat, soft/nontender, bowel sounds audible per auscultation in all four quadrants
GU: Voiding without difficulty, urine clear/yellow
SKIN: Skin integrity intact, skin turgor elastic, no tenting present
Mental Status Examination:
APPEARANCE: Diaphoretic, uncombed shoulder-length, somewhat greasy hair; cloths are stained and torn.
Cooperative with the admission process.
MOTOR BEHAVIOR: No abnormal muscle movements
SPEECH: Rapid and pressured. Client often repeats words and phrases he hears others in the
emergency room say. The client says, “He was brought to the emergency room” over and
over again when he is not distracted or engaged in conversation.
MOOD: Reports feeling very upset
AFFECT: Becomes agitated/anxious when talking about his co-workers and his meds; guarded and
suspicious, mood and affect are congruent.
THOUGHT PROCESS: Linear but irrational
THOUGHT CONTENT: Displays paranoid delusions that coworkers are following him to hurt him and are poisoning
his medication.
PERCEPTION: Denies auditory or visual hallucinations, or feelings of depersonalization (feeling detached
from self or environment)
INSIGHT: Poor-believes he was brought in to the emergency room for protection from his coworkers
JUDGMENT: Poor-stopped meds and is acting aggressively towards co-workers
COGNITION: Alert and oriented times 4 (person, place, time and purpose), is easily distracted
INTERACTIONS: Is in good control when talking with nursing staff, his boss, and police.
SUICIDAL/HOMICIDAL: Denies any suicidal thoughts or thoughts of self-harm. Stated he wants to “punish” his co-
workers.
What assessment data are RELEVANT and must be interpreted as clinically significant by the nurse?
RELEVANT Assessment Data: Clinical Significance:
Seems relaxed, breath sounds Patients genral assessment seems WNL, client could be
clear, A&Ox4, GI: bowel sounds expereinceing altered mental status symptoms
audible in all four quadrants, skin: in
tact
© 2018 Keith Rischer/www.KeithRN.com
History of Present Problem:
Jeremy Brown is a 30-year-old Caucasian male who was brought to the emergency department (ED) by the police after
being involved in an altercation at work. Jeremy was at work today, and he threw a large piece of metal at a coworker
and began yelling, “Stop following me, I know what you have been up to!” Because Jeremy was very agitated and upset,
and the police were called.
Since arriving in the ED, he has been agitated, displaying rapid pressured speech and repeating the phrases he hears
the police and others in the ED said. Jeremy reported that he recently stopped taking his risperidone and citalopram
because he believed his coworkers have been breaking into his house and poisoning his medications. Jeremy’s manager
reports that he was diagnosed with schizophrenia five years ago.
Personal/Social History:
Jeremy graduated from college with a 4.0 GPA and was in his first year at law school when he
experienced the first episode of acute mental illness and was diagnosed with schizophrenia. He had to drop out of law
school at age 24 and never finished. Jeremy lives at home with his mother and father and recently broke up with his
girlfriend.
Jeremy likes his job at the foundry but feels he is a disappointment because both of his sisters are lawyers, as is his
father. Jeremy has no close friends and only a few acquaintances. Jeremy’s mental health had been stable up until the
last three months. He has been feeling more paranoid the past three months and experienced a dramatic increase in
symptoms when he stopped taking all of his medications one month ago.
What data from the histories are RELEVANT and have clinical significance to the nurse?
RELEVANT Data from Present Problem: Clinical Significance:
Patient was brought into ED by police after Patient was unable to control his paranoia and became
altercation at work, threw a large piece of physical and dangerous to self and others. Patient isn't
metal at coworker and yelled "Stop follwoing
me, I know what you have been up to!"
taking medications making him unstable from baseline.
Seems agitated and upset, rapid pressured Patient was diagnosed 5 years ago, this history will help plan
speach and repeating the phrases he hears. of care and medication recomendation.
Stopped taking medication, paranoid
someone is poisoning his meds. Manager
reports that he was diagnosed with
schozophrenia five years ago.
RELEVANT Data from Social History: Clinical Significance:
Patient was a law student when he first Patient feels disappointed that everyone is a lawyer exept for
experienced an acute mental illness and diagnosed
with schizophrenia. Dropped out of law school. him. Patient lives with parents and recently could be in
Lives at home with his mother and father and distress due to relationship ending. Patient stopped taking
recently broke up with his gf. Feels disapointed medications a month ago creating unstability.
because both his sisters & father is a lawyer.
Stable mental health up to 3 months ago. Stopped
taking medications 1 month ago.
Patient Care Begins:
Current VS: P-Q-R-S-T Pain Assessment:
T: 97.8 F/36.6 C (oral) Provoking/Palliative: Denies pain
P: 100 (regular) Quality:
R: 22 (regular) Region/Radiation:
BP: 130/84 Severity:
O2 sat: 98% room air Timing:
© 2018 Keith Rischer/www.KeithRN.com
, What VS data are RELEVANT and must be interpreted as clinically significant by the nurse?
RELEVANT VS Data: Clinical Significance:
WNL Patients VS are WNL could indicate any other health issues and mental
health status.
Current Assessment:
GENERAL Calm, body relaxed, no grimacing, appears to be resting comfortably
APPEARANCE:
RESP: Breath sounds clear with equal aeration bilaterally ant/post, nonlabored respiratory effort
CARDIAC: Pink, warm & dry, no edema, heart sounds regular with no abnormal beats, pulses strong,
equal to palpation at radial/pedal/post-tibial landmarks, brisk cap refill
NEURO: Alert & oriented to person, place, time, and situation (x4)
GI: Abdomen flat, soft/nontender, bowel sounds audible per auscultation in all four quadrants
GU: Voiding without difficulty, urine clear/yellow
SKIN: Skin integrity intact, skin turgor elastic, no tenting present
Mental Status Examination:
APPEARANCE: Diaphoretic, uncombed shoulder-length, somewhat greasy hair; cloths are stained and torn.
Cooperative with the admission process.
MOTOR BEHAVIOR: No abnormal muscle movements
SPEECH: Rapid and pressured. Client often repeats words and phrases he hears others in the
emergency room say. The client says, “He was brought to the emergency room” over and
over again when he is not distracted or engaged in conversation.
MOOD: Reports feeling very upset
AFFECT: Becomes agitated/anxious when talking about his co-workers and his meds; guarded and
suspicious, mood and affect are congruent.
THOUGHT PROCESS: Linear but irrational
THOUGHT CONTENT: Displays paranoid delusions that coworkers are following him to hurt him and are poisoning
his medication.
PERCEPTION: Denies auditory or visual hallucinations, or feelings of depersonalization (feeling detached
from self or environment)
INSIGHT: Poor-believes he was brought in to the emergency room for protection from his coworkers
JUDGMENT: Poor-stopped meds and is acting aggressively towards co-workers
COGNITION: Alert and oriented times 4 (person, place, time and purpose), is easily distracted
INTERACTIONS: Is in good control when talking with nursing staff, his boss, and police.
SUICIDAL/HOMICIDAL: Denies any suicidal thoughts or thoughts of self-harm. Stated he wants to “punish” his co-
workers.
What assessment data are RELEVANT and must be interpreted as clinically significant by the nurse?
RELEVANT Assessment Data: Clinical Significance:
Seems relaxed, breath sounds Patients genral assessment seems WNL, client could be
clear, A&Ox4, GI: bowel sounds expereinceing altered mental status symptoms
audible in all four quadrants, skin: in
tact
© 2018 Keith Rischer/www.KeithRN.com
