NR 546 Week 3, 5, 6, 7 Case Study
Merged Together
Subjective Objective
Physical Examination: General
Patient’s Chief Complaints: Alert appropriately dressed Caucasian female in no apparent
distress. She appears older than her stated age.
“I think I am hearing voices”
Vital Signs: BP-116/76, T-98.6F, P-86, RR-20, SpO2: 100%
History of Present Illness
Wgt 170 lbs., Ht 5’6”
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.
, Past psychiatric history: None Mental status exam:
Past Medical History: Occasional headaches, • Cranial nerves II-VIII intact
overweight
• Gait steady
Family History
• Denies headache and dizziness
• Father is deceased, died by suicide
Appearance: appropriate dress for age and situation, well
• Mother is alive and well
nourished, eye contact poor, No apparent distress
• One brother has history of substance abuse
Alertness and Orientation: fully oriented to
person‚ place‚ time‚ and situation, Alert
Social History
Behavior: cooperative
• Lives with boyfriend and his son
Speech: soft, flat
• States she does not have any friends
• unemployed Mood: euthymic
• High school graduate
• Nonsmoker Affect: constricted, congruent
• Drinks socially, 1-2 times a week Thought Process: logical‚ linear
• Several cups of coke or sweet tea during Thought content: No thoughts of suicide‚ self-harm‚ or passive
the day
death wish
• vapes CBD 1-2 times a week.
• no formal exercise Perceptions: No evidence of psychosis, not responding to internal
stimuli, reports auditory hallucinations.
Review of Systems
Memory: Recent and remote WNL
• occasional headache, relieved with
acetaminophen Judgement/Insight: Insight is fair, Judgement is fair
• appetite good, weight stable Attention and observed intellectual functioning: Attention intact
• sleeps 7-9 hours at night for purpose of assessment.
Allergies: NKDA 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
Merged Together
Subjective Objective
Physical Examination: General
Patient’s Chief Complaints: Alert appropriately dressed Caucasian female in no apparent
distress. She appears older than her stated age.
“I think I am hearing voices”
Vital Signs: BP-116/76, T-98.6F, P-86, RR-20, SpO2: 100%
History of Present Illness
Wgt 170 lbs., Ht 5’6”
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.
, Past psychiatric history: None Mental status exam:
Past Medical History: Occasional headaches, • Cranial nerves II-VIII intact
overweight
• Gait steady
Family History
• Denies headache and dizziness
• Father is deceased, died by suicide
Appearance: appropriate dress for age and situation, well
• Mother is alive and well
nourished, eye contact poor, No apparent distress
• One brother has history of substance abuse
Alertness and Orientation: fully oriented to
person‚ place‚ time‚ and situation, Alert
Social History
Behavior: cooperative
• Lives with boyfriend and his son
Speech: soft, flat
• States she does not have any friends
• unemployed Mood: euthymic
• High school graduate
• Nonsmoker Affect: constricted, congruent
• Drinks socially, 1-2 times a week Thought Process: logical‚ linear
• Several cups of coke or sweet tea during Thought content: No thoughts of suicide‚ self-harm‚ or passive
the day
death wish
• vapes CBD 1-2 times a week.
• no formal exercise Perceptions: No evidence of psychosis, not responding to internal
stimuli, reports auditory hallucinations.
Review of Systems
Memory: Recent and remote WNL
• occasional headache, relieved with
acetaminophen Judgement/Insight: Insight is fair, Judgement is fair
• appetite good, weight stable Attention and observed intellectual functioning: Attention intact
• sleeps 7-9 hours at night for purpose of assessment.
Allergies: NKDA 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
