NR 546 Week 3 Case Study: Patient’s Chief Complaints: “I think I am hearing voices”
-
$25.00
| Institution | NR 546 Advanced Pharmacology: Psychopharmacology for Psychiatric Mental Health Nurse Practitioner |
| Contributor | LaToya |
|
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
A.
Select one drug to treat the diagnosis(es) or symptoms.
B.
List medication class and mechanism
of action for the chosen medication.
C.
Write the prescription in prescription format.
D.
Provide an
evidence-based rationale for the selected medication using at least one scholarly
reference. Textbooks may be used for additional references but are not the primary
reference.
E.
List any side effects
or adverse effects
associated with the medication.
F.
Include any required
diagnostic testing. State the time frame for this testing (testing is before medication initiation or q 3 months,
etc.). Includes normal
results range for any listed laboratory tests.
G. Provide a minimum of three appropriate medication-related teaching points for the client and/or family.
| Instituition / Term | |
| Term | Year 2022 |
| Institution | NR 546 Advanced Pharmacology: Psychopharmacology for Psychiatric Mental Health Nurse Practitioner |
| Contributor | LaToya |
