NR 546 Week 5 Case study
Subjective Objective
, The client is a 29-year-old, Latino Physical Examination:
single male referred by his primary
Height: 67″, weight: 200 lb.
care provider for a psychiatric
evaluation at an outpatient clinic. General: Well-nourished male appears stated age
Mental status exam:
Client’s Chief Complaints:
Appearance: appropriate dress for age and situation, well
“I think I might be depressed.”
nourished, eye contact poor, slumped posture
History of Present Illness Alertness and Orientation: alert, fully
oriented to person‚ place‚ time‚ and
The client reports increasingly depressive
situation,
symptoms with onset 3 months ago. He is
experiencing stress related to being Behavior:
unemployed, financial strain and needing to
cooperative
sell his home quickly because he cannot
afford the mortgage. He reports depressed Speech: soft, flat
mood, low energy, low motivation,
Mood: depressed
anhedonia, poor concentration, loneliness,
low self- esteem, hopelessness, and Affect: constricted, congruent with stated
decreased appetite with 12 lb. weight loss
moodThought Process: logical‚ linear
over the past month. He reports difficulty
falling and staying asleep due to anxiety and Thought content: Self-defeating thoughts, endorses
restlessness, difficulty making decisions and thoughts suggestive of low self-worth. No thoughts of
self-isolation. He endorses anxiety related to suicide‚ self-harm‚ or passive death wish
the stressors reported above, as manifested
Perceptions: No evidence of psychosis, not responding to
by restlessness, worry, and muscle tension.
internal stimuli, reports auditory hallucinations.
He reports that his current mental state is
impeding his ability to apply for new Memory: Recent and remote WNL
employment and prepare his home for the
Judgement/Insight: Insight is fair,
impending sale.
Judgement is fair
Past psychiatric history: no previous history,
this is the client’s first contact with a mental Attention and observed intellectual functioning: Attention
health provider. intact for purpose of assessment. Able to follow
Subjective Objective
, The client is a 29-year-old, Latino Physical Examination:
single male referred by his primary
Height: 67″, weight: 200 lb.
care provider for a psychiatric
evaluation at an outpatient clinic. General: Well-nourished male appears stated age
Mental status exam:
Client’s Chief Complaints:
Appearance: appropriate dress for age and situation, well
“I think I might be depressed.”
nourished, eye contact poor, slumped posture
History of Present Illness Alertness and Orientation: alert, fully
oriented to person‚ place‚ time‚ and
The client reports increasingly depressive
situation,
symptoms with onset 3 months ago. He is
experiencing stress related to being Behavior:
unemployed, financial strain and needing to
cooperative
sell his home quickly because he cannot
afford the mortgage. He reports depressed Speech: soft, flat
mood, low energy, low motivation,
Mood: depressed
anhedonia, poor concentration, loneliness,
low self- esteem, hopelessness, and Affect: constricted, congruent with stated
decreased appetite with 12 lb. weight loss
moodThought Process: logical‚ linear
over the past month. He reports difficulty
falling and staying asleep due to anxiety and Thought content: Self-defeating thoughts, endorses
restlessness, difficulty making decisions and thoughts suggestive of low self-worth. No thoughts of
self-isolation. He endorses anxiety related to suicide‚ self-harm‚ or passive death wish
the stressors reported above, as manifested
Perceptions: No evidence of psychosis, not responding to
by restlessness, worry, and muscle tension.
internal stimuli, reports auditory hallucinations.
He reports that his current mental state is
impeding his ability to apply for new Memory: Recent and remote WNL
employment and prepare his home for the
Judgement/Insight: Insight is fair,
impending sale.
Judgement is fair
Past psychiatric history: no previous history,
this is the client’s first contact with a mental Attention and observed intellectual functioning: Attention
health provider. intact for purpose of assessment. Able to follow
