Amanda Brown -- Clinical Case Study 2 1
Clinical Case Study 2: Sandra Littlefield
Amanda Brown
University of Maryland Baltimore
NURS 511: Psychiatric Mental Health Nursing for the Clinical Nurse
Leader Professor Zelda Falck
3/25/20
, `
2
Clinical Case Study 2: Sandra Littlefield
CASE TWO
Description of the patient:
Pt. S.L. is a 36-year-old Caucasian female. Pt. has been complaining of back pain and was
admitted for unrelieved back pain and further examination.
History of present illness:
Pt S.L. has been diagnosed with borderline personality disorder. Currently, the pt. was arrested
and is an inmate at the Blooming County Jail for the past week on prostitution charges. She has a
history of sexual abuse, attempted suicide, alcohol abuse, and back pain with frequent emergency
room visits. Pt states medication (acetaminophen and ibuprofen) is not enough to help endure her
pain – she rates pain 9 out of 10 on the pain scale. Pt. is convinced that stronger medication is the
only solution to her pain and is dismissive and uninterested in learning relaxation techniques.
She is angry, accusatory, and is feeling very lonely. She seems to be projecting her frustrations
onto the staff as a defense mechanism. Pt. states being in jail is very lonely, and she is not sure if
she can handle being alone like this.
Pt. S.L has stated that she no longer reads romance novels, walks, or listens to music—which she
enjoyed doing in the past to help her cope and be happy. Pt. S.L. is not coping well with her
personality disorder or her current situation in jail.
Mental status exam
Appearance: Appropriately dressed; pt is wearing orange jail jumpsuit. Hair is neatly styled in a
ponytail. Pt has large, colorful tattoos on both forearms. Piercings on nose and bridge of nose
removed.
Consciousness/Orientation: Pt. was alert and oriented X4. She was able to state her name,
DOB, date, location, and current situation. Based on her answers and awareness, she seems to be
a reliable historian.
Speech: Pt. demonstrated appropriate speech rate and sometimes with the proper volume; she
tended to get loud when she did not get her way. RN found no articulation issues during the
examination. Pt showed no presence of mutism or flight of ideas. Pt. did show circumstantiality
speech by uttering out
- “You think you are better than me because I’m in jail. Well, you are not!”
Clinical Case Study 2: Sandra Littlefield
Amanda Brown
University of Maryland Baltimore
NURS 511: Psychiatric Mental Health Nursing for the Clinical Nurse
Leader Professor Zelda Falck
3/25/20
, `
2
Clinical Case Study 2: Sandra Littlefield
CASE TWO
Description of the patient:
Pt. S.L. is a 36-year-old Caucasian female. Pt. has been complaining of back pain and was
admitted for unrelieved back pain and further examination.
History of present illness:
Pt S.L. has been diagnosed with borderline personality disorder. Currently, the pt. was arrested
and is an inmate at the Blooming County Jail for the past week on prostitution charges. She has a
history of sexual abuse, attempted suicide, alcohol abuse, and back pain with frequent emergency
room visits. Pt states medication (acetaminophen and ibuprofen) is not enough to help endure her
pain – she rates pain 9 out of 10 on the pain scale. Pt. is convinced that stronger medication is the
only solution to her pain and is dismissive and uninterested in learning relaxation techniques.
She is angry, accusatory, and is feeling very lonely. She seems to be projecting her frustrations
onto the staff as a defense mechanism. Pt. states being in jail is very lonely, and she is not sure if
she can handle being alone like this.
Pt. S.L has stated that she no longer reads romance novels, walks, or listens to music—which she
enjoyed doing in the past to help her cope and be happy. Pt. S.L. is not coping well with her
personality disorder or her current situation in jail.
Mental status exam
Appearance: Appropriately dressed; pt is wearing orange jail jumpsuit. Hair is neatly styled in a
ponytail. Pt has large, colorful tattoos on both forearms. Piercings on nose and bridge of nose
removed.
Consciousness/Orientation: Pt. was alert and oriented X4. She was able to state her name,
DOB, date, location, and current situation. Based on her answers and awareness, she seems to be
a reliable historian.
Speech: Pt. demonstrated appropriate speech rate and sometimes with the proper volume; she
tended to get loud when she did not get her way. RN found no articulation issues during the
examination. Pt showed no presence of mutism or flight of ideas. Pt. did show circumstantiality
speech by uttering out
- “You think you are better than me because I’m in jail. Well, you are not!”
