NR 546 Week 5 Case Study
Subjective @~ Objective
The client M.L. is a 34-year-old, Hispanic Physical Examination:
female being seen for a psychiatric evaluation
Height: 5’7", weight: 140 1b.
at an outpatient clinic.
General: Well-nourished female appears stated age
Client’s Chief Complaints:
Mental status exam:
“I feel sad. I can't seem to enjoy anything
anymore, and it's affecting my sleep and Appearance: Appropriate dress for age and situation, well
appetite.” nourished, poor eye contact, slumped posture
Alertness and Orientation: Alert, fully oriented to person,
History of Present Illness place, time, and situation,
M.L. reports a six-month history of persistent Behavior: Cooperative
sadness, loss of interest in activities, and
constant feelings of anxiety. She has trouble Speech: Soft, flat
sleeping, poor appetite, and frequent fatigue. Mood: Depressed
M.L. also mentions having trouble
concentrating and feeling overwhelmed by Affect: Constricted, congruent with stated mood
daily tasks.
Thought Process: Logical, linear
She denies any thoughts of self-harm or suicide
Thought content: Expresses feelings of worthlessness and
but admits to feelings of hopelessness about her
hopelessness. Denies thoughts of suicide, self-harm, or
future.
passive death wish. Denies homicidal ideation.
Past psychiatric history: Denies any history of
Perceptions: Denies experiencing any perceptual
previous psychiatric diagnoses or treatment for
disturbances, such as auditory or visual hallucinations. No
depression. However, she acknowledges a
evidence of psychosis, not responding to internal stimuli.
family history of depression, with her sister and
mother having been diagnosed and treated for Memory: Recent and remote WNL
the condition; this is the client’s first contact
Judgement/Insight: Insight is fair, Judgement is fair
with a mental health provider.
Attention and observed intellectual functioning: Attention
Past Medical History: none
intact for the purpose of assessment. Able to follow
Family History questioning.
e Father is alive and well. Fund of knowledge: Good general fund of knowledge and
e Mother is alive, has depression and vocabulary
being treated.
Musculoskeletal: Normal gait
e One sister 36, with depression
Social History
e Lives alone in an apartment.
09.24 MWS
Subjective @~ Objective
The client M.L. is a 34-year-old, Hispanic Physical Examination:
female being seen for a psychiatric evaluation
Height: 5’7", weight: 140 1b.
at an outpatient clinic.
General: Well-nourished female appears stated age
Client’s Chief Complaints:
Mental status exam:
“I feel sad. I can't seem to enjoy anything
anymore, and it's affecting my sleep and Appearance: Appropriate dress for age and situation, well
appetite.” nourished, poor eye contact, slumped posture
Alertness and Orientation: Alert, fully oriented to person,
History of Present Illness place, time, and situation,
M.L. reports a six-month history of persistent Behavior: Cooperative
sadness, loss of interest in activities, and
constant feelings of anxiety. She has trouble Speech: Soft, flat
sleeping, poor appetite, and frequent fatigue. Mood: Depressed
M.L. also mentions having trouble
concentrating and feeling overwhelmed by Affect: Constricted, congruent with stated mood
daily tasks.
Thought Process: Logical, linear
She denies any thoughts of self-harm or suicide
Thought content: Expresses feelings of worthlessness and
but admits to feelings of hopelessness about her
hopelessness. Denies thoughts of suicide, self-harm, or
future.
passive death wish. Denies homicidal ideation.
Past psychiatric history: Denies any history of
Perceptions: Denies experiencing any perceptual
previous psychiatric diagnoses or treatment for
disturbances, such as auditory or visual hallucinations. No
depression. However, she acknowledges a
evidence of psychosis, not responding to internal stimuli.
family history of depression, with her sister and
mother having been diagnosed and treated for Memory: Recent and remote WNL
the condition; this is the client’s first contact
Judgement/Insight: Insight is fair, Judgement is fair
with a mental health provider.
Attention and observed intellectual functioning: Attention
Past Medical History: none
intact for the purpose of assessment. Able to follow
Family History questioning.
e Father is alive and well. Fund of knowledge: Good general fund of knowledge and
e Mother is alive, has depression and vocabulary
being treated.
Musculoskeletal: Normal gait
e One sister 36, with depression
Social History
e Lives alone in an apartment.
09.24 MWS
