NRNP 6635 Case History Reports Example 2
Week 4: Anxiety Disorders, PTSD, and OCD
Training Title 15
Name: Mr. David Jackson Gender: male
Age:19 years old
T- 98.8 P- 89 R 18 110/62 Ht 5’7 Wt 133lbs
Background: Lives in Minneapolis, MN with both of his parents, only child. Works part time at Starbucks. Not currently partnered. No previous psychiatric history. Symptoms began in the last
1.5 months when he discovered he is being activated with the Navy Reserves. His MOS is SK1 Storekeeper; no medical illnesses Allergies: NKDA; sleeps 6.5 hrs; appetite good
Symptom Media. (Producer). (2017). Training title 15 [Video]. https://video-alexanderstreet- com.ezp.waldenulibrary.org/watch/training-title-15
Training Title 21
Name: Sergeant Patrick Flanrey Gender: male
Age:27 years old
T- 97.4 P- 84 R 18 B/P134/88 Ht 5’8 Wt 167lbs
Background: He entered the military just after high school and did three long tours of duty in warzones. He separated from active duty in the Marines (MOS 0800 Field Artillery) less than a year ago after eight years of service. He is engaged to be married (no date set) and is currently working as a furniture salesman. He said he grew up poor and would not do much else if
he didn’t go into the military. He denies ever using any drugs and avoids alcohol because his
father was “sloppy drunk.” Father is still alive, unwell (DM, liver disease, HTN), still
drinking. Paternal grandfather was also a veteran and suffered depression at times though he never told anyone except the patient because of their combat connection. Mother is alive and well, still “caring for dad.” He has one younger and one older sister. He lives in a different state, approximately five hours from his parents and siblings. After the military, he and his fiancé moved because she got a much better opportunity. They want kids someday and hope to marry
in a year or two. Has service-connected asthma, seasonal allergies; no hx of psychiatric or substance use treatment.
Symptom Media. (Producer). (2016). Training title 21 [Video]. https://video-alexanderstreet- com.ezp.waldenulibrary.org/watch/training-title-21
Training Title 37 Name: Mr. Tony Patelli Gender: male
Age:18 years old
T- 98.8 P- 94 R 20 126/88 Ht 5’4 Wt 131lbs
Background: Lives alone in New York, raised by parents in New Jersey, only child. He is a full- time student at local community college for graphic design. Has a girlfriend from high school. No previous psychiatric history. No medical illnesses; no history of psychiatric treatment; denied drugs or alcohol; Allergies: NKDA; sleeps 7.5 hrs; appetite eats 3 meals/day, likes to keep a routine schedule.
Symptom Media. (Producer). (2016). Training title 37 [Video]. https://video-alexanderstreet- com.ezp.waldenulibrary.org/watch/training-title-37
Training Title 40
Name: Ms. Barbara Weidre Gender: female
Age: 56 years old
T- 99.0 P- 99 R 24 132/89 Ht 5’4 Wt 168lbs
Background: Lives with her husband in Knoxville, TN, has one daughter age 23. She has never worked. Raised by mother, she never knew her father. Mother with hx of anxiety; no substance hx for patient or family. No previous psychiatric treatment. Has one glass red wine with dinner. Sleeps 10-12 hrs; appetite decreased. Has overactive bladder, untreated. Allergic to Phenergan; complains of headaches, takes prn ibuprofen, has diarrhea once weekly, takes OTC Imodium.
Symptom Media. (Producer). (2016). Training title 40 [Video]. https://video-alexanderstreet- com.ezp.waldenulibrary.org/watch/training-title-40
Training Title 55 Name: Matilda Johnson Gender: female
Age: 9years old
She refused vitals, ht and wt
Vaccinations are up to date; on target with developmental milestones. Appetite, she is a picky eater per mom. NKDA
Symptom Media. (Producer). (2017). Training title 55 [Video]. https://video-alexanderstreet- com.ezp.waldenulibrary.org/watch/training-title-55
Training Title 85
Name: Mrs. Carol Holliman Gender: female
Age: 42 years old
T- 98.0 P- 77 R 18 132/72 Ht 5’0 Wt 127lbs
Background: Born and raised in Northern Ireland, parents brought her and her 5 sisters to U.S. when she was 15 to go to U.S. university where she met her husband. They live in Charleston, SC. She obtained her bachelor’s degree in education; no history of mental health or substance use treatment, no family history. Her husband reported a recent school shooting nearby 3 weeks ago “flipped a switch” in her. She is watching the news 24/7, barely sleeping, and even when she does, it is only a few hours, Appetite is decreased. Hx of hysterectomy, NKDA, no legal hx.
Symptom Media. (Producer). (2017). Training title 85 [Video]. https://video-alexanderstreet- com.ezp.waldenulibrary.org/watch/training-title-85
Training Title 95
Name: Ms. Zahara Williams Gender: female
Age: 23 years old
T- 97.5 P- 86 R 18 112/64 Ht 5’2 Wt 130lbs
Background: Born and raised in Jacksonville, FL with her mother and 2 older brothers; her mother has hx of anxiety, brothers hx of cannabis; no previous mental health treatment, no medications; NKDA; no legal hx; sleeping 7 hrs; Appetite is good.
She has an associate of arts degree and works for Amazon warehouse. She has DX of diabetes since age 5. She recalls having great difficulty with her medical condition (uncontrolled blood sugar, fighting with mother over needle sticks, “kids want candy, and I was so different because of my diet”). She recalls having a difficult relationship with her mother who was a nurse and
really worked hard to control her daughter’s diabetes. She is not in a relationship, identifies as lesbian but has not come out to the family. Only her closest co-workers know she is gay, and she doesn’t plan to come out in the near future. She stated, “I don’t see why I would, they wouldn’t understand, and this is not important right now.”
Symptom Media. (Producer). (2018). Training title 95 [Video]. https://video-alexanderstreet- com.ezp.waldenulibrary.org/watch/training-title-95
Week 7 Schizophrenia and Other Psychotic Disorders; Medication- Induced Movement Disorders
Training Title 9
Name: Ms. Nijah Branning Gender: female
Age: 25 years old
T- 98.4 P- 80 R 18 128/78 Ht 5’0 Wt 120lbs
Background: Raised by parents, lives alone in Santa Monica, CA. Only child. Works in office supply sales, has a bachelor’s in business degree. Has medical history of hypothyroidism, currently treated with daily levothyroxine. Guarded and declined to discuss past psychiatric history. Denied family mental health issues, declined to allow you to speak to parents for collaborative information. Allergies: medical tape; menses regular
Symptom Media. (Producer). (2016). Training title 9 [Video]. https://video-alexanderstreet- com.ezp.waldenulibrary.org/watch/training-title-9
Training Title 24
Name: Ms. Jess Cunningham Gender: female
Age: 28 years old
T- 98.6 P- 86 R 20 120/70 Ht 5’2 Wt 126lbs
Background: Jess is brought for evaluation by her 2 roommates who are concerned with behaviors that began 12 days after Jess’s younger brother committed suicide in front of her via GSW after his girlfriend broke up with him. She is estranged from her parents and her brother was her only sibling. She is only sleeping 1–2 hours/24hrs; she will only canned foods. She smokes cannabis daily since she was 16, goes out on weekdays 2–3 times with her roommates and has couple drinks of beer. She was prescribed alprazolam 1mg twice daily as needed by her PCP for 15 days. She works as a bartender.
Symptom Media. (Producer). (2016). Training title 24 [Video]. https://video-alexanderstreet- com.ezp.waldenulibrary.org/watch/training-title-24
Training Title 29 Name: Mr. Jay Feldman Gender: male
Age:19 years old
T- 98.3 P- 69 R 16 106/72 Ht 5’7 Wt 117lbs
Background: European-American male. He has two younger brothers, one with history of ADHD, the other with history of anxiety. His mother has anxiety; his father has paranoia schizophrenia. He is home for spring break. He has no previous medical problems.
Developmental milestones met as child. Appetite is inconsistent and it seems he has lost 18lbs since first going back to school in the fall. Jason has not acted this way before but did have a short trial of aripiprazole in the last six months of high school for mild paranoia. He stopped the medication after graduation as he could not tolerate due to side effects of akathisia. Jason has several friends but has not kept in touch with them since being back home. He has not been showering. Sleeping 4–5 hrs.
Symptom Media. (Producer). (2016). Training title 29 [Video]. https://video-alexanderstreet- com.ezp.waldenulibrary.org/watch/training-title-29
Training Title 134
Name: Mrs. Bunny Warren Gender: female
Age: 33 years old
Background: Bunny was brought in by her best friend, Patty, after the police responded to her home the fifth time today. The police was threatening to arrest her for misuse of the 911 system, Bunny called you and you informed the police she needed to go the emergency room.
She has been calling 911 saying people are looking in her windows, standing across the street watching her, stated they are watching for her husband to return home so they can hurt him. Today, she has a stomachache. She believes there is a snake inside of her stomach which she would like to have removed. She stopped eating 2 days ago because of this.
During the assessment, the patient seemed on edge, anxious, and paranoid. The patient has history of scoliosis. This is her third presentation to this hospital, she had one psychiatric admission 2 years ago. No self-harm behaviors but has been physically aggressive toward others in the past. She is guarded and refuses to answer questions whether there are memory or concentration problems. She denies any recent head injuries. She states that she has been sleeping nightly, one or two hours at a time and waking up throughout the night. Refuses labs, refuses to have her vital signs obtained.
She obtains SSDI. She lives in Atlanta, GA. Bunny denies ever using any drugs and drinks occasionally, once a month. She has a sister who is ten years older, both parents deceased in the last two years. She has no children, her husband is out of town, truck driver. Family history includes that her father had two previous inpatient psychiatric hospitalizations after bad drug experiences in the 1970s, for one week each time. Mother had diagnosis and ongoing treatment for depression. Her paternal grandmother was state hospitalized for several years.
She denies any past history of traumatic experiences, but her friend does say that losing her parents was hard for her emotionally. No history of military service. No legal issues currently. Has HS diploma. Allergies: haloperidol
Symptom Media. (Producer). (2018). Training title 134 [Video]. https://video-alexanderstreet- com.ezp.waldenulibrary.org/watch/training-title-134
Week 8 Substance-Related and Addictive Disorders
Training Title 82 Name: Lisa Pittman Gender: female Age: 29 years old
T- 99.8 P- 101 R 20 178/94 Ht 5’6 Wt 140lbs
Background: Lisa is in a West Palm Beach, FL detox facility thinking about long term rehab. She has been smoking crack cocaine, approximately $100 daily. She admits to cannabis 1–2 times weekly (“I have a medical card”), and 2–3 alcohol drinks once weekly. She has past drug possession and theft convictions; currently on 2 yr probation with randomized drug screens.
She tries to find the pattern for the calls in order not to test dirty urine. Her admission labs abnormal for ALT 168 AST 200 ALK 250; bilirubin 2.5, albumin 3.0; her GGT is 59; UDS positive for cocaine, THC. Negative for alcohol or other drugs. BAL 0; other labs within normal ranges. She reports sexual abuse as child ages 5–7, perpetrator being her father who went to prison for the abuse and drug charges. She is estranged from him. Mother lives in Alabama, hx of anxiety, benzodiazepine use. Older brother has not contact with family in last 10 years, hx of opioid use. Sleeps 4-5 hrs, appetite decreased, prefers to get high instead of eating. Allergies: amoxicillin
She is considering treatment for her Hep C+ but needs to get clean first.
Symptom Media. (Producer). (2017). Training title 82 [Video]. https://video-alexanderstreet- com.ezp.waldenulibrary.org/watch/training-title-82
Training Title 114 Name: Ally Patel Gender: female Age: 48 years old
Background: Only child, raised by parents in San Francisco, CA. Has PhD in biology and
master’s degree in high school education (8–12). Her supervisor has asked the school EAP
counselor to intervene with concerns regarding potential substance use in effort to facilitate getting her help and be able to retain her.
Symptom Media. (Producer). (2018). Training title 114-2 [Video]. https://video-alexanderstreet- com.ezp.waldenulibrary.org/watch/training-title-114-2
Training Title 151 Name: Katarina Bykov Gender: female Age:41 years old
T- 97.4 P- 74 R 120 100/70 Ht 5’8 Wt 117lbs
Background: Moved to Washington State from Russia with her parents when she was 12 years old. She has 2 brothers, 2 sisters. Denied family mental health or substance use issues. No history of inpatient detox or rehab denied self-harm hx; Menses regular. Has chronic pain issues. She works part time cashier at Aldi Grocery Store. Dropped out of high school in 11th grade. Sleeps 4–9 hours on average, appetite good.
Symptom Media. (Producer). (2018). Training title 151 [Video]. https://video-alexanderstreet- com.ezp.waldenulibrary.org/watch/training-title-151
Week 10 Neurocognitive and Neurodevelopmental Disorders
Training Title 48 Name: Sarah Higgins Gender: female
Age: 9 years old
T- 97.4 P- 62 R 14 95/60 Ht 4’5 Wt 63lbs
Background: no history of treatment, developmental milestones met on time, vaccinations up to date. Sleeps 9hrs/night, meals are difficult as she has hard time sitting for meals, she does get proper nutrition per PCP.
Symptom Media. (Producer). (2017). Training title 48 [Video]. https://video-alexanderstreet- com.ezp.waldenulibrary.org/watch/training-title-48
Training Title 50 Name: Harold Griffin Gender: male Age:58 years old
T- 98.8 P- 86 R 18 134/88 Ht 5’11 Wt 180lbs
Background:
Has bachelor’s degree in engineering. He is homosexual and dates casually, never married, no children. Has one younger sister. Sleeps 4-6 hours, appetite good. Denied legal issues; MOCA 27/30 difficulty with attention and delayed recall; ASRS-5 20/24; denied hx of drug use; enjoys one scotch drink on the weekends with a cigar. Allergies Morphine; history HTN blood pressure controlled with losartan 100mg daily, angina prescribed ASA 81mg po daily, metoprolol 25mg twice daily. Hypertriglyceridemia prescribed fenofibrate 160mg daily, has BPH prescribed tamsulosin 0.4mg po bedtime.
Symptom Media. (Producer). (2017). Training title 50 [Video]. https://video-alexanderstreet- com.ezp.waldenulibrary.org/watch/training-title-50