Patient Psychiatric Case Study Sample

Client Psychiatric History: Depression and anxiety
Past psychiatric hospitalizations: N/A

Date __06/21/17__________, Reason _____Repeated suicide attempts____________________________________

Allergies: (Food and / or drug) _Seafood and bananas_______________________________________________

Legal status of admission: _____Voluntary_______________________________________

Reason for admission: __Repeated suicide attempts__________________________________________

Anticípated LOS: ___6-8 weeks_________________________________________

Treatment plans for the client: __DBT, a program in Canada__________________________________________

DSM-IV TR Multi Axial Diagnosis:
Axis I __Depression and anxiety Alcohol and drug addiction ________________________________________________________________
Axis II: ____N/A____________________________________________________________

Axis III: _____N/A__________________________________________________________

Axis IV: ___Substance use, absence coping skills, few friends, bullying, learning differences (dyslexia) _____________________________________________________________

Axis V: _Not found on chart ________________________________________________________________

Laboratory (pertinent values only) Include actual lab values and/or reference ranges (ie.
Lithium levels, Drug screens, Pregnancy test, etc.)
Date/Test Result Interpretation Nursing Implications
06/21/17 Drug Test Negative The patient does not have levels of drug in her system. The patient does not have concentrations of drug in the urine sample below the designed cut- off levels. A negative drug test result does not always mean there are no drugs present in the person being tested, it means there are not drugs present above the cut off limit.

Patient’s Current Medications
Class Trade/Generic name Dose Dose ranges Route Freq. Rationale for taking drug Side effects Nursing implications
Opioid antagonist Naltrexone
(Revia) 100mg n/a oral Once per day at bedtime Alcohol addiction, self- harm muscle cramps, muscle rigidity, muscle spasm, stiffness, depression, and
twitching fatigue, dizziness, headache, nausea hepatotoxicity Teach the patient to avoid alcohol
Teach the patient about side effects
Take the mediation as directed
Teach the patient about the risk for hepatotoxicity (signs and symptoms and to notify the healthcare provider)

Nerve pain medication and anticonvulsant Topiramate
(Topamax) 100mg n/a oral Once per day at bedtime Alcohol addiction, anxiety Seizures, suicidal thoughts, drowsiness, fatigue, nervousness, abnormal vision, nausea, weigh loss Monitor the patient closely for changes in behavior that may indicate worsening behavior
Teach the patient to take the medication as indicated
Maintain fluid intake
Teach about the adverse effects of the medication