Mother is concerned that daughter is not eating enough, restricting food intake for 8 months because she feels fat, feels she needs to lose ten pounds, feels that her thighs and stomach are to large, reporting 35 lb weight loss over last 8 months

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University of Texas at Arlington School of Nursing

N303 Psychiatric Management

     Case Study

Student Name:___Elishia Williams ___________        Clinical Advisor:_Dr. Snow_____________

Topic:_Case Study 1   Lauren 19 yr. old white female     Date:____06-07-05______

Subjective Data Provided:                                          Subjective Needed: in italics

Mother is concerned that daughter is not eating enough, restricting food intake for 8 months because she feels fat, feels she needs to lose ten pounds, feels that her thighs and stomach are to large, reporting 35 lb weight loss over last 8 months, denies any eating problems, began menarche at age 16 periods normally regular, stop three months ago, exercises daily 20 min. to 2 hours, experiences low energy, chronic constipation and lightheadedness, favorite TV show is “America’s Next Top Model” and reports “feeling down in the dumps” for about nine months, college student, good grades, finding it difficult to concentrate, admits to feeling worthless and having no friends, moved to new city middle of senior year, has difficulty falling asleep awakens in middle of night often, mother reports that she is often irritable and cries often. When did the depressed mood start in relation to the move, was it within three months of the move, Is she taking any medications, has she ever felt like this before and if so what made it better, dose she take naps, what time does she go to sleep and wake up, does she take meds to go to sleep, how much caffeine does she use, does she have nightmares, does your mind race when you try to go to sleep, have you ever binged or fasted, used laxatives or vomiting, how often do you weigh, 24 hour diet recall, are you afraid of gaining weight, how would you describe your energy level, what do you enjoy doing, are the activities you use to enjoy still enjoyable, have you been feeling sad, angry, irritable, or happy, describe your mood on a scale of 1-10 ten being best, have you ever thought it would be better if you were dead, are you sexually active, how many partners current and life time, safe sexual practices, birth control, change in sex drive, have you ever been diagnosed with any psychiatric disorders, ever been hospitalized, gone to counseling, attempted suicide, any tobacco, alcohol, or illicit drug use, any current medications used, OTC, herbal, any food or drug allergies, last physical exam, last paps smear, any major illnesses, accidents, surgeries, hospitalizations, any family history of eating disorders,  psychiatric or mood disorders, alcohol or drug abuse, suicide, any health problems in family, do you work, if so how is that going, any loss of family members or friends, any history of sexual, physical, or mental abuse, are you able to groom and cook for your self, what did you do for fun in the past week, did she have friends before the move, is she able to contact those friends now, what did she do socially before the move,  any criminal or legal problems, any boyfriends, how do you feel about your current living situation, any spiritual beliefs, who do you feel like you can talk to, any changes in your hair, skin, or nails, any headaches, or vision changes, any chest pain, palpitations, SOB, any joint pain or weakness.

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Objective Data Provided:                        Objective Needed: In Italics

5’8”, 105lbs, Temp, BP looking for hypotension, Pulse looking for bradycardia, RR, mental status exam- appearance, attitude toward examiner, mood, affect speech, thought process, thought content, orientation, judgment, insight, strengths and assets, Assessment of cardiac, respiratory, GI/GU looking for bloating, abdominal pain due to constipation, HEENT looking at teeth to observe for erosion of enamel indicative of frequent vomiting, MUSK, Lymph looking for dependent edema,  Neuro, Skin/Hair/Nails looking for lanugo, administer the inventory of depressive symptomatology.

Diagnosis:  Axis I   Anorexia Nervosa Restrictive type – BMI is less than 17.5, ...

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