Capstone Project Case Study Concept Map Created By: Metformin Brandi Anastacio Lisinopril N360 PMH

Lives alone in a Condo College Graduate Sociology Major

FBS: 90 mg/dL

Dx age of 24 Haldol Two previous episodes of AH in the 90s

Diabetes Mellitus Hypertension Medical History No Religious Preference Male

Paranoid Schizophrenia

Hyperlipidemia

Pravastatin

DSM IV TR:
+AH resulting in social/occupational dysfunction Hx of multiple episodes >1 month duration in a 6 month period

AXIS:
I: Paranoid Schizophrenia III: Diabetes Mellitus, Hypertension and Hyperlipidemia IV: Lives alone, unemployed V: GAF 31-40

Mother and Sister live in Chicago

Social History

50 yrs.-old

Unemployed Admission MH-5 Chief Complaint: +AH, +SI Assessment Asst Tool: Suicide Risk Score: 2, No risk

Per Client
I have a mental illness. Its difficult. It started when I was young, but this has never happened before with voices in my head. The voices are kind of like chanting and they manipulate things, like the TV.

Limitations:
Per Client: Im forgetful. Per Observation: Clients affect is blunted and appears to be experiencing poverty of speech. Per Staff: Although client is able to perform ADLs, he requires frequent reminders to perform hygienic self-care.

Strengths:
Per client: I am independent. Per Observation: Client actively participates in group activities and is appropriate with peers and staff. Per Staff: Client is pleasant within the milieu and approachable; nonimpulsive. Client is able to verbalize needs.

MSE:
Behavior: Calm and appropriate with staff and peers. Affect: Blunted Sensorium: +Auditory Hallucinations Imagery: Disheveled, unkempt Cognition: Inhibited with poverty of thought

Treatment Plan Schizophrenia, treat with Haldol 6mg qhs and

Congentin 1mg PRN BID. Follow up with CBC, BMP, fasting glucose, lipid, & EKG. Set up follow up with psychiatrist and collaborate. Diabetes Mellitus, Hyperlipidemia, & Hypertension continue to manage with current meds. Client will return home, work with case manager and family regarding possibility of moving to Chicago with mom and sister.

gths