He reports feeing unwell, lacking energy, and often feeling like not going to work and has missed five days of work in the past two weeks. The client informs about loss of appetite and that he has not been making healthy food choices. He also reports disruptive sleep habits and an inability to sleep at night and that he wants to sleep a great deal during the day.
1000
The client reports general malaise, fatigue. and decreased appetite. His skin is pale in color. He denies pain or discomfort. The client is withdrawn, soft spoken, and does not offer information without being prompted. The client reports a six pack of beer daily for the last eight months.
1015
A suicide risk assessment is completed. The client denies thoughts of self-harm or suicide. Laboratory sample are drawn. Results are pending.
1030
The mental status exam is complete.
β’ Client found to be alert and oriented to person. place. and time
β’ Personal hygiene is poor, and clothing was soiled with food
β’ Hearing was noted to be adequate as able to hear and answer questions
β’ Speech was soft and noted to be monotone
β’ Flat affect observed
β’ Memory was intact both short and long term
β’ Thought process and content were appropriate
β’ The client reveals during mental status exam the recent loss of his mother. He says that his mother was killed in a motor vehicle collision eight months ago.
β’ The client reports daily phone calls with his mother for several years.
1000
β’ Temperature: 98Β°F (36.6Β°C) orally
β’ Heart rate: 68 beats/minute
β’ Respirations: 16 breaths/minute
β’ Blood pressure: 110/72 mm Hg
β’ Oxygen saturation: 98% on room air
β’ Height: 5 feet, 9 inches (175.26 cm)
β’ Weight: 120 pounds (54.43 kg)
β’ Body mass index (BMI): 17.7 kg/m2 (normal 18 to 24.9 kg/m2)
1000
β’ Complete a Mental status exam (MSE)
β’ Obtain blood for a complete blood count (CBC), thyroxine, and thyroid stimulating hormone (TSH)
White Blood Cells (WBCs)
π· Result: 10,600/mmΒ³ (10.6 Γ 10βΉ/L)
π· Reference Range: 5,000 to 10,000/mmΒ³ (5 to 10 Γ 10βΉ/L)2. Hemoglobin (Hgb)
πΆ Result: 11 g/dL (6.83 mmol/L)
πΆ Reference Range: 14 to 18 g/dL (8.69 to 11.17 mmol/L)
Hematocrit (Hct)
βΌ Result: 36% (0.36 volume fraction)
βΌ Reference Range: 42% to 52% (0.42 to 0.52)
Platelets
β¦ Result: 349,000/mmΒ³ (349 Γ 10βΉ/L)
β¦ Reference Range: 150,000 to 400,000/mmΒ³ (150 to 400 Γ 10βΉ/L)
