How To Write A Case Study In Nursing

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AXIS I: Schizophrenia, undifferentiated type, acute relapse, alcohol abuse, marijuana abuse, noncompliance with the medical treatment.
AXIS II: None.
AXIS III: Obesity, non-insulin-dependent diabetes mellitus, hypertension.

The patient is a 45-year-old male who was admitted because of withdrawal from all social interactions, and mild catatonic symptoms. He did not want to communicate with his family members. He was nearly mute, but when I talked to him, after about 5 minutes, he started to talk and answer questions to some extent. He agreed to the need of inpatient stay. The patient has been living with his mother and sister. He said that they are harsh on him, and so he decided to withdraw from everything, and stop communicating with them. The mother did not want him to
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TSH was 0.9, cholesterol was 256 and triglycerides at 280. Blood glucose was 262 on admission. Alkaline phosphatase 170. White cell count was 11,100, and his hemoglobin 12.2. Urinalysis was negative. EKG showed normal sinus rhythm.

HOSPITAL COURSE: The patient was placed on Seroquel, and the dose was increased to 900 mg per day. He was also placed on Ativan 0.5 mg t.i.d. He started communicating after about 2 to 3 days. His self (___) slowly improved. He is still hearing voices, but now the voices are more positive. Now, the voices are telling him not to hate his mother. Only 2 days ago, the voices were telling not to talk to his mother. His mood is fairly stable. He is much more functional now.

He is discharged as improved on the following medications:
1. Seroquel 300 mg 2 h.s.
2. Ativan 1 mg b.i.d.
3. He is also to continue on (Vasotec) 5 mg daily.
4. Glucotrol XL 15 mg daily.

Follow up in the office on a weekly basis for group psychotherapy, and medication management. No restrictions on activities. He is to stay on an ADA
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