Copy of Demo | Clinical Case
CASE STUDY
Client: Sarah Lopez, 32 years • Setting: Outpatient Mental Health Clinic
Nurses’ Notes
0830 — Client arrived to clinic ambulatory, accompanied by partner. States “abdominal pain every day,” nausea, and fatigue for more than 12 months. Reports multiple prior evaluations without diagnosis. Requests additional testing.
Onset/character: abdominal pain described as diffuse, constant, non-radiating; rated 8/10 at time of visit. Reports symptoms worsen with stress and poor sleep. Denies fever, vomiting, diarrhea, hematemesis, melena, weight loss, dysuria, or hematuria. Reports intermittent palpitations. Appetite variable.
Medications: none currently. OTC use denied today. Allergies: NKDA.
Substance use: denies tobacco, alcohol, and recreational drugs.
Orientation: alert and oriented ×3. Speech rapid with detailed descriptions of symptoms. Affect anxious. Eye contact intermittent.
Safety: denies suicidal or homicidal ideation. No hallucinations endorsed.
Vital signs at 0835 — T 98.4°F (36.9°C), HR 92/min regular, RR 18/min unlabored, BP 118/74 mm Hg, SpO₂ 99% RA.
Abdomen: soft, nondistended; bowel sounds normoactive ×4 quadrants; no guarding or rebound; mild diffuse tenderness to light palpation; no masses; no CVA tenderness.
Skin warm/dry, mucous membranes moist. Gait steady without assistance.
Plan per provider: continue evaluation; review prior records; schedule follow-up; provide written instructions.
Medical & Social History
| Past Medical History | No chronic illnesses documented. Multiple specialist visits in past year; no organic etiology identified. |
|---|---|
| Medications | None prescribed; no current psychotropics or analgesics reported. |
| Allergies | NKDA |
| Family History | Mother with diagnosed anxiety disorder; no known GI malignancy. |
| Social | Lives with partner. Works part-time; reports limited social support. High perceived stress. Sleep 4–5 hrs/night. |
| Lifestyle | Diet irregular; low physical activity since symptom onset. |
Nursing Assessment (Clinic)
General: cooperative; appears stated age; hygiene appropriate.
Speech: spontaneous; increased rate; detailed somatic descriptions.
Thought content: focused on physical symptoms; fixed belief in physical cause.
Insight/judgment: limited insight regarding stress–symptom relationship.
Pain report: 8/10; no objective distress noted during exam; converses comfortably; ambulates independently.
Laboratory Results & Studies (Most Recent)
| Test | Result | Reference |
|---|---|---|
| CBC | Within normal limits | — |
| Basic Metabolic Panel | Within normal limits | — |
| Liver Function Tests | Within normal limits | — |
| Abdominal Ultrasound | No acute abnormality detected | — |
| Previous ED Records (past 6 mo) | Multiple visits for similar symptoms; no acute findings | — |