Dr. Martin and classmates,
Week 6 (Part 2) Mental Health Disorder
Patient Information:
J.P. is a 22-year-old caucasian female musician in 2nd year of college
S.
CC (chief complaint): Patient presents to the office with and states “My boyfriend and parents
made me come in because he says I am more moody than normal and sometimes I do not want
to get up and go to class or leave the house-but he is getting on my nerves anyway, I think I just
need to dump him”.
HPI: Onset: The patient reports that she has some days over the past few months where she
has not wanted to get out of bed or go to class but that is mainly when she is too tired from
doing something the night before. She reports some days she does go to class but finds it too
boring and goes out to the local bars and drinks- and forgets about the time and her boyfriend
at home. Location: No specific physical complaints, other than she does wake up with hang
overs from “partying all night” a few days a week. Duration: The patient reports starting to have
trouble in her senior year with alcohol but never used any drugs then. Has tried cocaine, ecstasy
and valium while at college. Characteristics: The patient does not believe she has done anything
wrong and is just present here because her boyfriend and parents recommend she see a doctor
due to the mood swings and promiscuous behavior. Aggravating Factors: The patient reports
sometimes she does not feel like herself when she is at home, says she is “suffocating” and
needs to be “out”. Occasional insomnia makes it worse- then she finds herself drinking more.
Relieving Factors: She says she has been experimenting with different kinds of alcohol and drugs
as they seem to make her “feel normal”.
Current Medications: norgestimate/ethinyl estradiol 0.25 mg/35 mcg po daily (Sprintec)
Allergies: PCN-rash as child (as told by parents), strawberries (lip swelling)
PMHx: Tonsillectomy as a child, Treated for Gonorrhea and Chlamydia last year.
Soc Hx: J.P. is in in college, majoring in music- but does not have much interest in the
classrooms. Lives with her parents and younger sister. Has boyfriend that she sees a couple
times per week. Occasional tobacco use and almost daily alcohol use. Does not remember the
last time she has seen a doctor- probably before she started college a couple years ago.
Fam Hx: Father- HTN, Mother- anxiety/ depression-not medicated, Younger sister- healthy,
Grandmother- Bipolar (does not see, only met as a child), Grandfather- deceased from
Parkinson’s disease.
ROS
This study source was downloaded by 100000837848174 from CourseHero.com on 02-10-2022 14:31:53 GMT -06:00
https://www.coursehero.com/file/37756324/NR603-Wk6-1docx/
, CONSTITUTIONAL: No weight loss, fever, chills, weakness or fatigue. HEENT: Eyes: No visual
loss, blurred vision, double vision or yellow sclerae. Ears, Nose, Throat: No hearing loss,
sneezing, congestion, runny nose or sore throat. SKIN: No rash or itching. CARDIOVASCULAR:
No chest pain, chest pressure or chest discomfort. No palpitations or edema. RESPIRATORY: No
shortness of breath, cough or sputum. GASTROINTESTINAL: No anorexia, nausea, vomiting or
diarrhea. No abdominal pain or blood. GENITOURINARY: No dysuria. No pregnancies. Last
menstrual period x 2 weeks ago. NEUROLOGICAL: Intermittent headaches, no dizziness,
syncope, paralysis, ataxia, numbness or tingling in the extremities. No change in bowel or
bladder control. MUSCULOSKELETAL: No muscle, back pain, joint pain or stiffness.
HEMATOLOGIC: No anemia, bleeding or bruising. LYMPHATICS: No enlarged nodes. No history
of splenectomy. PSYCHIATRIC: History of depression and anxiety and “disappearing for a couple
of days”. ENDOCRINOLOGIC: No reports of sweating, cold or heat intolerance. No polyuria or
polydipsia. ALLERGIES: No history of asthma, hives, eczema or rhinitis.
O.
Physical exam: Vitals: BP 130/82; pulse 89, regular; respiration 16, regular, 99% on RA
Height 5’6” Weight 142 Lbs.
General: Well-nourished female in no acute distress. Alert, oriented and cooperative. HEENT:
head normocephalic. Hair thick and distribution throughout scalp. Eyes without exudate, sclera
white. Wears contacts. Tympanic membranes gray and intact with light reflex noted. Pinna and
tragus nontender. Nares patent without exudate. Oropharynx moist without erythema. Teeth in
good repair, no cavities noted. Neck supple. Anterior cervical lymph nontender to palpation. No
lymphadenopathy. Thyroid midline, small and firm without palpable masses. CV: S1 and S2 RRR
without murmurs or rubs Lungs: Clear to auscultation bilaterally, respirations unlabored.
Abdomen- soft, round, nontender with positive bowel sounds present; no organomegaly; no
abdominal bruits. No CVAT. GU: Exam deferred Skin: Warm, pink, intact without rash or lesions,
no cyanosis or pallor.
Diagnostic results: Urinalysis/ Pregnancy- Negative, CMP- WNL, CBC- WNL, TSH/Free T4-
1.2mIU/L/ 0.8 ng/ dl., Vitamin B12- 150ng/L, Vitamin D-22ng/ml
A.
Bipolar 1 Disorder (F31.9)- The DSM- IV (APA, 2013) states the previously termed manic
depression diagnosis, is a psychiatric diagnosis characterized by at least one episode of
abnormally elevated or irritable mood episode accompanied by disruptive symptoms of
distractibility, indiscretions, grandiosity, flight of ideas, hyperactivity, decreased need for sleep,
and talkativeness. Symptoms range from manic to depressive and everything in between.
Effecting both men and women alike, between 1-3 % of the general population is diagnosed
with Bipolar 1 disorder (Brenner & Shyn, 2014). The risk of genetically inheriting the disorder
This study source was downloaded by 100000837848174 from CourseHero.com on 02-10-2022 14:31:53 GMT -06:00
https://www.coursehero.com/file/37756324/NR603-Wk6-1docx/
Week 6 (Part 2) Mental Health Disorder
Patient Information:
J.P. is a 22-year-old caucasian female musician in 2nd year of college
S.
CC (chief complaint): Patient presents to the office with and states “My boyfriend and parents
made me come in because he says I am more moody than normal and sometimes I do not want
to get up and go to class or leave the house-but he is getting on my nerves anyway, I think I just
need to dump him”.
HPI: Onset: The patient reports that she has some days over the past few months where she
has not wanted to get out of bed or go to class but that is mainly when she is too tired from
doing something the night before. She reports some days she does go to class but finds it too
boring and goes out to the local bars and drinks- and forgets about the time and her boyfriend
at home. Location: No specific physical complaints, other than she does wake up with hang
overs from “partying all night” a few days a week. Duration: The patient reports starting to have
trouble in her senior year with alcohol but never used any drugs then. Has tried cocaine, ecstasy
and valium while at college. Characteristics: The patient does not believe she has done anything
wrong and is just present here because her boyfriend and parents recommend she see a doctor
due to the mood swings and promiscuous behavior. Aggravating Factors: The patient reports
sometimes she does not feel like herself when she is at home, says she is “suffocating” and
needs to be “out”. Occasional insomnia makes it worse- then she finds herself drinking more.
Relieving Factors: She says she has been experimenting with different kinds of alcohol and drugs
as they seem to make her “feel normal”.
Current Medications: norgestimate/ethinyl estradiol 0.25 mg/35 mcg po daily (Sprintec)
Allergies: PCN-rash as child (as told by parents), strawberries (lip swelling)
PMHx: Tonsillectomy as a child, Treated for Gonorrhea and Chlamydia last year.
Soc Hx: J.P. is in in college, majoring in music- but does not have much interest in the
classrooms. Lives with her parents and younger sister. Has boyfriend that she sees a couple
times per week. Occasional tobacco use and almost daily alcohol use. Does not remember the
last time she has seen a doctor- probably before she started college a couple years ago.
Fam Hx: Father- HTN, Mother- anxiety/ depression-not medicated, Younger sister- healthy,
Grandmother- Bipolar (does not see, only met as a child), Grandfather- deceased from
Parkinson’s disease.
ROS
This study source was downloaded by 100000837848174 from CourseHero.com on 02-10-2022 14:31:53 GMT -06:00
https://www.coursehero.com/file/37756324/NR603-Wk6-1docx/
, CONSTITUTIONAL: No weight loss, fever, chills, weakness or fatigue. HEENT: Eyes: No visual
loss, blurred vision, double vision or yellow sclerae. Ears, Nose, Throat: No hearing loss,
sneezing, congestion, runny nose or sore throat. SKIN: No rash or itching. CARDIOVASCULAR:
No chest pain, chest pressure or chest discomfort. No palpitations or edema. RESPIRATORY: No
shortness of breath, cough or sputum. GASTROINTESTINAL: No anorexia, nausea, vomiting or
diarrhea. No abdominal pain or blood. GENITOURINARY: No dysuria. No pregnancies. Last
menstrual period x 2 weeks ago. NEUROLOGICAL: Intermittent headaches, no dizziness,
syncope, paralysis, ataxia, numbness or tingling in the extremities. No change in bowel or
bladder control. MUSCULOSKELETAL: No muscle, back pain, joint pain or stiffness.
HEMATOLOGIC: No anemia, bleeding or bruising. LYMPHATICS: No enlarged nodes. No history
of splenectomy. PSYCHIATRIC: History of depression and anxiety and “disappearing for a couple
of days”. ENDOCRINOLOGIC: No reports of sweating, cold or heat intolerance. No polyuria or
polydipsia. ALLERGIES: No history of asthma, hives, eczema or rhinitis.
O.
Physical exam: Vitals: BP 130/82; pulse 89, regular; respiration 16, regular, 99% on RA
Height 5’6” Weight 142 Lbs.
General: Well-nourished female in no acute distress. Alert, oriented and cooperative. HEENT:
head normocephalic. Hair thick and distribution throughout scalp. Eyes without exudate, sclera
white. Wears contacts. Tympanic membranes gray and intact with light reflex noted. Pinna and
tragus nontender. Nares patent without exudate. Oropharynx moist without erythema. Teeth in
good repair, no cavities noted. Neck supple. Anterior cervical lymph nontender to palpation. No
lymphadenopathy. Thyroid midline, small and firm without palpable masses. CV: S1 and S2 RRR
without murmurs or rubs Lungs: Clear to auscultation bilaterally, respirations unlabored.
Abdomen- soft, round, nontender with positive bowel sounds present; no organomegaly; no
abdominal bruits. No CVAT. GU: Exam deferred Skin: Warm, pink, intact without rash or lesions,
no cyanosis or pallor.
Diagnostic results: Urinalysis/ Pregnancy- Negative, CMP- WNL, CBC- WNL, TSH/Free T4-
1.2mIU/L/ 0.8 ng/ dl., Vitamin B12- 150ng/L, Vitamin D-22ng/ml
A.
Bipolar 1 Disorder (F31.9)- The DSM- IV (APA, 2013) states the previously termed manic
depression diagnosis, is a psychiatric diagnosis characterized by at least one episode of
abnormally elevated or irritable mood episode accompanied by disruptive symptoms of
distractibility, indiscretions, grandiosity, flight of ideas, hyperactivity, decreased need for sleep,
and talkativeness. Symptoms range from manic to depressive and everything in between.
Effecting both men and women alike, between 1-3 % of the general population is diagnosed
with Bipolar 1 disorder (Brenner & Shyn, 2014). The risk of genetically inheriting the disorder
This study source was downloaded by 100000837848174 from CourseHero.com on 02-10-2022 14:31:53 GMT -06:00
https://www.coursehero.com/file/37756324/NR603-Wk6-1docx/
