NRNP 6665 Week 4 Assignment: Assessing, Diagnosing and Treating Adults with Mood Disorders Example Subjective:

NRNP 6665 Week 4 Assignment: Assessing, Diagnosing and Treating Adults with Mood Disorders Example Subjective:

NRNP 6665 Week 4 Assignment: Assessing, Diagnosing and Treating Adults with Mood Disorders Example

Subjective:

CC (chief complaint): “I have a history of taking medications and then stopping them. I don’t think I need them. I really feel like the medication squashes who I am.”

HPI: P.P. is a 25-year-old Caucasian woman seeking a mental health evaluation due to a history of inconsistent medication use and ongoing mood issues. She has been referred for assessment because of persistent depressive symptoms and intermittent high-energy phases that disrupt her daily life. Currently, she is not on any prescribed psychotropic medications, having recently discontinued one that she found somewhat beneficial but felt it stifled her creativity.

An analysis of her symptoms indicates a pattern of mood fluctuations marked by episodes of heightened energy, decreased sleep, hyperactivity, racing thoughts, and increased creativity. These episodes typically last about a week and occur several times a year. During these high-energy phases, P.P. engages in impulsive behaviors, such as excessive sexual activity, and experiences pressured speech and disorganized thoughts. She describes these times as feeling “high, high, high,” which contributes to her reluctance to pursue medication, as she fears it may diminish her creative expression. Following these energetic episodes, she often experiences significant depressive phases lasting four to five days, characterized by extreme fatigue, lack of motivation, feelings of worthlessness, and excessive sleeping. P.P. notes that these depressive episodes often follow periods of reduced sleep, during which she is highly productive in her creative endeavors, such as writing, painting, and music. She admits that her depressive symptoms have caused her to miss work at her aunt’s bookstore as she struggles to get out of bed or find motivation.

P.P. does not express any current thoughts of suicide or intentions to harm herself, although she does mention a previous suicide attempt in 2017 involving an overdose of Benadryl. She also states that she is not engaging in self-harm or having thoughts of harming others. Occasionally, she experiences auditory hallucinations, specifically hearing voices that commend her abilities, but she clarifies that these episodes occur only during times of sleep deprivation and are not present at the moment. Additionally, P.P. reports no signs of anxiety, panic attacks, obsessive-compulsive behaviors, or substance abuse, aside from her daily habit of smoking one pack of cigarettes.

Substance Current Use: The individual has been using tobacco for an unspecified length of time, consuming approximately one pack daily. In the past, she consumed alcohol but ceased at the age of 19 for reasons that are not clearly defined. She experimented with marijuana once but decided to stop due to experiencing paranoid thoughts. She states that her substance use has not resulted in any legal issues with law enforcement or drug enforcement agencies. Additionally, she denies any use of heroin, cocaine, methamphetamines, hallucinogens, or the misuse of any sedative medications.

Medical History: The patient’s medical history is significant for hypothyroidism, which is being treated with medication, and polycystic ovarian syndrome (PCOS), for which she is using birth control pills. She reports no other major medical issues or recent injuries.

• Current Medications: She takes Levothyroxine at a dosage of 75 mcg daily for her hypothyroidism, a treatment she has been on for three years. Additionally, she has been using oral contraceptives for PCOS for the past two years and takes an over-the-counter multivitamin daily.

• Allergies:Regarding allergies, she has a known reaction to penicillin, which causes a rash, but reports no food allergies. She is also sensitive to seasonal pollen, which leads to sneezing and nasal congestion.
• Reproductive Hx: Reproductive History: The last menstrual period occurred three weeks ago, with cycles being regular. The pt is not currently pregnant and is not nursing or lactating. They are using oral contraceptive pills for birth control. There are concerns regarding impulsive sexual behaviors that arise during periods of high energy, which are causing strain in relationships.

ROS:

• GENERAL: No fever, fatigue, weight loss, or night sweats.
• HEENT: The patient reports no headaches, blurry vision, or double vision
• SKIN: No skin rash, itchiness, on swellings
• CARDIOVASCULAR: No chest pain, pressure, or discomfort, or palpitation
• RESPIRATORY: No pain, tightness, difficul