In this Assignment you will assess, diagnose, and devise a treatment plan for a patient in a case study who is presenting with a mood disorder.

Bipolar II Disorder Evaluation

Subjective:

CC: ” 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: Patient PP is a 25-year-old female patient who has come for a mental health assessment. The patient reports having problems with medication adherence, indicating her lack of need for the medication, stating that it “squashes” who she is. The patient also reports having been hospitalized as a teenager for going four to five days without sleep and hearing things during the period.

Since then, she has been hospitalized four times, with the current hospitalization being the past spring. She notes that she has previously been diagnosed with bipolar, anxiety, and depression. She also notes that she tried to use some medications like Zoloft, Seroquel, and another one which she only recalls the name to start with the letter “L”.

The patient explains that her prescribed medications seem to present some side effects. The patient also notes that she has once had some suicidal tendencies before. She also reports engaging in sexual intercourse with multiple partners since it elevates her moods. She also reports missing work due to feeling too depressed.

Substance Current Use and History: The patient reports smoking at least a packet of cigarettes a day, which she doesn’t intend to stop. She also reports having stopped using alcohol at 19 years. The patient also reports having a bad history of marijuana use which made her stop. She denies using cocaine, stimulant, inhalants, hallucinogens, and sedative medications. She also denies using any pain pills or opiate medications.

Family Psychiatric/Substance Use History: The patient reports having a family background with psychiatric and substance use issues. She indicates that her mother was bipolar with suicidal tendencies. She reports that her father was imprisoned for 8 to 10 years due to drug-related problems, and she considers her brother to also have mental issues though not hospitalized.

Psychosocial History: The patient was raised by her mother and her older brother. She currently lives with her boyfriend and at times her mother who is infuriated by her sexual habits. Her father is imprisoned and has not heard from him for some time. She has never been married before or had any children. She is currently working in her aunt’s stores albeit irregularly due to her occasional depressed moods. She is currently studying cosmetology and loves to paint and write.

Medical History: The patient has Polycystic ovary syndrome (PCOS) and hypothyroidism.

• Current Medications: the patient is currently under birth control pills for PCOS and an unnamed medication for hypothyroidism. She is also currently using some medication for her mental illness which she only remembers the first letter being “L.” She notes to have previously used Zoloft and Seroquel.
• Allergies:No allergies reported by the patient
• Reproductive Hx:The patient reports having her regular menses once a month, with the last one being sometime last month. She is diagnosed and under medication for PCOS. She reports being sexually active and with multiple partners

ROS:

• GENERAL: Varying levels of eating and sleeping depending on the mood.
• HEENT: negative for head traumas, hearing, sight, smell, neck, or throat problems.
• SKIN: Negative for dryness, itching, or rashes.
• CARDIOVASCULAR: Negative for CV issues.
• RESPIRATORY: Negative for respiratory symptoms.
• GASTROINTESTINAL: Negative for GI pain, diarrhea, nausea, or vomiting.
• GENITOURINARY: Reports negative for GU symptoms.
• NEUROLOGICAL: Reports negative for neurological issues.
• MUSCULOSKELETAL: denies having any MS problems.
• HEMATOLOGIC: denies having any abnormal bleeding or hematologic issues.
• LYMPHATICS: Denies lymphadenopathy.
• ENDOCRINOLOGIC: Reports having hypothyroidism

Objective:

Physical Exam

• Vital signs: RR: 18, PR: 90, T: 98.2, B/P: 138/88
• HEENT: Noncontributory
• Res: No wheezing or distress in breathing
• CV: Regular HR, BP, no murmurs or bruits

Diagnostic results:

Laboratory Data Available: The available laboratory results indicate negative