NRNP 6635 Assignment: Assessing and Diagnosing Patients With Mood Disorders
Subjective:
CC (chief complaint): “ When I have my periods I am on my back all day crying. My world is falling apart”.
HPI: Miss H. A, a 32-year-old patient, presents to the clinic complaining of an overwhelming feeling accompanying the intense cramps during her menstrual time. She complains of dizziness, headache, and back pain. She also reports having an increased appetite. She also complains of instability due to mood swings and feels stressed. Patient reports she has lost more than one job in direct relation to this problem.
Past Psychiatric History:
- General Statement: the patient has had issues of anxiety but has never been diagnosed with clinical depression
- Caregivers (if applicable): the patient has visited a psychiatrist in the past for several years after divorce but has since stopped since the feelings of anger and sadness due to the divorce have left her
- Hospitalizations: The patient has no history of hospitalizations
- Medication trials: The patient uses ibuprofen to relieve her pain, but no other legal medications
- Psychotherapy or Previous Psychiatric Diagnosis: Anxiety
Substance Current Use and History: no history or current substance use
Family Psychiatric/Substance Use History: The patient’s family from the mother’s side has a history of depression as the uncle killed himself due to depression
Psychosocial History: the patient currently lives in Phoenix with two children but is divorced. The patient was born and raised in Tucson with mother and four siblings
Medical History:
- Current Medications: no medications except for ibuprofen which she uses for pain
- Allergies: The patient has no know allergies
- Reproductive Hx: The patient is currently divorced and lives with her two children. The patient reports no history of sexually transmitted diseases.
ROS:
- GENERAL: The patient has an overwhelming feeling accompanying cramps during her menses. She gets sad
NRNP 6635 Assignment Assessing and Diagnosing Patients With Mood Disorders
and snaps at people.
- HEENT: The patient’s eyes appear normal. No abnormal discolorization of the sclera was observed. The ears are also normal. No sore throat or scratch. No sneezing and no cough.
- SKIN: no itchiness noted. The skin has no rashes, and no lesions were noted.
- CARDIOVASCULAR: No chest discomfort, no chest pressure or pain
- RESPIRATORY: no congestions nor respiratory issues were noted.
- GASTROINTESTINAL: No nausea, vomiting, anorexia, diarrhea, nor abdominal pain
- GENITOURINARY: normal passing of urine with no pain
- NEUROLOGICAL: no numbness. No bowel movement changes or bladder control. Experiences headache and dizziness
- MUSCULOSKELETAL: experiences back pain. No muscle pain, no stiffness
- HEMATOLOGIC: No bruises, bleeding, or anemia.
- LYMPHATICS: has no history of splenectomy and has no swollen lymph nodes
- ENDOCRINOLOGIC: has bo abnormal sweating or excessive thirst.
Objective:
Physical exam:
Vital signs: T- 98.2 P- 74 R 18 120/70 Ht 5’1 Wt 150lbs.
HEENT: the head is atraumatic and normocephalic. The pupils react well to light and are normal. The ear is normal, and no discharge nor canal swelling was seen. The neck is normal and flexible with the normal and unswollen tonsils. The throat has no swelling, clear and normal.
Chest/lungs: The breathing sounds were noted to clear upon auscultation.
Heart: no murmurs or abnormal sounds heart as the heart rate was regular and with expected rhythm.
Abdomen: Abdomen is normal, soft, and non-tender.
Diagnostic results: Various tools can be essential for screening to obtain the necessary diagnostic results.
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