NRNP 6665: PMHNP Care Across the Lifespan I Subjective: CC (chief complaint): “Constant anger outburst” HPI: J.Q is a 27 year old Caucasian female who presented to the office due to her constant outburst toward people, especially her husband. 

Family Psychiatric/Substance Use History: No family history of mental health, unknown death or suicide.

Past psychiatric history: Bipolar, schizophrenia, suicidal thought (Cuts her wrist when she was 13 year old).

Past psychiatric medications: Latuda 80 mg, Saphris (unknown dose), Vrayler( unknown dose), Zoloft (unknown dose),  Romeron ( unknown dose).

Medical History: No medical histories

  • Current Medications: Benadryl 25 mg at bedtime OTC, melatonin 1 mg at bedtime OTC
  • Allergies: Codeine
  • Reproductive Hx: Her LMP was 9/13/2022,  She is sexually active and currently on a birth control.

Psychosocial History:  J.Q was born born and raised in Tyler, Texas.  She moved to Kansas and moved back to Texas in march, 2022.  She has her high school diploma and current stays at home with her two daughtets.  She is married with two children ( 2 year old, and 1 year old).  She is currently living with her husband, children, and her parents.  She has a good relationship with her parents and siblings.  She has two older brothers, and one older sister. She was sexually, emotionally and physically abused by her uncle when she was young.  She doesn’t have any legal issues.  She had a history of head trauma when her neighbor threw a stone at the back of her head.

ROS:

  • GENERAL: Negative for weekness, chills, diaphoresis and fever
  • HEENT: Patient had history head trauma, Eyes: Negative for pains, discharge and vitual disturbance. Ear:Negative for congestion, or ear pain. Nose: No nosebleed, sinus, or rhinorrhea. Throat: No sore throat, or throuble swallowing
  • SKIN: Negative for rashes
  • CARDIOVASCULAR: No chest pain and palpitations.
  • RESPIRATORY: Negative for cough, chest tightness or cough.
  • GASTROINTESTINAL: Negative for abdominal pain, constipation, diarrhea, and N/V
  • GENITOURINARY: Negative for dysuria, flank pain, hematuria, frequency and difficulty urinating.
  • NEUROLOGICAL: Negative for dizziness, syncope, weekness, or seizure.
  • MUSCULOSKELETAL: Negative for backpain, and myalgias
  • HEMATOLOGIC: Negative for anemia or bleeding.
  • LYMPHATICS: Negative enlarged node reported.
  • ENDOCRINOLOGIC: Negative for cold intolerance, heat intolerance, polyuria and polydipsia.
  • PSYCHIATRIC: Reports depression, mood change and anger outburst.

Objective:

Diagnostic results:

Assessment:

Mental Status Examination:  The patient is a 27 year old Caucasian female who confirmed that she been feeling mood swing, angerger outburst especially with her husband.  She has been getting worse.  She was alert and oriented to self, time, location and situation and appeared calm, and cooperative during the interview.  She answers allthe questions appropriately. She appears reliable historian.  There is no developmental problem.  She denies any suicidal thoughts or anxiety at this time, but her problem is depression and frequesnt anger

Diagnostic Impression: You must begin to narrow your differential diagnosis to your diagnostic impression.  You must explain how and why (your rationale) you ruled out any of your differential diagnoses. You must explain how and why (your rationale) you concluded to your diagnostic impression.  You will use supporting evidence from the literature to support your rationale. Include pertinent positives and pertinent negatives for the specific patient case.

What were your differential diagnoses? Provide a minimum of three possible diagnoses and why you chose them. List them from highest priority to lowest priority. What was your primary diagnosis and why? Describe how your primary diagnosis aligns with DSM-5 diagnostic criteria and supported by the patient’s symptoms. Diagnosis/Diagnoses – include all mental health diagnoses and the ICD-10 codes for each.  Be Specific with diagnosis

Reflections: . Reflect on this case and discuss whether or not you agree with your preceptor’s assessment and diagnostic impression of the patient and why or why not. What did you learn from this case? What would you do differently?

Also include in your reflection a discussion related to legal/ethical considerations (demonstrating critical thinking beyond confidentiality and cons

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