NRNP 6635 Week3 Assignment Mood Disorders

NRNP 6635 Week 3: Mood Disorders Example

Patient Information:

Patient Initials: N. C                 Age: 17   Gender: Female Race: White American

Subjective:

Chief Complaint (CC): The patient’s mother expressed concern about her daughter’s moodiness during this time of year and requested an evaluation.

History of Present Illness (HPI): Ms. N. C, a 17-year-old White American female, presents with a chief complaint of feeling down and not doing well. Her mother expressed concern about her mood worsening during this time of year. She left the business program at school and is struggling with her academic projects, including a mock company assignment. She has difficulty concentrating, experiencing memory lapses, and has gained weight. Ms. N. C has also been sleeping through some of her classes and has experienced a decline in her social activities. She initially made friends and enjoyed outings, but lately, she has found her friends annoying and feels less motivated to engage in social activities. She dislikes the cold weather and describes the city as dark, grey, and miserable, contributing to her negative mood.

Past Psychiatric History:

• General Statement: The patient has no previous psychiatric history.
• Caregivers (if applicable): N/A
• Hospitalizations: No history of past hospitalizations
• Medication trials:  No previous history of medication trials
• Psychotherapy or Previous Psychiatric Diagnosis: The patient does not have a previous psychiatric diagnosis or history of psychotherapy.
• Substance Current Use and History: She denies any history of substance use for herself, including nicotine, illicit substances (including marijuana), or alcohol. However, she reports taking caffeine daily. The patient does not report any withdrawal complications, such as tremors, delirium tremens, or seizures.

Family Psychiatric/Substance Use History: The patient acknowledges a known history of depression within the family but denies any history of substance use.

Psychosocial History: N.C. is a 17-year-old White American female born and raised in New Orleans, Louisiana. Growing up, N.C. lived with both of her parents and four brothers. However, her residence is a specialty high school dormitory in Chicago, Illinois. Among her siblings, N.C. is the only girl and the youngest. Presently, she is not married and remains single, without any children. Being a full-time high school student, Natalie prioritizes her studies in the business program. In addition to her academic pursuits, she also holds a part-time job at a local coffee shop. She enjoyed socializing and participating in recreational activities in the past, but her interest in them has waned. Notably, N.C. has a clean record with no history or current legal issues.

Medical History: No history of hospital admission

• Current Medications: She takes no medications
• Allergies: NKDA

Reproductive History: She experienced menarche at 14 and continues to have regular menstrual cycles within a 28-day cycle without complications such as dysmenorrhea or menorrhagia. At present, she is unmarried and remains single, without any children. Furthermore, there is no record of her using contraceptives, and she confirms not being sexually active.

Review of Systems (ROS):

GENERAL: Ms. N. C is a 17-year-old White American female with a height of 5’2″ and a weight of 192 pounds. She presents with a downcast mood, slouched posture, and signs of decreased engagement, such as a lack of eye contact, reflecting her reported feelings of not doing well and exhibiting a low mood.

HEENT:

• Eyes: She has no loss of vision, double vision, painful eyes, or jaundice.
• Ears, Nose, and Throat: She does not experience any auditory impairments, such as hearing difficulties. Additionally, she is unaffected by symptoms like sneezing, congestion, a runny nose, or a sore throat. Furthermore, no recent nasal polyps, nosebleeds, or sinus infections have occurred. She exhibits no challenges related to chewing or swallowing, and there are no indications of gingivitis or bleeding gums.
• Skin: She denies experiencing any skin rashes or lesions. Her hair appears e