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JACQUELINE RUSSELL IHUMAN-FATIGUE CASE STUDY (4).docx

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JACQUELINE RUSSELL IHUMAN: "FATIGUE"




Jacqueline Russell iHuman
Case Study: “Fatigue”“A 17
Year Old”ihuman Case
Study

, JACQUELINE RUSSELL IHUMAN: "FATIGUE"



HPI (OLDCARTS)

References

BrightFutures. (2019). Anticipatory guidelines. https://brightfutures.aap.org/Bright%20Futures
%20Documents/BF4_AdolescenceVisits.pdf Centers for Disease and Control and Prevention (CDC). (2021).
Are you getting enough sleep. https://www.cdc.gov/sleep/features/getting-enough-sleep.html

Dunphy, C., Laor, L., Te, A., Kaplan, S., & Chughtai, B. (2015). Relationship Between Depression and Lower
Urinary Tract Symptoms Secondary to Benign Prostatic Hyperplasia. Reviews in urology, 17(2), 51–57.
https://doi.org/10.3909/riu0658

Gao, S. Y., Wu, Q. J., Zhang, T. N., Shen, Z. Q., Liu, C. X., Xu, X., Ji, C., & Zhao, Y. H. (2017).
Fluoxetine and congenital malformations: a systematic review and meta-analysis of cohort studies. British
journal of clinical pharmacology, 83(10), 2134–2147. https://doi.org/10.1111/bcp.13321

Groenman, A., Janssen, T., Oosterlaan, J. (2017). Childhood psychiatric disorders as risk factor for subsequent
substance abuse. https://doi.org/10.1016/j.jaac.2017.05.004

Kuria, M. W., Ndetei, D. M., Obot, I. S., Khasakhala, L. I., Bagaka, B. M., Mbugua, M. N., & Kamau, J. (2012). The
Association between Alcohol Dependence and Depression before and after Treatment for Alcohol Dependence.
ISRN psychiatry, 2012, 482802. https://doi.org/10.5402/2012/482802

Mullen S. (2018). Major depressive disorder in children and adolescents. The mental health


Jacqueline Russell is a 17-year-old female who comes in the clinic with complaints of generalized fatigue
which started two months ago. Accompanying symptoms include anxiety, anhedonia, irritability, and problems
concentrating. Major life changes include recent breakup with her boyfriend and pressure in school while
expected by her parents to have a scholarship. She stated that she gets enough sleep but still feel tired
upon waking up. Key findings include being overweight, easily cries, unintentional 25-30 weight gain last
year, history of marijuana use, Acanthosis Nigricans, and striae on abdomen and buttocks. She denies
taking any medications other than Ibuprofen for menstrual cramps. She occasionally drinks beer. The
patient skips breakfast but eats high calorie foods like pizza and French fries several times per week. The
patient denies any suicidal ideations but stated that she wants to “disappear” and not deal with her situation.
Risk factors include family history of diabetes II and obesity . Lab findings are negative for anemia, negative
urine drug screen, normal T4, TSH levels, and CBC.


Key Findings:
BMI 28.8 (overweight)
Patient is reluctant to make eye contact Crying
Pressure from being a senior at school
Mother made her come, pressure from parents Per patient
gets enough sleep but wakes up tired Unintentional 25-30
weight gain last year Stretch marks
Marijuana use Hx with old boyfriend Breakup
with boyfriend
Low self-esteem
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