NR602 WEEK 7 I HUMAN CASE FINAL DIAGNOSIS
INFECTIOUS VULVOVAGINITIS CHAMBERLAIN
UNIVERSITY Case Study Analysis Patient Presentation: •
Chief Complaint (CC): Vaginal itching, burning,
abnormal discharge, or odor.
Patient History: Sarah Jamieson
1. Chief Complaint (CC):
o Presents with mood instability, depressive episodes, and
impulsive behaviors.
2. History of Present Illness (HPI):
o Reports ongoing mood swings for several years.
o Episodes of elevated mood with increased energy, reduced
need for sleep, and impulsive decisions.
o Alternating periods of depression, low energy, and feelings
of hopelessness.
o Engages in risky behaviors, including alcohol use.
3. Past Psychiatric History:
o Possible previous diagnosis of bipolar disorder or related
mood disorder.
o History of depressive and manic/hypomanic episodes.
o Possible prior psychiatric hospitalizations or therapy.
4. Medical History:
o No major physical health concerns reported (unless
specified).
o Any history of substance use affecting mental health?
5. Family History:
o Family history of mood disorders, such as bipolar disorder
or depression?
o Any genetic predisposition to mental health conditions?
www.stuvia.com/user/hopeliz
, 6. Social History:
o Possible stressors, including work, relationships, or financial
issues.
o History of substance use (alcohol).
o Support system – family, friends, or therapy?
7. Medications:
www.stuvia.com/user/hopeliz
, Currently on mood stabilizers, antidepressants, or other
o
psychiatric medications?
o History of medication noncompliance?
8. Diagnosis & Plan:
o Likely bipolar disorder given symptoms.
o Treatment could include medications (mood stabilizers,
antipsychotics, therapy) and lifestyle modifications.
Physical Exam for Sarah Jamieson
A physical exam in the context of a psychiatric evaluation is primarily
used to rule out medical conditions that might contribute to mood
instability. Below is a structured physical exam based on Sarah
Jamieson's case:
General Appearance:
Well-groomed or disheveled?
Signs of psychomotor agitation (restlessness, excessive movement)
or retardation (slow movements, low energy)?
Eye contact: appropriate, poor, or intense?
Vital Signs:
Blood Pressure (BP): Elevated or within normal range?
(Hypertension could indicate anxiety or stimulant use.)
Heart Rate (HR): Elevated in mania, anxiety, or stimulant use.
Respiratory Rate (RR): Normal vs. increased (could indicate
anxiety or substance withdrawal).
Temperature: Rule out fever (infection-related causes of
delirium).
Weight/BMI: Any significant weight loss/gain (suggestive of
depression, metabolic issues, or medication side effects)?
Neurological Exam:
www.stuvia.com/user/hopeliz
INFECTIOUS VULVOVAGINITIS CHAMBERLAIN
UNIVERSITY Case Study Analysis Patient Presentation: •
Chief Complaint (CC): Vaginal itching, burning,
abnormal discharge, or odor.
Patient History: Sarah Jamieson
1. Chief Complaint (CC):
o Presents with mood instability, depressive episodes, and
impulsive behaviors.
2. History of Present Illness (HPI):
o Reports ongoing mood swings for several years.
o Episodes of elevated mood with increased energy, reduced
need for sleep, and impulsive decisions.
o Alternating periods of depression, low energy, and feelings
of hopelessness.
o Engages in risky behaviors, including alcohol use.
3. Past Psychiatric History:
o Possible previous diagnosis of bipolar disorder or related
mood disorder.
o History of depressive and manic/hypomanic episodes.
o Possible prior psychiatric hospitalizations or therapy.
4. Medical History:
o No major physical health concerns reported (unless
specified).
o Any history of substance use affecting mental health?
5. Family History:
o Family history of mood disorders, such as bipolar disorder
or depression?
o Any genetic predisposition to mental health conditions?
www.stuvia.com/user/hopeliz
, 6. Social History:
o Possible stressors, including work, relationships, or financial
issues.
o History of substance use (alcohol).
o Support system – family, friends, or therapy?
7. Medications:
www.stuvia.com/user/hopeliz
, Currently on mood stabilizers, antidepressants, or other
o
psychiatric medications?
o History of medication noncompliance?
8. Diagnosis & Plan:
o Likely bipolar disorder given symptoms.
o Treatment could include medications (mood stabilizers,
antipsychotics, therapy) and lifestyle modifications.
Physical Exam for Sarah Jamieson
A physical exam in the context of a psychiatric evaluation is primarily
used to rule out medical conditions that might contribute to mood
instability. Below is a structured physical exam based on Sarah
Jamieson's case:
General Appearance:
Well-groomed or disheveled?
Signs of psychomotor agitation (restlessness, excessive movement)
or retardation (slow movements, low energy)?
Eye contact: appropriate, poor, or intense?
Vital Signs:
Blood Pressure (BP): Elevated or within normal range?
(Hypertension could indicate anxiety or stimulant use.)
Heart Rate (HR): Elevated in mania, anxiety, or stimulant use.
Respiratory Rate (RR): Normal vs. increased (could indicate
anxiety or substance withdrawal).
Temperature: Rule out fever (infection-related causes of
delirium).
Weight/BMI: Any significant weight loss/gain (suggestive of
depression, metabolic issues, or medication side effects)?
Neurological Exam:
www.stuvia.com/user/hopeliz
