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Bipolar Disorder 2

Chief complaint: “I don’t know myself anymore”.

 Demographic data: Mrs. J is a 35 year old, Caucasian female. Highest level of education: High school. She has been married for 7 years and has 2 young children and had several jobs. She currently works as a customer service representative for an auto insurance company. Her husband owns a small moving company, he works long hours. She reports they both share household chores. Denies belonging to a religious group. Does not exercise regularly. She gets together with her friends every other Saturday.

 HPI: Mrs. J explains that she has been experiencing episodes of depressed mood, lack of energy, deep feelings of guilt, loss of interest in sex and some thoughts that life wasn’t worth living. She states that her symptoms began after the birth of her first child and that her symptoms have “just been getting worse and worse” and it is beginning to affect her relationship with her husband. At work, she has concerns that her new boss and colleagues think her work is poor and slow, and that she is not friendly. She explains she has no energy or enthusiasm at home. Instead of playing with her children or talking to her husband, she watches TV for hours, eats lots of snack and sleeps long hours. She gained six pounds in just three weeks, which is making her feel even worse about herself. She states that she cried many times through the week, especially at night when the kids are asleep. Going out with other moms makes feel better about herself, but explains that her husband wouldn’t let her do that anymore because “I have too much fun for my own good”. She feels sad because her husband recently opened up a separate bank account and that makes her feel that he’s somewhat pushing her away.

Additionally, she complains of an IBS exacerbation. “I had been feeling cramps in the abdomen and diarrhea all day today which always happen every time I get stressed out.” She reports either sleeping “10 hours or 3 hours, there is no middle ground”.

 

PMHX: Bilateral plantar fasciitis, lower back pain, right shoulder tendinitis, IBS.

PSHX: Cholecystectomy (2013)

Social History: Reports 2 - 4 cans of beers on weekends only. Former cigarette smoker for 12 years (quit with 1st pregnancy in 2015), denies recreational drug use

Family History:  Father HTN, HLD. Mother diseased year 1999. She passed away while being hospitalized for complications of alcohol intoxication.   

Hospitalizations: Cholecystectomy (2013). Deliveries x 2 (2015, 2017)

Immunizations: up to date, never had a flu shot

 

Medications: Tizanidine 4mg BID as needed for back pain. Ibuprofen 800mg Q8Hs as needed for right shoulder pain or foot pain.

Allergies: NKDA

 

Subjective findings:

General: Reports “I’m tired of feeling this way, I’m exhausted”, also “had 3 trips to the bathroom today due to my IBS”

Skin: no concern for lesions

HEENT: No sore throat, ear pain, eye drainage, or lymphadenopathy

Lungs: No SOB or decreased activity tolerance

CV: No murmurs heard, denies CP

Abdomen:  intermittent diarrhea with increased stress

 

Objective findings:

PE: Height 5'4", Weight 152 pounds, BMI 26.1

Vital signs: BP 128/75, T 98.1, P 82, R 20 Sao2 99% on RA 

General: 35-year-old Caucasian female appears stated age in no apparent distress. Alert, oriented, good eye contact, answers to questions appropriately with lengthy responses. Able to speak in full sentences and does not appear breathless. She is moving constantly and ruffling through her purse but does not know what she is looking for. When describing her HPI she alternates laughing and crying with intermittent tearfulness.

Skin: Skin warm, dry, and intact. Skin color is pale pink, no cyanosis or pallor. 

HEENT: Head normo-cephalic. Hair thick and distribution even throughout scalp.  Eyes: Sclera clear. Conjunctiva: white, PERRLA, EOMs intact. Ears: Tympanic membranes gray and intact with light reflex noted. Pinna and tragus non-tender Nose: Nares patent with thin white exudate noted. Mucosa appears boggy and pale. Deviated septum noted. Sinuses non-tender to palpation. Throat: Oropharynx pink, moist, no lesions or exudate. Teeth in good repair, no cavities noted. Tongue smooth, pink, no lesions, protrudes in midline. Neck supple. No cervical lymphadenopathy or tenderness noted. Thyroid midline, small and firm without palpable masses. 

Lungs: Lungs clear to auscultation bilaterally. Respirations unlabored. No wheezing noted. 

CV: Heart S1 and S2 noted, slight tachycardia, regular rate, no murmurs noted, no displaced PMI. Peripheral pulses equal bilaterally, no peripheral edema 

Abdomen: Abdomen round, soft, with bowel sounds noted in all four quadrants.

Diagnostic Testing:

PHQ-9: 15, GAD-7: 9