Determine the Diagnoses of a Patient Encounter

Determine the Diagnoses of a Patient Encounter

Chief Complaint:

Older sister reports – “Our mother died three weeks ago and we lost our father several months ago. I think that my sister was depressed and just wanted to be with them.”

History of Present Illness:

31-year-old female who was brought to the hospital by ambulance. She was found slumped over in her car in front of the funeral home where memorial services for both her father and mother had recently been held. On the seat beside her were two empty bottles of sleeping pills, a Bible opened to Psalm 23, and a note that read: “I am going to be with mom and dad. It is just too sad being here anymore without them. I love you all and you will be in my prayers.” When she was found by the funeral home director her hair was oily and unkempt and she smelled as if she had not bathed in a long time. She was wearing a dirty orange T-shirt and jeans.

PMH:

Depression when she was a junior in HS which led to psychiatric admissions at 15 and 19 years of age. For these admissions she was treated with antidepressants and psychotherapy. Length of stay for both admissions was approximately 5 weeks. At age 19, following a suicide attempt, she met her first husband in the psych ward of the hospital. Diagnosed with bipolar disorder 6 years ago.

Information from Sister:

Older sister reports ‘hard life’. Reports both parents were alcoholics. Parents would go to bars almost every night and leave the 8 children in the care. The children were eventually removed from the home. Some of the children went to the Catholic girls’ home others were placed in “horrible” foster homes where they were subjected to physical and sexual abuse.

Reports numerous siblings, including the patient, have been through several detoxification centers for alcohol abuse.

Patient is in her second marriage with 3 daughters – 2 from the first marriage and 1 from the current marriage.

Reports that after having her third baby the patient went into a ‘terrible depression’. The patient was under the care of a psychiatrist for this depression and was placed on an anti-depressant after about 3 months of being under the psychiatrist’s care. After 3 weeks of being on this anti-depressant the patient is reported as having gotten ‘really weird’; patient was staying up all night pacing around her house and talking to people on the phone, she would go on shopping sprees for 2-3 days at a time and max out all her credit cards. The patient finally crashed and was taken to the hospital by her family and it was during this admission, 6 years ago, that the patient was diagnosed with bipolar disorder. Sister reports the patient has been on Lithium since being diagnosed with bipolar disorder.

Reports their father had been sick for a while so his death was not unexpected. However, their mother went downhill fast and the patient is reported to not cope well with the mother’s illness/death.

Reports the patient hadn’t been eating lately with noted weight loss. Additionally, the sister reports the patient had been smoking and drinking ‘more than usual’ lately.

Family Hx:

Paternal grandmother – depression

Two maternal aunts – bipolar disorder

Mother and father – alcohol abuse

Father died from pancreatic cancer

Mother died from heart failure

3 living brothers, 3 living sisters, one deceased brother who had an AMI at age 34

Social Hx:

Divorced and remarried

Worked as a nurse’s aid and health insurance claims adjuster

Attends church regularly

Smoked 1ppd for 15 years

History of alcohol abuse with several DWI violations

History of IV drug use, not in the last 10 years

ROS:

Information from sister:

Neuro – history of migraine headaches since late teens, takes Imitrex prn

SIGECAPS:

Sister reports: at times the patient is up all night – particularly when bipolar symptoms not well controlled, the patient seemed to be more depressed since the loss of their mother, does not believe the patient felt guilty surviving parents, patient has been not been attentive to her personal hygiene, the patient appeared to be obsessing on parental loss, patient appeared to be losing weight and therefore suspect she was not eating well, patient seemed to not be engaging in typical daily activities; patient had not expressed having suicidal ideations, had not expressed homicidal ideations

Medications:

Lithium 600mg po Q AM and 600mg po Q HS

Sumatriptan 50-200mg po PRN

Allergies:

ASA – swelling of face

Physical Examination:

General – lethargic and slow to respond to questions; BP 110/72, P 66, RR 12, T 97.0, SpO2 on RA 95%, Ht 66 in, Wt 135 lbs, BMI 21.8

Integument – skin pale, warm, dry; good turgor; several cystic lesions on chin; no rashes, ecchymoses or petechiae noted

HEENT – Head is normocephalic and atraumatic, pupils dilated with sluggish reaction to light, TMs gray and shiny bilateral, nares patent without discharge noted, no tonsillar enlargement, moist mucous membranes

Neck – supple without adenopathy, no thyromegaly

Lungs – CTA

Breasts – deferred

Cardiovascular – heart with RRR without murmur/gallop, multiple varicosities noted bilateral lower extremities

Abdomen – soft, non-distended, active bowel sounds, non-tender, no organomegaly

Genitalia/Rectum – deferred

Musculoskeletal – no major limitations of ROM or gross abnormalities noted

Neurologic – oriented to person, DTRs 2+ and equal bilateral, no localizing signs, CN II- XII grossly intact

Diagnostics – Na 139 meq/L, K 3.7 meq/L, Cl 108 meq/L, HCO3 23 meq/L, Bun 10 mg/dL, Cr 0.7 mg/dL, fasting Glu 102 mg/dL, Ca 8.7 mg/dL, PO4 3.2 mg/dL, Protein 4.8 g/dL, Mg 2.0 mg/dL, AST 33 IU/L, ALT 20 IU/L, GGT 82 IU/L, Alb 2.9 g/dL, TSH 4.1, Vit B12 203 pg/mL, Hgb 12.2 g/dL, HCT 36.8 %;

Lithium 0.08meq/L

Urine dipstick – 6.3 pH, SG 1.021, all other parameters negative

Assessment:

You will be evaluating the subjective and objective data sets to determine the diagnoses for a patient encounter.

Plan:

The plan cannot be developed until the diagnoses are assigned.

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