Physical Examination
Chief Complaint
The patient was a male, and he sought medical help since he felt sad, and he felt down. He felt as if he always wanted to stay alone to mean that he had lost pressure as well as the interest in the daily activities. This had had a substantial impact on him. He had no friends, and this made him unhappy with the life he was living.
History of the Present Illness
The man has been having this condition for approximately four months. Recently, he tried committing suicide since he felt as if he was worthless, but his efforts proved futile. His lonely life has made him feel as if he is unwanted in society, and he feels unworthy of having any friends. He has tried listening to music and even going for nature walks as a way of relieving himself, but he thinks that this is not a complete solution to his problem.
Medications
The patient was initially administered with mood stabilizers. These are medicines that treat as well as prevent the highs and lows, which are known as mania and depression, respectively (Jann, 2014). The drugs have helped the patient to keep his moods from interfering with his social, work, and even school life. The mood stabilizers that the patient was administered with was Valproic acid. The medicines helped in treating the full episodes of both depression and mania for a while.. Don't use plagiarised sources.Get your custom essay just from $11/page
Allergies
The patient has an allergy to fish, beans, and even fur.
Past Medical History
The patient’s condition started after he lost his parents in a tragic road accident. From then, he felt alone, and he has been battling with his condition for a long time. Earlier on, he had been diagnosed with PTSD (Post- Traumatic Stress Disorder). PTSD is described as a mental health condition that is often triggered by a terrifying event whereby the individual can witness and even experience it (Culpepper, 2014). The patient had symptoms such as nightmares, anxiety, and even flashbacks. He also had uncontrollable thoughts about the event, which made it hard for him to cope with the situation.
Past Surgical History
The patient had earlier gone through an appendectomy. This is the surgical removal of the appendix. The surgical operation was done in a bid to treat appendicitis, which was a condition characterized by the inflammation of the appendix.
Family History
The patient’s family has a history of high blood pressure and Diabetes.
Social History
The patient is literate, he is an alcohol and cigarette addict, and he is sexually inactive.
Lifestyle habits
The patient does no exercise at all, and he has a low appetite. He eats very little and can even go a day without food. He lives a stressed life, and he smokes and drinks a lot.
Overview
From looking at the patient, he seems as if he is confused. When he is given an instruction, he has to be reminded about it twice or thrice for him to do it. He is also not alert, and he has a poor concentration.
Mental status
The patient is always in a bad mood, and he gets delusions and hallucinations often. He also has a poor memory, and he does not pay attention to what he is being told.
Vital Signs
Temperature: 36.9 0 C
Blood Pressure: 123/79
Pulse Rate: 88
General: The patient was distressed and not alert. He had a low appetite and, at times. His movement and speech as slowed. We talked with him for a while, and it was clear that his self- esteem was low. He was a poor decision maker and even claimed that he had unintentionally lost weight.
Heart: No, murmurs.
Respiration Rate: 13 breaths per minute.
Lungs: CTA bilaterally
Skin: No, rashes.
Labs: The TSH, CBC, and lytes have normal limits.
PV: 48%
Weight: 50 kgs
Mouth: The mucous membranes in the mouth are moist.
Neurologic: The patient experience changes in mood, anxiety, and even headaches. She claims that she does not have any tingling or numbness.
Chest: The patient has no chest pain, fatigue with exertion, and palpitations.Musculoskeletal: The patient has no muscle weakness, hypotonia, and even hypertonic pain.
Face: The patient has no rashes on the face.Neck: The patient has a full active ROM, and the thyroid is non- palpable.
Breast: The patient has no dominant masses on the breasts, and he has no nipple abnormality.Abdomen: The bowel sounds are normal; there are no masses or tenderness.
HEENT
Head: The scalp has no lesions, and his hair has a normal texture.
Eyes: the sclera and conjunctiva are white and pink, respectively.
Ears: There are no lesions on the external ear, and the auditory canal is normal.
Nose: The septum is in the middle.
Throat: No lesions are present on the throat.
Diagnosis
The patient has bipolar disorder. It is a condition characterized by recurrent episodes of depression and mania (Rowland & Marwaha, 2018). The patient was administered with antidepressants such as Fetzima. He was also to talk to a counselor thrice a week where he could be helped on how to cope with negative feelings.
Educational
The patient was also to exercise for at least 45 minutes for 4 to 6 days a week, and he was to avoid cigarettes and alcohol.
Consultation/ Collaboration
The patient was to consult with his doctor every week, and he was not to visit another doctor as a way of promoting consistency in his treatment.
References
Culpepper, L. (2014). The diagnosis and treatment of bipolar disorder: decision-making in primary care. The primary care companion for CNS disorders, 16(3), PCC.13r01609. https://doi.org/10.4088/PCC.13r01609
Jann M. W. (2014). Diagnosis and treatment of bipolar disorders in adults: a review of the evidence on pharmacologic treatments. American health & drug benefits, 7(9), 489–499.
Rowland, T. A., & Marwaha, S. (2018). Epidemiology and risk factors for bipolar disorder. Therapeutic advances in psychopharmacology, 8(9), 251–269. https://doi.org/10.1177/2045125318769235