Assessing and Treating Adults With Mood Disorders

 
Subjective:

CC (chief complaint): “have a history of taking medications and then stopping them. I don’t think I need them. I really feel like the medication squashes who I am.”

HPI: Petunia Park is a 25-year-old female presenting for a mental health assessment. She reports a history of inconsistent medication adherence, expressing a belief that medication suppresses her true self. Petunia recalls a hospitalization during adolescence after experiencing four to five days of sleep deprivation and auditory hallucinations. She has since been hospitalized four times, with the most recent occurrence in the past spring. Past diagnoses include bipolar disorder, anxiety, and depression.

Petunia mentions trying medications like Zoloft and Seroquel, with vague recollection of another medication beginning with the letter “L”. She describes adverse reactions to prescribed medications. Additionally, Petunia discloses a previous suicide attempt. She acknowledges engaging in sexual activity with multiple partners as a means to elevate her mood. Furthermore, Petunia reports absenteeism from work due to depressive symptoms.

Substance Current Use: Petunia reports smoking one pack of cigarettes daily and expresses no intention to quit. She ceased alcohol consumption at the age of 19 due to negative effects. Past marijuana use induced paranoia, leading to discontinuation. She denies usage of cocaine, stimulants, inhalants, hallucinogens, sedatives, pain pills, or opiates.

Family Psychiatric/Substance Use History: Petunia discloses a family history of psychiatric and substance use disorders. Her mother was diagnosed with bipolar disorder and exhibited suicidal tendencies. Her father was incarcerated for approximately 8 to 10 years due to drug-related issues. Petunia suspects her brother to have mental health concerns but has not sought professional help.

Psychosocial History: Raised by her mother and older brother, Petunia currently resides with her boyfriend, occasionally staying with her mother. Her father is absent due to incarceration. She has no history of marriage or children. Employed irregularly at her aunt’s bookstore due to intermittent depressive moods, Petunia is pursuing cosmetology studies and enjoys painting and writing.

Medical History

Current Medications: Petunia has been diagnosed with Polycystic ovary syndrome (PCOS) and hypothyroidism. She is currently prescribed birth control pills for PCOS and an undisclosed medication for hypothyroidism. Petunia also takes a medication for her mental illness, vaguely recalling its name starting with the letter “L”. Past medications include Zoloft and Seroquel.
Allergies: Petunia reports no known allergies.
Reproductive Hx: Petunia experiences regular monthly menstrual cycles, with the last occurring last month. She is sexually active with multiple partners and under treatment for PCOS.
ROS: