NRNP 6635 Case History Reports

Week 3: Mood Disorders

Training Title 2

Name: Ms. Julie Houston Gender: female

Age:19 years old

T 98.1 P-78 R-18 119/74 Ht 5’2” Wt 184lbs

Background: Recently started a business undergraduate program in Boston, MA after growing up and living in South Carolina her whole life. Grew up with both parents, two brothers, and one sister. Currently lives in off-campus housing with two other female roommates. Currently a full-time student, not employed. Not married, currently single. She has no previous psychiatric history; takes no medications. There is no psychiatric or substance use history for her or family. No legal hx NKDA

Symptom Media. (Producer). (2016). Training title 2 [Video]. https://video-alexanderstreet- com.ezp.waldenulibrary.org/watch/training-title-2

Training Title 8

Name: Mrs. Leslie Tilman Gender: female

Age: 32 years old

T- 97.6 P- 97 R 22 149/98 Ht 5’3 Wt 245lbs

Background: Recently had her first child two months ago. Currently married; stay at home mother after working in retail for 5 years. Grew up with both parents, one sister in Omaha, NE. Completed education through bachelor’s level, studying physics. Previous employment included research science as well as high school substitute teaching for 5 years prior to birth. No previous suicidal gestures; has uncle who committed suicide via GSW. She denied drugs/alcohol; uncle was opioid abuser. Hx of HTN-prescribed labetalol 100mg twice daily, admits to missing doses due to forgetting. No legal hx. Allergies: codeine

Symptom Media. (Producer). (2016). Training title 8 [Video]. https://video-alexanderstreet- com.ezp.waldenulibrary.org/watch/training-title-8

Training Title 18

Name: Ms. Ashley Domingo Gender: female

Age:20 years old

T-97.9 P-68 R-18 118/82 Ht 5’1 Wt 120lbs

Background: Currently living off-base in California, active duty in the Army, MOS 92M Mortuary Affairs Specialist. Grew up in Houston, TX with both parents and one brother. Completed education through high school. Currently partnered. No children. Mother history of depression; brother hx of cannabis use. No medical history. No legal hx; NKDA

Symptom Media. (Producer). (2017). Training title 18 [Video]. https://video-alexanderstreet- com.ezp.waldenulibrary.org/watch/training-title-18

Training Title 28

Name: Mrs. Louise Carson Gender: female

Age: 49 years old

T- 98.8 P- 99 R 20 150/88 Ht 5’5 Wt 135lbs

Background: Currently living in Indianapolis, IN, working full-time as a logistics buyer in a medical facility. Has an MBA. Lives with her husband and three children, three boys who are all teenagers. Born and raised in Indianapolis, IN with her mother and two sisters. Father deceased in MVA when she was 2 years old. Sister has depression; mother has history of being a “functioning alcoholic”. Recently informed by her PCP she has a “fatty liver.” Allergies: latex

Symptom Media. (Producer). (2016). Training title 28 [Video]. https://video-alexanderstreet- com.ezp.waldenulibrary.org/watch/training-title-28

Training Title 38

(same patient in video 43 but presentation of his illness pre-hospitalization) Name: Mr. Will Loman

Gender: male Age:19 years old

T- 98.6 P- 94 R 24 128/78 Ht 5’7 Wt 152lbs

family suicides. Mother reports he has slept 2–3 hours in past week, up spending money buying and playing new video games and says he is writing a book on how others can be a video game master. Appetite is decreased. No medical hx; Hx of trespassing as a juvenile. Has pending court date for indecent exposure. Allergies: PCN

Symptom Media. (Producer). (2016). Training title 38 [Video]. https://video-alexanderstreet- com.ezp.waldenulibrary.org/watch/training-title-38

Training Title 43

(same patient in video 38 but presentation of his illness with hospital treatment)

Name: Mr. Will Loman Gender: male

Age:19 years old

T- 98.2 P- 74 R 18 120/70 Ht 5’7 Wt 156lbs

Background: Currently lives with his sister and two parents in Jacksonville, FL. Not currently employed. Completed high school, not currently in school. Hx of treatment for mood disorder began age 15, previous trials of Depakote, Olanzapine off and on, side effects of wt. gain. Has hx of a three-day hospitalization one year ago after found wandering on the side of the freeway, but he signed himself out ‘against medical advice.’ He refused medication due to previous experiences. Not currently partnered. He has been sexually inappropriate with comments to female neighbors; pulled his pants down in the mall. He is currently in hospital admitted one week ago, was initiated on lithium 300mg po three times daily and risperidone 1mg at bedtime. Denies any recent alcohol or substance use. Father has history of bipolar disorder. No history of self-harm behaviors, no family suicides. Mother reports he has slept 2–3 hours in past week, up spending money buying and playing new video games and says he is writing a book on how others can be a video game master. Appetite is decreased. No medical hx; hospital admission labs within normal ranges, UDS negative; Hx of trespassing as a juvenile. Has pending court date for indecent exposure. Allergies PCN

Symptom Media. (Producer). (2016). Training title 43 [Video]. https://video-alexanderstreet- com.ezp.waldenulibrary.org/watch/training-title-43

Training Title 150 Name: Ms. Liliana Ball Gender: female Age:16 years old

T- 97.4 P- 84 R 18 134/88 Ht 5’3 Wt 118lbs

Background: Currently living with her parents in Tacoma, WA along with two young siblings. She is a sophomore in high school, not currently partnered, reports she is bisexual, lately having lot

of unprotected sex that her parents don’t know about. She has been stealing money out of her mom’s purse to buy clothes, makeup, “and just other things.” She has history of treatment since age 7 for conduct disorder, depression, history of taking sertraline which worsened her irritability, aggression, impulsivity. She has been in a 3-month teen residential mental health facility discharged one month ago with lithium 300mg in am and 600mg at bedtime, aripiprazole 10mg in the morning. When discharged, her labs were within normal ranges and urine toxicology negative. She was positive for cannabis upon admission. Her parents believe she is hiding her medication as she has made comments “they slow me down; they crush my creative art.” She has hx of domestic violence toward her mother and 2 younger sisters as juvenile. No current legal issues. Her grandmother has hx of bipolar disorder; her mother and her maternal aunt have anxiety. She is sleeping 3–4hrs/24 hrs. Reports her appetite “is great.” She has no medical issues; has Nexplanon implant; hx of self-harm with cutting.

Symptom Media. (Producer). (2018). Training title 150 [Video]. https://video-alexanderstreet- com.ezp.waldenulibrary.org/watch/training-title-150

Training Title 118 Name: Mr. Oscar Luna Gender: male

Age: 52 years old

T- 98.6 P- 90 R 24 140/84 Ht 5’8 Wt 170lbs

Background: Born and raised in Leopold, IN. Is staying at a shelter after being homeless in MacArthur Park for 1 year in Los Angeles. He lost his apartment and his job working part-time as a dishwasher. Enjoys playing music. He has long hx of mental health treatment since age 14. Previous medication trials include lithium (toxicity), Depakote (wt gain), aripiprazole (akathisia), risperidone (dystonia), haloperidol (didn’t give a fair trial), quetiapine (wt gain), reports in past helpful medication was lurasidone, lamotrigine, olanzapine but states “they really squash my creative song writing though.” Poor historian. Never married, reports he is gay, no children; estranged from only living sister, parents deceased. He is not sure of his family mental health or substance use history but feels like he is most like his aunt, she has history of mental health treatment “but I’m not sure for what.” States that he got a master’s degree in music theory at Stanford. Admits to 1–3 drinks of alcohol when “playing music in the clubs”, denied illicit drugs, has history of overdose at age 28, history of 3 inpatient psychiatric hospitalization, most recent was 1 year ago. Allergies: doxycycline; hx of rosacea.

Symptom Media. (Producer). (2018). Training title 118 [Video]. https://video-alexanderstreet- com.ezp.waldenulibrary.org/watch/training-title-118

Training Title 144 Name: Ms. Amy Hartford Gender: female

Age: 32 years old

T- 98.2 P- 74 R 18 120/70 Ht 5’1 Wt 150lbs

Background: Currently lives in Phoenix, AZ, divorced with two children ages 10 and 8. Born and raised in Tucson, AZ with her mother and four sisters NKDA; no legal hx

Symptom Media. (Producer). (2018). Training title 144 [Video]. https://video-alexanderstreet- com.ezp.waldenulibrary.org/watch/training-title-144