Dr. Martin and classmates, Week 6 (Part 2) Mental Health Disorder Patient Information: J.P. is a 22-year-old caucasian female musician in 2nd year of college S. CC (chief complaint): Patient presents to the office with and states “My boyfriend and parents made me come in because he says I am more moody than normal and sometimes I do not want to get up and go to class or leave the house-but he is getting on my nerves anyway, I think I just need to dump him”. HPI:Onset: The patient reports that she has some days over the past few months where she has not wanted to get out of bed or go to class but that is mainly when she is too tired from doing something the night before. She reports some days she does go to class but finds it too boring and goes out to the local bars and drinks- and forgets about the time and her boyfriend at home.Location: No specific physical complaints, other than she does wake up with hang overs from “partying all night” a few days a week. Duration: The patient reports starting to have trouble in her senior year with alcohol but never used any drugs then. Has tried cocaine, ecstasy and valium while at college.Characteristics: The patient does not believe she has done anything wrong and is just present here because her boyfriend and parents recommend she see a doctor due to the mood swings and promiscuous behavior. Aggravating Factors: The patient reports sometimes she does not feel like herself when she is at home, says she is “suffocating” and needs to be “out”. Occasional insomnia makes it worse- then she finds herself drinking more. Relieving Factors: She says she has been experimenting with different kinds of alcohol and drugs as they seem to make her “feel normal”. Current Medications:norgestimate/ethinyl estradiol 0.25 mg/35 mcg po daily (Sprintec) Allergies:PCN-rash as child (as told by parents), strawberries (lip swelling) PMHx:Tonsillectomy as a child, Treated for Gonorrhea and Chlamydia last year. Soc Hx:J.P. is in in college, majoring in music- but does not have much interest in the classrooms. Lives with her parents and younger sister. Has boyfriend that she sees a couple times per week.Occasional tobacco use and almost daily alcohol use. Does not remember the last time she has seen a doctor- probably before she started college a couple years ago. Fam Hx:Father- HTN, Mother- anxiety/ depression-not medicated, Younger sister- healthy, Grandmother- Bipolar (does not see, only met as a child), Grandfather- deceased from Parkinson’s disease. ROS

CONSTITUTIONAL:No weight loss, fever, chills, weakness or fatigue. HEENT:Eyes:No visual loss, blurred vision, double vision or yellow sclerae. Ears, Nose, Throat:No hearing loss, sneezing, congestion, runny nose or sore throat. SKIN:No rash or itching. CARDIOVASCULAR: No chest pain, chest pressure or chest discomfort. No palpitations or edema. RESPIRATORY:No shortness of breath, cough or sputum. GASTROINTESTINAL:No anorexia, nausea, vomiting or diarrhea. No abdominal pain or blood. GENITOURINARY:No dysuria. No pregnancies. Last