Week 12 Assignment 1: O'Neil inhuman Case Study

Week 12
Assignment 1:
O'Neil inhuman
Case Study
Week 12 Assignment 1: O'Neil inhuman Case Study
Informed Consent
The patient was presented with informed consent about the psychiatric interview process and
treatment. She verbally agreed and signed the informed consent to be treated.
Identifying Data
Name: Sarah O'Neil Age: 25 years old Gender: Female
Sarah, a 25-year-old female, Depression
Subjective:
Chief Complaint: Depression. "I've been so sad almost every day for the past month
Sarah is aged 25 years and married. Her primary physician referred her to the emergency
department care for a depression diagnosis after a physical examination revealed no organic
explanations. Sarah came to PCP for an evaluation after her manager encouraged her to do so due
to sobbing bouts at work and impaired work performance. Sarah has been sad every day for the
past month and "every minute of the day" for the previous two weeks, according to her. She
supports suicidal thoughts but says she would not act on them because of her family and faith.
She's having paranoid thoughts and feels her coworkers are conspiring to get her fired. Sarah also
claims that about six weeks ago, she went days without sleeping, attempted to write a novel, and
acted in a way that was out of character for her. She went to a pub by herself, considered having
an extramarital affair, almost left with a male stranger, and passed out. Sarah also claims to have
gained weight recently and is dissatisfied with her appearance. Her sadness affects her
employment and relationships, and her marriage is suffering. Sarah recalls a previous depressive
period in high school, during which she engaged in self-harming behavior. Family history is
crucial because of the mother's illness and suicide seven years ago, the father's alcoholism, and
the sister's sadness.
Psychiatric History: None
Medical History: Up-to-date immunizations. Childhood asthma. Fatigue. Obesity
Social History: Married. Her spouse is kind, but her depression is straining their relationship.
There have been no reports of domestic violence.
• Cardiovascular: Denies chest pain, decreased exercise tolerance, palpitations, edema,
cold fingers, syncope, and cold toes.
• Gastrointestinal: Denies vomiting, bloating, constipation, nausea, early satiety, and
diarrhea
4
• Pulse: 68 bpm
• Respiration: 14 bpm
• SP02: 97%
Physical Exam
• Height: 5'3"
• Lymphatic: no lymphadenopathy
• Psychiatric
General: Oriented and alert to time and place. Casually dressed and obese.
Speech: increased speech rate (Hyperverbal)
Mood: Seems anxious and depressed
Thought content: Has passive suicidal thoughts, has paranoia, focuses on shame, writing
assessment Findings
Sarah seems to be having bipolar II disease with psychotic characteristics. For the last month,
Sarah says she's been sad every day, and for the past two weeks, she's felt sad "every minute of
every day." Because of her faith and family, she admits to having suicidal thoughts, but she says
she will not act on them. As a result of some delusional thinking, she believes she's being
targeted for dismissal by her colleagues. About six weeks ago, Sarah says she went days without
sleeping and behaved in a way that was clearly out of character for her. An extra-marital affair
was discussed at the pub, she nearly departed with a stranger, and she became blackout drunk.
Sarah has also recently gained weight and is dissatisfied with the way she looks, she tells us. For
a mother with schizophrenia, a father with alcoholism, and a sister with depression, the family
history is significant.