Jacqueline Russell iHuman Case Study: “Fatigue” “A 17 Year Old” ihuman Case StudyGuaranteed A+: Latest 2023:2024

Jacqueline Russell iHuman

Case Study: “Fatigue”“A 17

Year Old”ihuman Case

Study

HPI (OLDCARTS)

Jacqueline Russell is a 17-year-old female who comes in the clinic with complaints of

generalized fatigue which started two months ago. Accompanying symptoms include anxiety,

anhedonia, irritability, and problems concentrating. Major life changes include recent breakup

with her boyfriend and pressure in school while expected by her parents to have a scholarship.

She stated that she gets enough sleep but still feel tired upon waking up. Key findings include

being overweight, easily cries, unintentional 25-30 weight gain last year, history of marijuana

use, Acanthosis Nigricans, and striae on abdomen and buttocks. She denies taking any

medications other than Ibuprofen for menstrual cramps. She occasionally drinks beer. The

patient skips breakfast but eats high calorie foods like pizza and French fries several times per

week. The patient denies any suicidal ideations but stated that she wants to “disappear” and

not deal with her situation. Risk factors include family history of diabetes II and obesity. Lab

findings are negative for anemia, negative urine drug screen, normal T4, TSH levels, and CBC.

Key Findings:

BMI 28.8 (overweight)

Patient is reluctant to make eye contact

Crying

Pressure from being a senior at school

Mother made her come, pressure from parents

Per patient gets enough sleep but wakes up tired

Unintentional 25-30 weight gain last year

Stretch marks

Marijuana use Hx with old boyfriend

Breakup with boyfriend

Low self-esteem

Skips breakfast, eats high calorie foods like pizza and french fries several times per week

Constantly snack at night to keep going

Anhedonia in school and leisure activities

Upset, irritable, angry, frustrated, and cries daily

Feels irritable and annoyed a lot by family and parents, they blame on her periods.

Problems concentrating daily

Wants to disappear and not deal with situation

Occasionally drinks beer

Acanthosis Nigricans at nape

Striae on abdomen and buttocks

Meds:

Takes Ibuprofen for menstrual cramps, pain is not bad per patient.

Social

Tried marijuana last year with old boyfriend, denies any other recreational drugs

Used to baby sit for a family neighbor

Primary Dx:

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