iHuman Case Study: Jacqueline Russell, 17-Year-Old Female Presenting with Fatigue, Exams of Nursing

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Female Presenting with Fatigue 2025

Patient reports doing poorly in school and lack of interest Patient reports having sexual intercourse with her ex-boyfriend. Reports drinking one-two alcohol drinks Reports trying marijuana one time V i t a l s :

S kin: Warm, dry

Temp : 98.6 F

Pulse: not documented

BP: not documented

Resp iration: not documented

Female Presenting with Fatigue 2025

M ental

status: A and O x 4

S p O2: 99%

G e n e r a l : Ms. Jacqueline Russell is a 17-year old Caucasian female who came into today with her moms due to increase fatigue. The patient is reluctant to make eye contact during the interview. Patient reports a weight gain of 15-20 pounds. S k i n / B r e a s t : Skin/hair/nails: Thickness and distribution pattern typical for patient gender and age. Capillary refill is normal H E E N T & N e c k : Neck: Neck is supple full range of motion, No abnormal lumps felt around cervical or thyroid. No visible scars or deformities Trachea is midline C a r d i o v a s c u l a r : Heart sounds are normal. Pulses are felt in all extremities R e s p i r a t o r y : Chest wall is symmetrical upon expansion. No distention masses or rashes noted over chest wall. Bilateral lungs clear to auscultation. A b d o m e n / G a s t r o i n t e s t i n a l : Abdomen is mildly obese with scattered abdominal striae. No palpable mass noted. G e n i t o u r i n a r y : Normal external genitalia. No signs of vulvar infectin or trauma. Striae noted on buttocks. M u s c u l o s k e l e t a l : No asymmetry or deformity of back, no tenderness noted. No tenderness, muscular resistant, rigidity or deformities noted in extremities. O s t e o p a t h i c : Deferred N e u r o l o g i c a l : Alert and Oriented times 4. Irritable at times P s y c h o l o g i c a l : Patient will not maintain eye contact while talking. Positive for decrease in activities and lack of motivation. Denies any homicidal or suicidal thoughts or self-harm. Patient does report that she just wants to disappear A l l e r g i c / I m m u n o l o g i c : No known allergies L y m p h a t i c / E n d o c r i n e : No enlarged lymph nodes noted H e m a t o l o g i c : Deferred

Female Presenting with Fatigue 2025

K e y F i n d i n g s D D x

Evaluated MSAP: Depression Related: Anxiety Related: Weight-gain Related: Irritability Unrelated: Stria

Your Findings

Key Finding Relation to MSAP Depression MSAP Anxiety Related Weight-gain Related Irritability Related Stria Unrelated

Expert's Feedback

Key Finding MSAP Relation

Decreased energy / interest in pleasurable activities (anhedonia) MSAP

Fatigue RELATED

Irritability RELATED

25+ lb weight gain RELATED

Crying more than usual RELATED

Recent decline in school grades RELATED

Mild to moderate obesity/elevated BMI RELATED

Acanthosis nigricans UNKNOWN

Acne UNKNOWN

Striae UNKNOWN

Family history of obesity, DM, and HTN UNKNOWN

The medical key findings list, or list of pertinent findings you have compiled, should include everything that is out of the ordinary about this patient, even when it is not a "problem" in the true sense of the word.

Female Presenting with Fatigue 2025

The key findings list allows you to begin to see the overall or unified constellation of significant signs and symptoms. It is also the starting point for developing, and then ranking, your diagnostic hypotheses. The pertinent presence or absence of other critical signs and symptoms will aid your assessment of the severity of the presenting complaint and your assessment of potential comorbidities. Jacqueline's main reason for her visit today and most significant active problem (MSAP) is her anhedonia or loss of interest and decreased energy for activities that used to give her pleasure. Her fatigue, irritability and daily episodes of crying could be related factors contributing to her anhedonia. Jacqueline also states that she has had difficulty concentrating at school. Her decline in her school grades could be a result of all of the chronic issues listed above. Because Jacqueline has had fatigue, her decreased level of activity could contribute to her weight gain and obesity. The physical exam findings of acanthosis nigricans, acne and striae are important to note, but at this point, we are unsure if they are related to the most significant active problem. Her family history of obesity, DM and HTN is also important to note as this will guide our differential and testing. However, we are unsure at this point if it is related to the most significant active problem.

Your Problem Statement

Patient is showing signs and symptoms of depression

Expert's Feedback

Jacqueline RUssell is a 17-year-old female who presents with a history of fatigue and lack of energy for the past two months; associated with irritability and weight gain. Her symptoms have led to a decline in her school performance and lack of participation in her usual activities. She has been crying on a near daily basis over the past month. On physical exam, she has an elevated BMI, is tearful, and is noted to have acne, striae, and acanthosis. She denies any active suicidal thoughts.

History Physical Exam Assessment Tests Diagnosis P

O r g a n i z e K e y F i n d i n g s W r i t e P r o b l e m S t a t e m e n t S e l e c t P r o b l e m C a t e g o r i e s S e l e c t D i f f e r e n t i a l D i a g n o s e s R a n k D i f f e r e n t i a l D i a g n o s e s S e l e c t T e s t s

Expert's Problem Statement

Jacqueline RUssell is a 17-year-old female who presents with a history of fatigue and lack of energy for the past two months; associated with irritability and weight gain. Her symptoms have led to a decline in her school performance and lack of participation in her usual activities. She has been crying on a near daily basis over the past month. On physical exam, she has an elevated BMI, is tearful, and is noted to have acne, striae, and acanthosis. She denies any active suicidal thoughts.