The final H&P

Chief complaint:
Chronic fatigue, poor concentration and procrastination

History of present illness:
Patient is a previously healthy 25 year old female who presents with a three month history of increasing sleeplessness, fatigue, mood swings and procrastination. Excessive caffeine intake provokes palpitations and nausea, and she notes having severe withdrawal headaches when not drinking sufficient amounts of coffee. She also states reacting friable and out of proportion to normal challenges and problems. Patient notes that symptoms started upon arrival in Irvine, California, where she has now finished two rotations in the third year of medical school. She states that symptoms have been fluctuating, especially worsening with night shifts, extremely early mornings, long hours at the hospital, drowned in what she states being "unnecessary amounts of paperwork" rather than actually learning what she is supposed to. The procrastination is her main concern when she actually has time to study, and instead feels the need to spend time painting her nails, sending text messages and playing Wordfeud. Symptoms have been relieved by golden weekends and occational opportunities to sleep in. She also states that this has happened before, but only for short periods of time right before exams in the past, and never to this extent.

PMHx/PSHx/FHX:
Not contributory

Social Hx: 
Patient is a 5th year medical student from the University of Oslo, now living in California. Denies any ellicit drug use, but admits to be consuming very large amounts of caffeine and diet sodas. She also states that she has sobered up the last couple of months. She has only been drinking alcohol on special occations while staying here, and especially decided to tone it down after an unpleasant episode of severe hangover and post-consumption anxiety.

Allergies: 
Alarm clock ringtone: Palptations and nausea when going off before 5 a.m.
No known drug allergies.

Review of systems:
Normal, except for what is noted in the HPI.  

Physical exam:
GEN: Patient is tired, irritable and not entirely cooperative, but not in any apparent distress.
HEENT: Marked dark periorbital circles, conjunctival injection
CV: Irregular rate and rythm, no murmurs, rubs or gallops
PULM: Clear to auscultation bilaterally, no wheezes, rhales or rhonchi
GI: Soft, non-tender, non-distended.
NEURO: grossly nonfocal.
SKIN: Pale, no rashes or cyanosis noted.

Impression:
This is a previously healthy 25 year old woman with symptoms of fatigue, mood lability and procrastination for the past three months. The reason for her symptoms can most likely be attributed to the abrupt change in living situation, increased work load and little time to rest. She is otherwise healthy, it is not likely that any other form of underlying illness can be the cause of her symptoms. After finishing her final exam today, the stress exposure should decline almost instantly. Her prognosis for full recovery is very good.

Plan: 
FEN/GI:
- Regular diet
- Recommend moderate alcohol consumption in the future - continue to monitor
- Decrease amount of caffeine containing beverages
Cardiovascular: Hemodynamically stable
Lungs: Stable on room air
- Recommend increased outdoor time and fresh air for the next couple of weeks
Activity level:
- Exercise as tolerated, in general increase activity level over the next couple of weeks.
Social:
- Post SHELF exam: Return to normal social life, including End of Rotation party in Long Beach tomorrow. Return to family and friends in Norway after a 10 day vacation to Las Vegas and along the California coast.
- Patient has been informed on and agrees with plan of care.

Kristin Vik, MS3