NR 603 Week 6 Part 1 Mental Health Disorders

NR 603 Week 6 Mental Health Disorders

Include their actual chief complaint, demographic data, HPI, PMHX, PSHX, medications, allergies, subjective and objective findings without identifying the patient’s name.

Dr. Deering and class,

The following information is in regards to a patient with a mental health disorder:

Subjective:

Chief Complaint:  Difficulty sleeping and fatigue

HPI:

            D.W is a 32 year old female who presented to the office three weeks ago with complaints of difficulty sleeping and fatigue. She reported that it takes her several hours to fall asleep and that some nights she could not fall asleep at all. She stated that she spends a lot of time worrying about work deadlines and taking care of her family. She and her husband divorced a month ago, and she is currently taking care of her four-year old twin daughters with the help of her mother. She works as a human resources recruiter. She reports little interest in hobbies that she used to love, including playing golf and soul cycling. She states that she’s been having very low energy, tired, and difficulty concentrating in the last few weeks. She tries to do at least one social activity with her friends, but most nights she feels too tired. She also finds that social events with couples make her feel very sad and uncomfortable. She has not tried any prescription or over-the-counter medications.

Current medications: Multivitamin and metoprolol 25 mg once daily

Allergies: Pollen

PMHx: Hypertension

PSHX: Cesarean delivery in 2015

Social history: Divorced with four-year old twin daughters. Denies tobacco use or recreational drug use. Drinks three cups of coffee daily. Drinks one to two glasses of wine in one month.

ROS:

General: Denies fever, chills, or night sweats. Reports fatigue and inability to sleep in the past three weeks. Reports unintentional weight loss of 5 pounds in the last month.

HEENT: Denies head trauma, visual loss, hearing loss, tinnitus, sore throat, or hoarseness.

Neuro: Denies headaches, dizziness, seizures, vertigo, loss of balance, or incoordination.

Cardiovascular: Denies chest pain, palpitations, or peripheral edema.

Respiratory: Denies dyspnea, wheezing, shortness of breath, cough, or hemoptysis.

Gastrointestinal: Reports decreased appetite in the last month. Denies nausea, vomiting, diarrhea, constipation, or abdominal pain.

Genitourinary: Denies dysuria, nocturia, hematuria, or vaginal discharge. Currently on menstrual period.

Hematologic: Denies easy bruising or bleeding.

Psychiatric: Reports inability to sleep, difficulty concentrating, and excessive worrying. Denies a history of depression or family history of other psychiatric disorders. Denies hallucinations, delusions, or suicidal thoughts.

Objective:

Vital Signs: HR 92, BP 122/72, RR 16 (regular). Height: 5’5; Weight: 144 lbs

General: D.W appears fatigue but is in no respiratory distress. She is awake, alert, cooperative, and dressed appropriately.

HEENT: Head is normocephalic. No exudate noted in the eyes. No vision loss or blurred vision. Bilateral TMs are pearly gray. No hearing loss noted. Patent nares with no exudate. Moist and intact oropharynx. Neck is supple. No cervical lymph node tenderness and lymphadenopathy. Midline thyroid without enlargement and masses.