JA is a 31 year old Hispanic female CC: Sadness, hopeless and sudden weight gain HPI: JA arrived to the office by herself stating she recently broke up with her fiancé after five years of being t... ogether. Patient mentioned she found out her fiancé had an affair with a coworker. She recently moved out from the apartment she was leaving with her fiancé and move into her childhood home with her mother while she gets back on her feet. She used to be active in many social groups like an intramural soccer league but since she broke up with her fiancé she stopped all her outside activities besides going to work. Recently, she has been written up at work multiple times for tardiness and major mistakes from lack of concentration. They have lost many clients due to this reason. She has been coming home from work with fast food every day and does not leave her room unless she needs to use the restroom. She cries almost every day and has suddenly gained 15lbs over the last few weeks. She feels like she is tired all the time even though she sleeps much more than before. JA stated she has no energy to do anything and feels like her break up was her fault because she was not giving her fiancé everything he needed and she missed the signs. She feels worthless and guilty after moving back with her mother because she is now putting a financial burden on her. JA has thought about taking her own life by taking all of her mother’s pills from her cabinet but feels guilty stealing from her own mother. Alg: NKDA, NK food, latex, or seasonal allergies Immunization status: All up to date. Flu shot last month. MHx: Tonsillitis, influenza A, R foot sprain. Is current with dentist and eye physician appointments. SHx: Tonsillectomy and adenoidectomy Social Hx: JA works at an Interior Design office Monday-Friday. Participates in intramural soccer with some friends on Wednesday nights. Has a large social friend group and is usually out on weekends when she is not at work. She usually attends a gym but recently has not gone because she is too tired and has no motivation. She usually eats a well-balanced diet including vegetables, protein, and smoothies while staying away from fast food but lately she has been eating McDonalds among other fast food. JA mentioned she has gained 15lbs in the last few weeks since she is living at home with her mother. Normally, she sleeps 8-10 hours per night but has been increasing to 12-14 hours a day. She did have a romantic relationship but is going through a rough breakup. Usually, she drinks socially on the weekends but has been coming home every night with a bottle of vodka. She is a non-smoker. She has never thought about killing herself but recently she though of ending her life by taking her mother’s prescription drugs. Family Hx: Mother: Cholecystectomy, hypertension, and hypothyroidism Father: ETOH abuse, DM2, Pat. GF: hypertension, DM, otherwise unknown Pat. GM: HTN, otherwise unknown Mat.GM: Died 4 years ago from NHL Mat. GF: COPD, obesity, arthritis, No psychiatric history of any family members or immediate family. ROS: Constitutional symptoms- Report fatigue and increased appetite. Pt denies chills or night sweats. EENMT- Denies visual issues. No glasses or corrective lenses. Last eye exam was in 2018 and exam was 20/20 vision. Denies throat or swallowing issues. Denies hearing loss or changes, nasal congestion. Last dental visit was about 4 months ago. Neurologic-Headaches at times. Denies weakness, numbness or tingling, memory issues, involuntary movements or tremors, syncope, or seizures. Cardiovascular- Denies hx of murmur, cp, palpitations, activity intolerance, or edema. Respiratory- Denies history of resp. infections, SOB, wheezing, difficulty breathing. Gastrointestinal-Increased appetite. Denies heartburn, bloating, N/V, diarrhea, constipation, abdominal or epigastric pain, change in bowel habits. Genitourinary- pt. denies any urinary issues Musculoskeletal- Lower lumbar pain. Denies swelling, muscle pain or cramps, neck pain or stiffness, changes in ROM. Pt does has hx of right foot strain x 4 years ago from soccer, with no residuals. Integumentary- Pt denies any issues currently. No moles, rashes, or itching. Psych: Pt. denies nightmares. Has had increasing anxiety and nervousness. Suicidal thoughts present. No homicidal thoughts, or excessive anger. Loss of interest in anything, seems depressed, changes at work and socialization. Reports periods of waking during the night, sleeping a lot, and “just don’t care right now.” Endocrine- Pt. denies cold/heat intolerance; polydipsia, -phagia, -uria; changes in skin, hair or nail texture; denies unexpected changes facial or body hair. Hematologic/lymphatic-Denies unusual bleeding or bruising, lymph node enlargement or tenderness, history of anemia, or blood transfusions. Objective: Const: -VS:Temp-98.5, BP-126/88, HR-85,R 16, O2 sat-100%,Height-62 inches Wgt-150 lbs, BMI-27.4. GEN: healthy-appearing, obese, and well-developed. NAD. Affect: Flat HEENT: sclera white, conjunctivae pink. PERRLA, 3 mm bilaterally. Extraocular movements intact. normal-no lesions, redness, or swelling; tympanic membranes pearly gray, with no redness, fluid, or bulging noted. Hearing is intact. Nose normal with no mucus, inflammation, or lesions present. Nares patent. Septum is midline. Oral cavity is pink, moist, and intact. No missing or decayed teeth. Throat is pink, moist and intact. No tonsils. No lesions present. No ulcers, masses, or exudate present. Neuro- Grossly oriented x3, speech clear and articulate. Flat affect with some eye contact. Pt seems preoccupied with phone. Attention and concentration are distracted. Sensation intact. DTR intact all ext.’s. Cardio-S1, S2. AHR and pulses = RRS. Rad and Ped pulses 2+ bilaterally. No murmurs, gallops, or rubs heard. Carotid arteries have normal pulses bilaterally with no bruits present. No cyanosis, clubbing or edema to ext.’s. Cap refill less than 2 second in all ext.’s. Resp- Respirations even and unlabored. CTA bilaterally with no wheezes, rales, or rhonchi noted. GI -abdomen soft and non-tender to palpation, nondistended. No rigidity, guarding, or masses present. BS + all 4 quadrants GU-Denies dysuria or hematuria. Voids 6-8 times a day. No bladder distention, suprapubic pain, or CVA tenderness. MS-AROM normal in all extremities w/ no tenderness to palpation Skin: No scaling or breaks on skin, face, neck, or arms. No rashes, lesions, or discoloration noted throughout skin. No open areas. Good turgor. Lymph: No lymphadenopathy. No tenderness or masses present. Psychiatric- Pt insight and knowledge of right and wrong intact. Patient has flat affect. Thinking is rational and logical. No pressured speech. Pt is pleasant, anxious, and cooperative and responds to answers appropriately. Patient appears to be sad and unsure. JA stated she has thoughts of harming herself. No plans or thoughts of harming others. Hem: no bruises or bleeding noted. [Show More]
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