Wk7
This is my assessment from my client
Client is a 31-year-old female.
Subjective: Pt. is 31 year old female seen today for anxiety and depression. Pt. present with chief complain ” I knew I needed to come in and get help. I have been depressed and stuff for a long time. Pt. reports depressive symptoms began at age 19. Patient has one child who is now 12 stays with the dad and pt. owes over 22 thousand in child support arrears. Patient reports long standing difficulties with her mother. Stated she was sexually assaulted mother’s boyfriends as a child and mother did not believe her when she told her. Pt. reports that she has no significant mental health history. Pt. reports history heavy alcohol in her mid 20’s and last used alcohol 6 months ago. Pt. currently lives in a shelter since January 2022, she recently started working part time. Pt. reports current mood is ” horrible”. She reports mood is worse at night and in the mornings it’s a little better “. Denies SI/HI. She also endorses racing thoughts particularly at night that prolongs sleep onset. Pt. reports good sleep duration once she achieves sleep. No issues with daytime energy.Poor appetite” sometimes I don’t feel like eating” No hx of Psychosis.
Objectives: A/O x 3, Very engaging, Clear speech and coherent, Affect is normal,
Assessment: Depression, Anxiety, PTSD,
Plan: Pt. refused meds Recommended OTC Melatonin up to 10mg qHS for sleep. Risks and benefits of Melatonin discussed Call ED/911 for SI/HI Return to clinic in 4 weeks Pt. verbalized understanding of treatment plan
Family History: Father died at age 33 from car accident. Mother diagnosed with HTN, history of drug use, depression, anxiety.
· Allergies: No drug, latex, or food allergies.
· Reproductive Hx:She is heterosexual and single
ROS:
· GENERAL: Not sure of weight loss, poor to fair appetite. The patient indicates that he has insomnia.
· HEENT: The patient denies any visual loss, double vision, or blurred vision. Denies any pain or discomfort in the ears and throat. The patient does not have any pain or injury in the neck.
· SKIN: No issues
· CARDIOVASCULAR: The patient does not admit to any pain or discomfort in the CV.
· RESPIRATORY: The patient denies any pain or discomfort at the time of examination.
· GASTROINTESTINAL: Poor appetite
· GENITOURINARY: History of STD, Chlamydia. He is heterosexual.
· NEUROLOGICAL: See notes
· MUSCULOSKELETAL: The patient denies back pains, muscle pains or joint pains, and stiffness.
· HEMATOLOGIC: No history of transfusion, lesion removal, skin cancer, and bleeding disorders.
· LYMPHATICS: No enlarged nodes
· ENDOCRINOLOGIC: No reports of heart intolerance.