Subjective
Chief Complaint: Depression. “I’ve been so sad almost every day for the past month”
History of Present Illness:
Sarah is a 25-year-old married female who was referred by her PCP for evaluation of her
depre
...
Subjective
Chief Complaint: Depression. “I’ve been so sad almost every day for the past month”
History of Present Illness:
Sarah is a 25-year-old married female who was referred by her PCP for evaluation of her
depression after medical evaluation negative for organic causes. Sarah initially presented to PCP
after encouragement from her boss for evaluation due to crying episodes at work and decreased
work performance. Sarah reports feeling sad daily for the past month and sad “every minute of
the day” for the past two weeks. She endorses suicidal ideation but states she would not act on it
due to her family and faith. She is experiencing some paranoid ideation and believes her coworkers are trying to get her fired. Additionally, Sarah reports going days without sleeping
approximately 6 weeks ago, trying to write a novel, and behaving in a manner that was distinctly
out of character for her. She went out alone to a bar, contemplated engaging in an extramarital
affair, almost left with a male stranger, and became black out drunk. Sarah also reports recent
weight gain and being unhappy with the way she looks. Her depression is impacting her work
and her relationships, putting a strain on her marriage. Sarah reports previous depressive episode
with self-injurious behavior in high school. Family history significant for mother with
schizophrenia and suicide 7 years ago, father with alcohol-use-disorder, and sister with
depression.
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IHUMAN CASE WEEK #12: SARAH 25 Y/O FEMALE CC: DEPRESSION
Medical History:
Immunizations up to date
Previously played tennis a few times per week for exercise but not recently due to fatigue
Obesity
Childhood asthma
Surgical History:
Appendectomy
Medications:
Orthotricyclen (birth control)
Multivitamin
Psychiatric History:
None reported
Family History:
Father – alcohol-use-disorder
Mother – schizophrenia, suicide
Sister - Depression
Social History:
Married, reports husband is supportive, but her depression is putting strain on their marriage
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No report of domestic violence
No guns or weapons in home
Employed at pediatrician’s office
Education – Currently has an Associate’s Degree, attending night school pursuing Bachelor’s
Degree
Drinks 1-2 alcoholic beverages a week, rare heavy use of alcohol, has experienced blackouts
with drinking in past (high school) and 5 weeks ago.
No tobacco use.
No illicit drug use.
Review of Systems
General/Constitutional:
HEENT: Denies difficulty with vision or hearing. Denies ear pain, sinus congestion, or difficulty
swallowing.
Skin/Nails: Denies concern.
Respiratory: denies shortness of breath
Cardiovascular: Denies irregular heartbeat or rh
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