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NR603 Week 6 Mental Health Disorders

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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

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