PMHNP Care Across the Lifespan

Subjective:
CC (chief complaint): “I have a lot of psychological and mental stuff going on with me”
HPI: The patient is a 32 y/o female who presents for a new patient evaluation via video call. She reports that she has struggled with depression and anxiety since high school, but it has worsened within the last two years since moving to Arizona. The patient endorses having impulsive and intrusive thoughts when angry. She reports that she constantly worries, which causes negative and disorganized thoughts. She states that she often worries and feels/ hopeless about her life, feeling like she’s not doing enough. She endorsed constant fatigue and having trouble falling asleep but takes long naps throughout the day. She reports a weight gain of 30lbs in the last year. She reports being fixated about her weight and indulging in food but feels bad about it afterward. She reports using laxatives in the past, not eating for long periods, and going to the gym for hours. She reports having nightmares and flashbacks of events that have taken place in her life. She also states that she tries to avoid certain memories of her childhood. The patient reports experiencing these symptoms on a daily, and nothing has helped to manage her symptoms, but she does remain in therapy. The patient endorsed that her symptoms have affected her intimate relationships with others. She states that she often avoids people when she experiences feeling down or angry. She also endorsed that she often feels anxious about her work and her workload. She was previously diagnosed with Anxiety and Depression a few years ago and was started on Zoloft 50mg. She reports taking Zoloft for about a month but explains that she was not taking it as prescribed and reported gaining 7-8lbs while taking the medication. She denies taking any psychiatric medications currently. She reports that she has seen and heard things in the past that no one else had, as a teenager, in her mother’s home. She states that she currently does not have any AVH. The patient also endorsed that she had frequent thoughts of suicide by hanging herself around ages 16 and 17 but denies having any currently.

Substance Current Use: She reports that she does drink one glass of wine socially and occasionally. However, she denies the use of any other substances.
Medical History: The patient has been diagnosed with allergies, anemia, headaches, and fatigue.

• Current Medications: Denies taking any current medications.
• Allergies: NKDA
• Reproductive Hx: The patient reports regular periods, no use of contraceptives, and no children. LMP 6/02/2024. Patient reports being sexually active.

ROS:
• GENERAL: Recent weight gain of 30lbs and fatigue. No fever, chills or weakness.
• HEENT: Eyes: No visual loss, blurred vision, double vision, or yellow sclerae. Ears,Nose, Throat: No hearing loss, sneezing, congestion, runny nose, or sore throat.
• SKIN: No rash or itching
• CARDIOVASCULAR: No chest pain, chest pressure, or chest discomfort. No
palpitations or edema.
• RESPIRATORY: No shortness of breath, cough, or sputum.
• GASTROINTESTINAL: No anorexia, nausea, vomiting, or diarrhea. No abdominal pain or blood.
• GENITOURINARY: No burning on urination, urgency, hesitancy, odor, odd color
• NEUROLOGICAL: No headache, dizziness, syncope, paralysis, ataxia, numbness, or tingling in the extremities. No change in bowel or bladder control.
• MUSCULOSKELETAL: No muscle pain, back pain, joint pain or stiffness
• HEMATOLOGIC: No anemia, bleeding, or bruising
• LYMPHATICS: No enlarged nodes. No history of Spleenectomy
• ENDOCRINOLOGIC: No reports of sweating, col, or heat intolerance. No polyuria or polydipsia.
Objective:
Diagnostic results: PHQ9 results show a score of 19.
GAD-7 Score results show 15.
CBC and Vitamin D are ordered.
Assessment:
Mental Status Examination: The patient is a 32 y/o female whose general appearance is alert, well-groomed, clean, well-developed, and appears well-rested. Behavior is cooperative, calm, and pleasant; eye contact is good, appears engaged and not guarded. Her mood is dysphoric, depressed, anxious, irritable, and sad. Her affect is incongruent with her mood. Thought Process associations are logical, and attention span is normal throughout the interview; concentration is intact and circumferentially. Her thought content shows obsessions and hallucinations and no delusions. Judgment is intact. Insight: is intact. Appearance: normal weight. Her cognition is oriented to situation, time, place, and person, and her memory is intact. Intelligence is above average.

Diagnostic Impression:
Reflections:
Case Formulation and Treatment Plan:
PRECEPTOR VERFICIATION:
I confirm the patient used for this assignment is a patient that was seen and managed by the student at their Meditrek approved clinical site during this quarter course of learning.

Preceptor signature: ____________________________________________

Date: ____________

References