Psychiatric case report 2

Sample Case Report: Psychiatric Case Report
Patient ID: Ms. E.B
History and Physical conducted by:
History and Physical conducted on:
Source: History obtained from the patient.
Chief Complaint: “I still feel depressed and seem to have increased anxiety for the past a
week.”
History of Present Illness
Mrs. E.B is a 34-year-old Caucasian woman with a history of depression presenting to the clinic
for the complaints of still feeling depressed and having had anxiety over the past a week. She
then presents to the clinic for the follow-up on the postpartum depression. According to the
patient, she reports the blue signs and symptoms to improve; however, she still sometimes feels
down. Mrs. E.B reports sleeping of approximately 6-7 hours every night. Also, the patient feels
that her medications work quite well. She even denies appetite loss, insomnia, and mood swings.
Current Medications:
•
Synthorid 75mg through mouth daily.
•
Zoloft 100mg by mouth daily.
PMH:
•
Diagnosed with Depression in 2019
•
ADHD-attentive in 2017
•
Hypothyroidism in 2016
Immunizations: Tetanus and hepatitis last year.
Preventive Care: Was always on the Adderall for almost three years.
Surgical History: None
Family History: Mother-alive, 78 years, Hypertension, Depression, Anemia, anxiety, ADHD.
Father- died at 81years, ADHD, Depression, and Anxiety
Three siblings-alive, two adopted, all healthy.
Daughter 10 years, healthy.
Social History: The patient denies tobacco and illegal drug use and also drinking alcohol in the
past. Mrs. E.B lives with the husband in their single-family home. She reports being active at
work, where she works as the retail clerk. E.B never walks or even performs another exercise.
The patient as well reports a monogamous connection with the husband. She also denies an
abusive environment.
Sexual Orientation: Straight
Nutrition History: Normal diet
Subjective Data:
Review of Systems (ROS)
CONSTITUTIONAL: E.B appears well. She denies sleep concerns. The patient reports normal
energy levels. She also reports weight stability.
NEUROLOGIC: She denies chills and fever. Denies any change in the LOC. Also, E.B denies a
history of seizures or tremors.
HEENT: HEAD: The patient denies head injuries or even any change in the LOC. Eyes: E.B
also denies changes in the vision, blurred vision, or just the diplopia. Ear: She refutes pain within
her ears. E.B also denies the loss of hearing or drainage. Nose: The patient refuses nasal drainage
and congestion. THROAT: She also denies neck or throat pain, and hoarseness, and even
difficulty swallowing. The patient also denies toothache and mouth sores.
RESPIRATORY: Mrs. E.B refutes any chest pain, orthopnea, palpitations, regular rate, and
rhythm. She reports no gallop or murmur. There is no peripheral edema.
CARDIOVASCULAR: Mrs. E.B refutes any tachycardia, chest pain, orthopnea, or even the
paroxysmal nocturnal dyspnea.
GASTROINTESTINAL: Denies abdominal discomfort or pain. Mrs. E.B as well refutes
nausea, diarrhea, flatulence, or vomiting.
GENITOURINARY: The patient denies dysuria, hematuria, or even any change in the urinary
frequency. She as well refuses difficulties in starting or stopping the urine stream or
inconsistency. The patient also denies heavy menstrual bleedings.
MUSCULOSKELETAL: Mrs. E.B denies pain or fall. She as well denies hearing a snapping or
clicking sound.
SKIN: The casualty denies any element of skin problem. E.B denies any itching rash. There is
also no hair or nail growth.
Objective Data:
Vital signs: Temperature: 97.4 °F, BP: 130/67 mmhg, Ht- 5’9”, Wt 165 lb, BMI 24.4, Pulse: 64,
RR 16.
General appearance: Mrs. E.B is a well-nourished and well-developed adult female. She is
orientated and alert to time, place, and person. The patient answers every question accurately.
Neurologic: E.B is orientated and alert to time, place, and person. The CNII-XII is grossly intact.
Her sensation is also intact to the bilateral lower and upper extremities. The bilateral LE/UE
strength is 5/5.
HEENT: Head: The head is normocephalic with no lesion or injury. The hair is also evenly
distributed. Eyes: The conjunctiva is normal, and the sclera is white. Ears: The patient has
bilateral normal and external ears. There are canals patent with no wax build-up. There is
bilateral TMs pearly grey having a positive light reflex. The landmarks quickly get visualized.
Nose: There is no discharge, nosebleeds, or stuffiness. Neck: There is trachea midline, supple
symmetrical; the thyroid is never enlarged, not tenderness, symmetric. There is no carotid bruit
and no JVD. Throat: The oral mucosa is moist and pink. The pharynx is also pink without
exudates or lesions. The tongue has no masses. The teeth have no dental decay.
Cardiovascular: the patient has S1S2 with regular rhythm and rate. There is no murmur or even
gallop identified. The capillary refill