iHuman Case Study Week 12 Assignment 1: Sarah O'Neil 25-year-old female CC: Depression
Week 12 Assignment 1: Sarah O'Nei
... [Show More] l iHuman Case Study
Jose Crossier
Regis College School of Nursing
NU 664C: Family Psychiatric Mental Health I Professor Dave Adeleye
March 13, 2022
Week 12 Assignment 1: Sarah O'Neil iHuman Case Study
Informed Consent
The patient was presented with informed consent about the psychiatric interview process and treatment. She verbally agreed and signed the informed consent to be treated.
Identifying Data
Name: Sarah O'Neil Age: 25 years old Gender: Female
Sarah, a 25-year-old female, Depression
Subjective:
Chief Complaint: Depression. "I've been so sad almost every day for the past month."
HPI
Sarah is aged 25 years and married. Her primary physician referred her to the emergency department care for a depression diagnosis after a physical examination revealed no organic explanations. Sarah came to PCP for an evaluation after her manager encouraged her to do so due to sobbing bouts at work and impaired work performance. Sarah has been sad every day for the past month and "every minute of the day" for the previous two weeks, according to her. She supports suicidal thoughts but says she would not act on them because of her family and faith. She's having paranoid thoughts and feels her coworkers are conspiring to get her fired. Sarah also claims that about six weeks ago, she went days without sleeping, attempted to write a novel, and acted in a way that was out of character for her. She went to a pub by herself, considered having an extramarital affair, almost left with a male stranger, and passed out. Sarah also claims to have gained weight recently and is dissatisfied with her appearance. Her sadness affects her employment and relationships, and her marriage is suffering. Sarah recalls a previous depressive period in high school, during which she engaged in self-harming behavior. Family history is crucial because of the mother's illness and suicide seven years ago, the father's alcoholism, and the sister's sadness.
Psychiatric History: None
Medical History: Up-to-date immunizations. Childhood asthma. Fatigue. Obesity
Social History: Married. Her spouse is kind, but her depression is straining their relationship. There have been no reports of domestic violence.
There are no firearms in the house. Working in a pediatrician's office
Education – Currently has an Associate's Degree and taking a Bachelor's Degree at a night school Has encountered blackouts with drinking in the past (high school) and 5 weeks ago. Drinks 1-2 alcoholic beverages per week, rarely heavy usage of alcohol.
There are no tobacco use. There is no use of illegal drugs.
Surgical History: Appendectomy
Medications: Multivitamin and Orthotricyclen for birth control
Allergies: None
Family History: Father abuses alcohol but is in recovery at the moment Mother had schizophrenia and committed suicide
Review of Systems
• Constitutional: Patient is positive for fatigue, weight changes, difficulty sleeping but denies fever and sweating at night.
• HEENT: Denies headache, blurred vision, difficulty swallowing, nasal congestion, sinus pain, problem hearing, and sore throat.
• Cardiovascular: Denies chest pain, decreased exercise tolerance, palpitations, edema, cold fingers, syncope, and cold toes.
• Gastrointestinal: Denies vomiting, bloating, constipation, nausea, early satiety, and diarrhea
• Genitourinary: Denies pain, continency, changes in urination frequency, odor, dribbles, and dysuria
• Musculoskeletal: Denies cramps, walking limitations, discomfort when sitting, redness, joint deformities, hip and neck pain.
• Neurological: Denies unconsciousness, speech dysfunction, disorientation, sensory
disturbances, dizziness, seizures, hallucinations, attention difficulties, tingling, numbness, concentration, and [Show Less]
