Informed Consent
The patient was presented with informed consent about the psychiatric interview process and
treatment. She verbally agreed and signed
... [Show More] 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.
3
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.
4
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 motor disturbances.
Psychiatric: Positive for nervousness, anxiety, lack of interest, depression, mood
changes, memory loss, difficulty, and hearing or seeing things that do not exist.
Endocrine: Denies appetite change, unusual thirst, cold intolerance, frequent urination,
and heat intolerance
Hematologic/Lymphatic: Denies glands that are swollen, unusual bleeding, and bruising
easily.
Allergic/Immunologic: Denies any kind of allergies.
Objective
Vitals
Temperature: 98.9 F (oral)
Blood Pressure: 110/76 left arm while sitting
Pulse: 68 bpm
5
Respiration: 14 bpm
SP02: 97%
Physical Exam
Height: 5'3"
Weight: 175 lbs.
BMI: 31
General: The 25 y/o female is interactive and answers appropriately but appears to be
obese.
HEENT: Normal hair distribution and thickness, normocephalic, supple neck eyes
PERRL with equal pupils that react to light.
Neck: No lymphadenopathy and Carotids 2+
Respiratory: No wheezing or coughing. Lungs sound is clear
Cardiovascular: Heart with regular S1 and S2 and rythm
Abdomen: Normal, soft, and non-distended with no masses
Neurologic: Intact CN I-XII grossly
Musculoskeletal: Normal range of movement and symmetrical.
Genitourinary: No enlarged prostate and tenderness, no testicular lump, no change in size,
ulcer, and warts.
Gastrointestinal: Bowel sounds are present in all [Show Less]