Chief complaint: “I lost my dog and I got so upset, but I see it as blessing.” H

by | Sep 18, 2022 | Other | 0 comments

Chief complaint: “I lost my dog and I got so upset, but I see it as blessing.”
History of present illness:
This is a /F/U of a 33 year old married female who presented to clinic with depression as evidenced by reporting low energy, sad mood, tearful at times, hopelessness.
Pt. reported that her father who has PTSD was diagnosed with Colon cancer and this is stressing the whole family as in one wants to talk about it.
Pt. used to work in fashion for 6 years and since COVID-19 pandemic she has not been at work.
She finally got a job but reported that her manager is condescending and guilting.
Pt.’s Husband was the breadwinner until he was laid off his job 4 mothsago and she felt so depressed she could not afford paying bills with
one income. Patient reported growing up with an abusive father who was Alcoholic and physically abusive to her mother.
Patient reports history of SI with possible derealization. Pt. has one brother and one sister. Pt. reported feelings of hopeless,
sad, crying all the time reporting that she feels guilty of her husband being laid off because of his color. “People don’t treat him right and when he makes mistakes
they look down on him, and he won’t say anything because he wants to keep his job.” Denies SI/ HI/ AH. Hx of SI without plan.
Allergies: NKA
Denied hx of seizure.
Family MH Hx
Denied Fx Hx of SA
Covid Vaccine, Pfizer, vaccine X 2
Social history
Nutrition
Appears well nourished. Denied hx of eating issue. Denied weight gain/loss. Patient’s BMI WNL, < 30 Developmental History SUBJECTIVE Appetite: Sleep: Abuse: Drugs: Legal issue - OBJECTIVE DIAGNOSIS per DSMV ICD-10 codes F Medications: PLAN:

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