NR 603 Week 6 Mental Health Clinical Presentation - Part 1

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Institution	NR 603 Advanced Clinical Diagnosis and Practice Across the Lifespan
Contributor	Shanzay

Description

JA is a 31 year old Hispanic female

CC:

Sadness, hopeless and sudden weight gain

HPI:

JA arrived to the office by herself stating she recently broke up with her fiancé after five years of being together. Patient mentioned she found out her fiancé had an affair with a coworker. She recently moved out from the apartment she was leaving with her fiancé and move into her childhood home with her mother while she gets back on her feet. She used to be active in many social groups like an intramural soccer league but since she broke up with her fiancé she stopped all her outside activities besides going to work. Recently, she has been written up at work multiple times for tardiness and major mistakes from lack of concentration. They have lost many clients due to this reason. She has been coming home from work with fast food every day and does not leave her room unless she needs to use the restroom. She cries almost every day and has suddenly gained 15lbs over the last few weeks. She feels like she is tired all the time even though she sleeps much more than before. JA stated she has no energy to do anything and feels like her break up was her fault because she was not giving her fiancé everything he needed and she missed the signs. She feels worthless and guilty after moving back with her mother because she is now putting a financial burden on her. JA has thought about taking her own life by taking all of her mother’s pills from her cabinet but feels guilty stealing from her own mother.

Alg:

NKDA, NK food, latex, or seasonal allergies

Immunization status:

All up to date. Flu shot last month.

MHx:

Tonsillitis, influenza A, R foot sprain. Is current with dentist and eye physician appointments.

SHx:

Tonsillectomy and adenoidectomy..........continue