Chief Complaint: I have a problem falling asleep, feelings of hopelessness and self-harm.
History of Present Illness: Magdalene is 43-year-old Hispanic female who reports that for the
last 4 months, she has been experiencing foul moods coupled up with low physical and mental
energy drive. She reveals experiencing hopelessness and lacks interest in activities of pleasure
such as reading. She has difficulties falling asleep. The patient says she began noticing the
symptoms immediately her husband died.
Previous Medical History: Magdalene says that before her husband died, she was in good
health. Her lifestyle entailed regular swimming exercise four days a week and slight lifting of
weights three days a week. She had a tonsillectomy surgery while aged six years in a hospital in
Boston, Texas. She does indicate having small pox while aged 18. She indicated receiving all
required immunizations and receives flu jab each year.
Current medications: medication administered currently include, Lipitor 10mg every day, and
Allegra 10mg every day.
Psychiatric History: the patient reveals that she has no previous record of mental health issues
until now.
Personal History: Magdalene was born and brought up in Louisiana. She is the second born
among four siblings. She was married for 17 years to her late husband. She has three daughters
aged 7, 9 and 13. She currently lost a job, which can contribute to stress sometimes.
Substance Abuse History: initially, the patient indicated that she has never smoked anything,
but during the interview, she admitted smoking marijuana and cigarettes twice every week while
swimming. She reports not taking alcoholic beverages at any point. She does not report any
history of exposure to industrial or environmental toxins.
, Family History: her husband died four years ago. She has a family history of heart conditions
and stroke. Her father battled hypertension for a long period. Her father died of stroke aged 55
years. Her grandmother died of breast cancer aged 65. The patient however, says that she knows
very little about cancer in her other family members. Her uncle too died of cancer aged 56.
Obesity is rife in the family as her brother and mother both described as morbidly obese.
Review of systems
General
Magdalene denies any feverish symptoms, night or day chills, or sweating at night. She
maintains an upright body posture and weight.
Diet
She denies having good appetite
Skin, Hair, Nails
The patient has no rashes on her skin or any signs of inching. She reports using sunscreen on a
daily basis. Additionally, when she goes swimming, she makes sure that she applies
sunscreen. Her nails are visibly strong. She denies any problem with her hair with no evidence
of balding. Head and Neck
The patient denies having any form of headaches, feelings of dizziness or injuries on the head.
Eyes
She denies double vision or blurred vision. Reports no previous eye injury and does not require
glasses when reading or watching television.
Ears
Denies any problem with hearing. No painful aches from the ears or discharge.
Nose
History of Present Illness: Magdalene is 43-year-old Hispanic female who reports that for the
last 4 months, she has been experiencing foul moods coupled up with low physical and mental
energy drive. She reveals experiencing hopelessness and lacks interest in activities of pleasure
such as reading. She has difficulties falling asleep. The patient says she began noticing the
symptoms immediately her husband died.
Previous Medical History: Magdalene says that before her husband died, she was in good
health. Her lifestyle entailed regular swimming exercise four days a week and slight lifting of
weights three days a week. She had a tonsillectomy surgery while aged six years in a hospital in
Boston, Texas. She does indicate having small pox while aged 18. She indicated receiving all
required immunizations and receives flu jab each year.
Current medications: medication administered currently include, Lipitor 10mg every day, and
Allegra 10mg every day.
Psychiatric History: the patient reveals that she has no previous record of mental health issues
until now.
Personal History: Magdalene was born and brought up in Louisiana. She is the second born
among four siblings. She was married for 17 years to her late husband. She has three daughters
aged 7, 9 and 13. She currently lost a job, which can contribute to stress sometimes.
Substance Abuse History: initially, the patient indicated that she has never smoked anything,
but during the interview, she admitted smoking marijuana and cigarettes twice every week while
swimming. She reports not taking alcoholic beverages at any point. She does not report any
history of exposure to industrial or environmental toxins.
, Family History: her husband died four years ago. She has a family history of heart conditions
and stroke. Her father battled hypertension for a long period. Her father died of stroke aged 55
years. Her grandmother died of breast cancer aged 65. The patient however, says that she knows
very little about cancer in her other family members. Her uncle too died of cancer aged 56.
Obesity is rife in the family as her brother and mother both described as morbidly obese.
Review of systems
General
Magdalene denies any feverish symptoms, night or day chills, or sweating at night. She
maintains an upright body posture and weight.
Diet
She denies having good appetite
Skin, Hair, Nails
The patient has no rashes on her skin or any signs of inching. She reports using sunscreen on a
daily basis. Additionally, when she goes swimming, she makes sure that she applies
sunscreen. Her nails are visibly strong. She denies any problem with her hair with no evidence
of balding. Head and Neck
The patient denies having any form of headaches, feelings of dizziness or injuries on the head.
Eyes
She denies double vision or blurred vision. Reports no previous eye injury and does not require
glasses when reading or watching television.
Ears
Denies any problem with hearing. No painful aches from the ears or discharge.
Nose
