Subjective data: K.R. 29 y.o. female
Chief complaint- persistent feeling of sadness/hopelessness
HPI- KR is a 29-year-old Caucasian female accompanied by a friend presenting today with
persistent feelings of sadness and hopelessness since her sister passed away from an
overdose 5 months ago. She also gained custody of her sister’s children after she passed away.
She reports she has lost interest in things she once enjoyed, has been calling into work, and
has difficulty focusing. Her friend reports that she does not want to leave the house, her house
is a mess, and her water just recently got turned off because she let the bill go past due. Pt
reports she has been drinking alcohol more often to try to numb the pain of losing her sister.
The patient denies suicidal ideations.
Current medications- none
Allergies- NKDA
PMH-
Immunizations up to date
surgeries: appendectomy at 9 years old, cholecystectomy at 26 years old
Social: lives alone, former smoker, drinks alcohol daily 5-6 drinks a day, denies substance use
Psychiatric hx: no history of mental health problems
Family hx:
, Mother-stroke at 64 yo
Father-stroke, type 2 diabetes
Living sister- healthy
Grandparents-unknown
Objective data:
ROS-
General: reports fatigue, denies weight changes, fevers
HEENT: denies visual disturbances, loss of vision, hearing loss, sore throat
Cardio: denies chest pain or heart palpitation
Resp: denies shortness of breath, chest tightness, or cough
GI: denies nausea, vomiting, diarrhea, constipation, or abdominal pain
GU: denies burning with urination, change in urination frequency, or incontinence
MS: denies muscle pain or cramps, denies joint pain
Endo: denies heat/cold intolerance, polyphagia, polydipsia, or hair loss
Neuro: denies headaches not relieved by Tylenol/Motrin, dizziness, or syncope
Psych: reports feelings of sadness/hopelessness, unable to focus, and anhedonia
Chief complaint- persistent feeling of sadness/hopelessness
HPI- KR is a 29-year-old Caucasian female accompanied by a friend presenting today with
persistent feelings of sadness and hopelessness since her sister passed away from an
overdose 5 months ago. She also gained custody of her sister’s children after she passed away.
She reports she has lost interest in things she once enjoyed, has been calling into work, and
has difficulty focusing. Her friend reports that she does not want to leave the house, her house
is a mess, and her water just recently got turned off because she let the bill go past due. Pt
reports she has been drinking alcohol more often to try to numb the pain of losing her sister.
The patient denies suicidal ideations.
Current medications- none
Allergies- NKDA
PMH-
Immunizations up to date
surgeries: appendectomy at 9 years old, cholecystectomy at 26 years old
Social: lives alone, former smoker, drinks alcohol daily 5-6 drinks a day, denies substance use
Psychiatric hx: no history of mental health problems
Family hx:
, Mother-stroke at 64 yo
Father-stroke, type 2 diabetes
Living sister- healthy
Grandparents-unknown
Objective data:
ROS-
General: reports fatigue, denies weight changes, fevers
HEENT: denies visual disturbances, loss of vision, hearing loss, sore throat
Cardio: denies chest pain or heart palpitation
Resp: denies shortness of breath, chest tightness, or cough
GI: denies nausea, vomiting, diarrhea, constipation, or abdominal pain
GU: denies burning with urination, change in urination frequency, or incontinence
MS: denies muscle pain or cramps, denies joint pain
Endo: denies heat/cold intolerance, polyphagia, polydipsia, or hair loss
Neuro: denies headaches not relieved by Tylenol/Motrin, dizziness, or syncope
Psych: reports feelings of sadness/hopelessness, unable to focus, and anhedonia
