NR 603 Week 6 Mental Health Disorders
Include their actual chief complaint, demographic data, HPI, PMHX, PSHX, medications, allergies,
subjective and objective findings without identifying the patient’s name.
Dr. Deering and class,
The following information is in regards to a patient with a mental health disorder:
Subjective:
Chief Complaint: Difficulty sleeping and fatigue
HPI:
D.W is a 32 year old female who presented to the office three weeks ago with complaints of
difficulty sleeping and fatigue. She reported that it takes her several hours to fall asleep and that
some nights she could not fall asleep at all. She stated that she spends a lot of time worrying about
work deadlines and taking care of her family. She and her husband divorced a month ago, and she is
currently taking care of her four-year old twin daughters with the help of her mother. She works as a
human resources recruiter. She reports little interest in hobbies that she used to love, including
playing golf and soul cycling. She states that she’s been having very low energy, tired, and difficulty
concentrating in the last few weeks. She tries to do at least one social activity with her friends, but
most nights she feels too tired. She also finds that social events with couples make her feel very sad
and uncomfortable. She has not tried any prescription or over-the-counter medications.
Current medications: Multivitamin and metoprolol 25 mg once daily
Allergies: Pollen
PMHx: Hypertension
PSHX: Cesarean delivery in 2015
Social history: Divorced with four-year old twin daughters. Denies tobacco use or recreational drug
use. Drinks three cups of coffee daily. Drinks one to two glasses of wine in one month.
ROS:
General: Denies fever, chills, or night sweats. Reports fatigue and inability to sleep in the past three
weeks. Reports unintentional weight loss of 5 pounds in the last month.
HEENT: Denies head trauma, visual loss, hearing loss, tinnitus, sore throat, or hoarseness.
Neuro: Denies headaches, dizziness, seizures, vertigo, loss of balance, or incoordination.
Cardiovascular: Denies chest pain, palpitations, or peripheral edema.
Respiratory: Denies dyspnea, wheezing, shortness of breath, cough, or hemoptysis.
Gastrointestinal: Reports decreased appetite in the last month. Denies nausea, vomiting, diarrhea,
constipation, or abdominal pain.
, Genitourinary: Denies dysuria, nocturia, hematuria, or vaginal discharge. Currently on menstrual
period.
Hematologic: Denies easy bruising or bleeding.
Psychiatric: Reports inability to sleep, difficulty concentrating, and excessive worrying. Denies a
history of depression or family history of other psychiatric disorders. Denies hallucinations,
delusions, or suicidal thoughts.
Objective:
Vital Signs: HR 92, BP 122/72, RR 16 (regular). Height: 5’5; Weight: 144 lbs
General: D.W appears fatigue but is in no respiratory distress. She is awake, alert, cooperative, and
dressed appropriately.
HEENT: Head is normocephalic. No exudate noted in the eyes. No vision loss or blurred vision.
Bilateral TMs are pearly gray. No hearing loss noted. Patent nares with no exudate. Moist and intact
oropharynx. Neck is supple. No cervical lymph node tenderness and lymphadenopathy. Midline
thyroid without enlargement and masses.
Cardiovascular: S1 and S2 with regular rate and rhythm. No murmurs or rubs noted.
Respiratory: Symmetric chest expansion. Unlabored respirations. Lung sounds clear bilaterally. No
crackles or wheezes noted.
Psych: PHQ-9 score is 14. Speech is clear. Able to express thoughts in a logical manner.
Diagnostic or Lab results:
Available lab results drawn last month during D.W’s annual physical:
RBC 4.5 million/ mcL; Hgb 13.2 g/dL; HCT 37%; PLT 256,000; WBC 7,000 mc/L; Na 143 mEq/L;
K 4.2 mEq/L; Mg 2.0 mEq/L; HCO3 24 mEq/L; BUN 10 mg/dL; Creatinine 0.7 mg/dL
TSH: 2.31, Free T4 0.9 ng/dL, Cholesterol: TC- 190 mg/dl, LDL- 97 mg/dl, VLDL- 36 mg/dl, HDL-
43 mg/dl, triglycerides- 100 mg/dl
Vitamin B12: 300 ng/ml
Vitamin D: 22 ng/ml
Part 2: Treatment Plan
Major depressive disorder (MDD) is considered one of the top reasons for disability in the United
States (WHO, 2018). Depression affects 350 million people worldwide. It is more prevalent in
women than men. This disorder can go undetected for many years, often leading to increased
morbidity from other physical illnesses, substance abuse, and increased suicidal ideations.As
healthcare providers, it is important to conduct a complete history and physical, and use appropriate
screening tools, such as PHQ-9, to diagnose depression. While many concerning histories should be
referred to a mental health specialist, healthcare providers can certainly initiate treatment to help
alleviate their symptoms. Keeping an open line of communication with patients who suffer from
Include their actual chief complaint, demographic data, HPI, PMHX, PSHX, medications, allergies,
subjective and objective findings without identifying the patient’s name.
Dr. Deering and class,
The following information is in regards to a patient with a mental health disorder:
Subjective:
Chief Complaint: Difficulty sleeping and fatigue
HPI:
D.W is a 32 year old female who presented to the office three weeks ago with complaints of
difficulty sleeping and fatigue. She reported that it takes her several hours to fall asleep and that
some nights she could not fall asleep at all. She stated that she spends a lot of time worrying about
work deadlines and taking care of her family. She and her husband divorced a month ago, and she is
currently taking care of her four-year old twin daughters with the help of her mother. She works as a
human resources recruiter. She reports little interest in hobbies that she used to love, including
playing golf and soul cycling. She states that she’s been having very low energy, tired, and difficulty
concentrating in the last few weeks. She tries to do at least one social activity with her friends, but
most nights she feels too tired. She also finds that social events with couples make her feel very sad
and uncomfortable. She has not tried any prescription or over-the-counter medications.
Current medications: Multivitamin and metoprolol 25 mg once daily
Allergies: Pollen
PMHx: Hypertension
PSHX: Cesarean delivery in 2015
Social history: Divorced with four-year old twin daughters. Denies tobacco use or recreational drug
use. Drinks three cups of coffee daily. Drinks one to two glasses of wine in one month.
ROS:
General: Denies fever, chills, or night sweats. Reports fatigue and inability to sleep in the past three
weeks. Reports unintentional weight loss of 5 pounds in the last month.
HEENT: Denies head trauma, visual loss, hearing loss, tinnitus, sore throat, or hoarseness.
Neuro: Denies headaches, dizziness, seizures, vertigo, loss of balance, or incoordination.
Cardiovascular: Denies chest pain, palpitations, or peripheral edema.
Respiratory: Denies dyspnea, wheezing, shortness of breath, cough, or hemoptysis.
Gastrointestinal: Reports decreased appetite in the last month. Denies nausea, vomiting, diarrhea,
constipation, or abdominal pain.
, Genitourinary: Denies dysuria, nocturia, hematuria, or vaginal discharge. Currently on menstrual
period.
Hematologic: Denies easy bruising or bleeding.
Psychiatric: Reports inability to sleep, difficulty concentrating, and excessive worrying. Denies a
history of depression or family history of other psychiatric disorders. Denies hallucinations,
delusions, or suicidal thoughts.
Objective:
Vital Signs: HR 92, BP 122/72, RR 16 (regular). Height: 5’5; Weight: 144 lbs
General: D.W appears fatigue but is in no respiratory distress. She is awake, alert, cooperative, and
dressed appropriately.
HEENT: Head is normocephalic. No exudate noted in the eyes. No vision loss or blurred vision.
Bilateral TMs are pearly gray. No hearing loss noted. Patent nares with no exudate. Moist and intact
oropharynx. Neck is supple. No cervical lymph node tenderness and lymphadenopathy. Midline
thyroid without enlargement and masses.
Cardiovascular: S1 and S2 with regular rate and rhythm. No murmurs or rubs noted.
Respiratory: Symmetric chest expansion. Unlabored respirations. Lung sounds clear bilaterally. No
crackles or wheezes noted.
Psych: PHQ-9 score is 14. Speech is clear. Able to express thoughts in a logical manner.
Diagnostic or Lab results:
Available lab results drawn last month during D.W’s annual physical:
RBC 4.5 million/ mcL; Hgb 13.2 g/dL; HCT 37%; PLT 256,000; WBC 7,000 mc/L; Na 143 mEq/L;
K 4.2 mEq/L; Mg 2.0 mEq/L; HCO3 24 mEq/L; BUN 10 mg/dL; Creatinine 0.7 mg/dL
TSH: 2.31, Free T4 0.9 ng/dL, Cholesterol: TC- 190 mg/dl, LDL- 97 mg/dl, VLDL- 36 mg/dl, HDL-
43 mg/dl, triglycerides- 100 mg/dl
Vitamin B12: 300 ng/ml
Vitamin D: 22 ng/ml
Part 2: Treatment Plan
Major depressive disorder (MDD) is considered one of the top reasons for disability in the United
States (WHO, 2018). Depression affects 350 million people worldwide. It is more prevalent in
women than men. This disorder can go undetected for many years, often leading to increased
morbidity from other physical illnesses, substance abuse, and increased suicidal ideations.As
healthcare providers, it is important to conduct a complete history and physical, and use appropriate
screening tools, such as PHQ-9, to diagnose depression. While many concerning histories should be
referred to a mental health specialist, healthcare providers can certainly initiate treatment to help
alleviate their symptoms. Keeping an open line of communication with patients who suffer from
