Assessing and Diagnosing Patients With Anxiety Disorders PTSD and OCD

 

Biodata

Initials: Z.W     Gender: Female      Age: 23             Ethnicity: African American

Subjective

CC (chief complaint): Embarrassment, feelings of loss of control, shame

HPI: The patient is a 23-year-old African-American female who presents to the clinic with feelings of shame, embarrassment, and loss of control. The patient states that these feelings are strong and started when she started pulling her hair. This was about five to six years ago. She is, however, not sure about the onset of these symptoms. She stated that she rubbed her eyebrows when proofreading reports she wrote as a habit. This happened when she was nervous. Her co-worker, however, told her that she was plucking her eyebrows, and when she checked the mirror, she noticed that she had fewer eyebrows. The patient then started pulling hair from her scalp. She felt sorry when she realized she was doing this. She feels ashamed because of her bald head. The patient has a habit of plugging and unplugging her hairdryer. She states that she constantly switches on and off her light switch eleven times. She has had this behavior since she was a child. She further states that she always thinks about cats since they carry diseases.

Past Psychiatric History:

General Statement: This patient has no treatment experience.

Caregivers (if applicable): Not applicable

Hospitalizations: No previous hospitalizations

Medication trials: No medication trials.

Psychotherapy or Previous Psychiatric Diagnosis: No previous mental health diagnosis

Substance Current Use and History: Denies any use of alcohol, tobacco, or any illicit substances

Family Psychiatric/Substance Use History: The mother has a history of anxiety. The brother has a history of cannabis use.

Psychosocial History: The patient was born and raised in Jacksonville with her mother and two older brothers. She has an associate of arts degree and works for an Amazon warehouse. She is not in a relationship but identifies as a lesbian. She has not come out to the family yet—no history of legal issues.

Medical History: Diabetes since she was five years.

Current Medications: No current medications

Allergies: No known drug or medication allergies

Reproductive Hx: She is not pregnant or lactating. She is a lesbian who has not come out yet to her family.

ROS:

GENERAL: Denies fatigue, weight loss, or fever.

HEENT: Head: Minimal hair and wears wigs. Eyes: No diplopia, blurred vision, or vision loss. Ears: Denies hearing loss. Nose: Denies nasal congestion or rhinorrhea. Throat: No sore throat.

SKIN: No rash or skin itching

CARDIOVASCULAR: Denies chest pressure, pain, discomfort, palpations, or peripheral edema.

RESPIRATORY: Denies dyspnea, sputum, or wheezing

GASTROINTESTINAL: Denies appetite loss, vomiting, nausea, or abdominal pain

GENITOURINARY: Denies urinary urgency or burning sensation

NEUROLOGICAL: No ataxia, dizziness, paralysis, tingling sensations, syncope, or changes in bowel control.

MUSCULOSKELETAL: Denies joint pain, muscle pain, muscle stiffness, or back pain.

HEMATOLOGIC: Denies easy bruising, bleeding, or anemia.

LYMPHATICS: Denies lymphadenopathy

ENDOCRINOLOGIC: Denies polyuria, polydipsia, heat/cold intolerance

Objective

Vitals

T- 97.5 P- 86 R 18 112/64 Ht 5’2 Wt 130lbs

Physical exam:

HEENT: Head is normocephalic and atraumatic. PERRLA. Visual acuity is 18/20. The TM is intact and grey. Lips are moist and pink. No tonsillitis was noted. No discharge in the ears or eyes.

Neck:  No lymphadenopathy on palpation

Lungs/ Cardiovascular: S1, S2 heard. Capillary refill is less than three seconds. Chest is clear to

auscultation bilaterally. No labored breathing with normal rhythm and depth.No peripheral edema

Breast: No nodes or lump palpated.

Abdominal: Normoactive bowel sounds were heard on all four quadrants. The abdomen is non-tender in palpation.

Skin: Skin is moist and warm on the touch.

Cervix: Firm, smooth, with no vaginal sores.<