Comprehensive: premenstrual symptoms, depression,
agitation
39 year old Caucasian female, recently divorced, currently unemployed
computer analyst, living at home with parents. Client is a reliable
historian.
Chief Complaints: PMS. Client states she feels very depressed
about five days prior to menses. Seems to cry and argue with her
mother. States she has had PMS for several years but this past year it
has gotten much worse. She tries to sleep a lot when feeling these
symptoms but generally her ability to help herself is minimal.
Past History
Childhood illnesses: Chicken pox. Urethral dilation, age 6.
Adult illnesses: None.
Accidents/Injuries: None.
Operations: See childhood.
Hospitalizations: See childhood.
Psychiatric illness: Treated for depression with Zoloft after first
marriage ended in divorce two years ago, continued treatment for 2
years. Stopped meds because she “didn’t feel good taking them
although depression got better. Described strange reaction when
coming off Zoloft – “like I wasn’t really here.”
Current Health Status
Allergies: None.
Immunizations: Current.
Screening Tests: Pap about two years ago.
Environmental Hazards: None.
Exercise: Walks around the lake.
Leisure: Reading.
Sleep Patterns: Sleeps long hours, sometimes 12 hours straight.
Diet: Poor appetite recently.
Current Medications: None.
Tobacco: None.
Alcohol/Illicit Drugs: Occasional ETOH,
Family History
Mother: 57, history of depression.
Father: 59, MS.
Maternal Grandmother: Deceased age 60s, heart disease.
Maternal Grandfather: Deceased age 50s, heart disease.
Paternal Grandmother: 85, arthritis.
Paternal Grandfather: 70s, alcoholic.
Siblings: 1 brother, no contact.
PSYCHOSOCIAL History
First marriage ended four years ago, lasted three years, “too involved
with his work,” client’s choice to end it. Second marriage, to college
sweetheart, he is from Africa, her parents did not approve, married 2
years, separated 6 months ago, states he was physically and
emotionally abusive. Client has been living with parents since divorce.
This is a stressful environment, although parents are happy that
marriage is ended. One sibling, younger brother age 25, has been
estranged from parents and the family for several years. Client is a
computer analyst and previously worked at IBM prior to moving to her
divorce. She has been laid off due to budget cuts.
Review of systems
General: Usual wgt, often feels fatigued, denies fever.
Skin: Denies rashes, lumps, sores, itching, dryness, color change,
change in hair and nails.
Head: Denies headaches, head injury.
Eyes: Denies vision changes, pain, redness.
Ears: Denies hearing problems, tinnitus, vertigo, earaches, infection.
Nose and sinuses: Denies frequent colds, nasal stuffiness, discharge,
itching, nosebleeds, sinus trouble.
Mouth and Throat: Denies bleeding gums, sore tongue, frequent sore
throats, hoarseness.
Neck: Denies lumps, goiter, pain, stiffness.
Breasts: Denies lumps, pain, discharge, BSE.
Respiratory: Denies cough, sputum, hemoptysis, wheezing, asthma,
bronchitis, emphysema, pneumonia, TB, pleurisy.
Cardiac: Denies heart trouble, high blood pressure, rheumatic fever,
heart murmurs, chest pain or discomfort, palpitations, dyspnea,
orthopnea, PND, edema, EKG, other heart tests.
Gastrointestinal: Denies trouble swallowing, heartburn, appetite,
nausea, vomiting, indigestion, increased bowel movements,
constipation, change in bowel habits, rectal bleeding, hemorrhoids,
abdominal pain, excessive belching or passing of gas, jaundice,
hepatitis.
Urinary: Denies frequency of urination, polyuria, nocturia, burning,
pain, hematuria, urgency, hesitancy, incontinence, stones.
Genital: GoPo, age at menarche – 14, q 26-28 days, lasting 5 days,
some clotting. LMP – May 8. Denies discharge, itching, sores, lumps,
STDs, exposure to AIDS. Not sexually active at this time. Denies
sexual trauma.
Peripheral vascular: Denies leg cramps, varicose veins, clots.
Musculoskeletal: Denies muscle or joint pains, arthritis, gout,
backache, redness, pain, tenderness, stiffness, weakness, limited
motion.
Neurologic: Denies fainting, blackouts, seizures, weakness, paralysis,
numbness, tingling tremors, or other involuntary movements.
Hematologic: Denies anemia, easy bruising, bleeding, past
transfusions.
Endocrine: Denies heat or cold intolerance, excessive sweating,
diabetes, excessive thirst, hunger, polyuria.
Psychiatric: States she is depressed, denies suicidal tendency.
Physical exam
39-year-old female, who walks and moves easily and responds quickly
and appropriately to questions. Affect is pleasant but somewhat flat.
Pulse: 80.
Resp: 12.
BP: 118/80.
Height: 5’7”.
Weight: 170 lbs
Skin: Color good.
Head: Hair of average texture. Scalp and skull normal.
Eyes: Conjunctiva pink, sclera clear, PERRLA. Disc margins sharp. No
crossing changes, hemorrhages or exudates.
Neck: Trachea midline. Thyroid not palpable.
Lymph nodes: No adenopathy in neck, axillary, epitrochlear or inguinal
areas.
Thorax and lungs: Thorax symmetrical, good expansion. Lung fields
resonant. Vesicular breath sounds throughout. No adventitious
sounds.
Peripheral vascular: All pulses strong and regular, no bruits. Normal
JVP. Extremities warm, without pallor, cyanosis, edema. No
varicosities or calf tenderness. Homan’s negative.
Cardiac: Apical impulse at 5th ICS. No heaves, lifts or thrills. S1 – S2
normal, no S3 or S4. No murmurs.
Breasts: No masses. Nipples erect without discharge. Does SBE.
Abdomen: BS normal, no masses or tenderness. No
hepatosplenomegaly. No CVA tenderness.
Genitalia: External – no lesions or discharge. Vaginal walls pink, nl.
mucous. Cervix pink, mulliparous os. Uterus anteverted, normal size,
shape and configuration. No tenderness. Adnexa negative, ovaries
normal size, non-tender.
Rectum: Not indicated.
Musculoskeletal: ROM normal. No joint deformities.
Neurologic: Alert, oriented x 3, CN intact II-XII, coordinated
movements and gait, negative Rhomberg. Cerebellar, sensory and
motor testing intact bilaterally for both upper and lower extremities.
DTRs intact and bilaterally equal.