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INITIAL EVALUATION NOTE PART 1: HISTORY OF PRESENT ILLNESS (HPI)

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Initial Evaluation Note Part 1: History of Present Illness (HPI)

Heidy Canavaciolo

West Coast University

NURS 686

Dr. Vardah Seraphin

May 22, 2022

 

 

 

 

 

 

 

Initial Evaluation Note Part 1: History of Present Illness (HPI)

Identification:

 

Gender: Female

Marital status: Married

Occupation: Bachelor’s in art history and worked at the museum

Language: English

Birth place: United States

Race / ethnicity: American

Religion: None

Source: Patient

 

Chief Complaint

 

“I have been feeling really down and I’m crying over everything”, “I feel like I cry over every little thing”

 

History of Present Illness

 

Patient started feeling depressed for the past four months and she feel that this has been the worse year ever. She was recently laid off and her mother passed away and she had to identify her body which she explained was a very traumatic experience. Patient has a special needs son who have been in the hospital for a week now. Patient’s son is autistic and had epilepsy. Because of this patient is always anxious waiting for the next crisis or hospitalization. Due to the current condition, patient feel like she sleeps all the time and despite this she is always tired. Patient stated “I just can’t seem to even start doing anything. Dishes are piling up in the laundry needs to be done”. She expressed that since she is not working now, there shouldn’t be any reason for not doing house shores; however, she just feel like sitting around doing nothing. Furthermore, patient feels a combination of lack of motivation with feeling overwhelmed and guilty. During patient’s son last hospitalization, patient expressed to have suicidal thoughts because believed that her son got sick due to her given him the wrong medication, which was not the case. Even though, husband was really supportive at during that time, it made her realized that the depression was getting worse and she needed help.

 

Past Psychiatric and Medical History

 

Patient had symptoms like the ones presented and at that time she was diagnosed with depression. Furthermore, she had postpartum depression after her son was born; however, she has been able to manage with everything else after that. On the other hand, she noticed that lately everything has been building up and she is having a hard time copying with everything.

 

Patient claims that when she was diagnosed with depression, she was prescribed Paxil and she was seeing a therapist for about a year. Patient denies any hospitalization due to depression. Patient claims that treatment with Paxil and the therapy helped her to gradually start getting better and learned how to handle the stress of being a mother of a special needs child.

Patient only medical history is high blood pressure which is being controlled with lisinopril and had only one surgery which was the cesarean section with her son. Patient denies any allergies to food or medications

 

Past and current medications

 

Paxil

Lisinopril

 

Family History

 

Mother had history of depression and she had a treatment Patient doesn’t recall medication her mother was taking.

 

Substance Use/Abuse/ Addiction

 

Patient drink and use marijuana edible, but denies the use of any other drugs or smoking cigarettes

 

Developmental & Social History

 

Patient was born and raised by both parents and has a brother that two years younger than her. Patient described her parents always being loving and every time she will get into trouble her parents would ground her. Patient denies any spanking or abuse from her parents. In school age she denies any bullying and she claims to be star student. She had lots of friends and in school she was really active in sports. Patient denies any legal problems.

 

Patient have been married for ten years and has been her only marriage. Husband is a teacher and is good support for her and the family. Patient denies attending any support groups. Furthermore, she claims to have a few friend at the moment; however, having a special care child is keeping her really busy.

 

Review of Systems

 

Patient denies any allergies to food or medications

No muscle pain or joint pain

No problem with balance

No pain in your neck, no Stiffness

No numbness or tingling

Poor appetite

Patient denies any weight loss

No headaches or seizures

No vison or hearing problems

No problem with smell or taste

No sore throat

No thyroid problems

No difficulty of breathing, chest pain or discomfort

No Cough, no Sputum

No nausea or vomiting

No constipation or diarrhea

No urination problems

No rashes

No bleeding problems or bruising noted

 

Appearance: Good hygiene, well dressed

Patient is awake and alert

Behavior: Cooperative, engaged, appropriate eye contact

Motor: Normal with no psychomotor retardation/agitation noted

Speech: Fluent, coherent, normal tone, rate and volume.

Mood: Lack of motivation, feeling of overwhelmed and guilt

Affect: Feelings of guilt

Thought content: Thought of suicidal attempt with son last hospitalization because feeling of guilt “I thought about taking pills. I was in a really bad place that day”

Cognition: Intact

Insight/Judgment: Full/Good

Impulse Control: Low

 

Summary of Findings

Patient in question is a female that presents with clinical finding of feeling really down and crying over everything. Patient started feeling depressed four months ago claiming that this years has been really stressful since her mother passed aways, she lost her job and her son, that is a special needs one, has been sick. Looking at all these happenings we have to remember that life events play a major role in the development of the perception and behavior of individuals. Furthermore, patient in question have a psychiatric history where medication was prescribed. Family history includes mother diagnosed with psychiatric illness and with treatment as well. What’s more, patient had thought of suicidal attempt with son last hospitalization because feeling of guilt “I thought about taking pills. I was in a really bad place that day”. According to American Psychiatric Association, depression is a serious yet treatable mental illness that has an adverse influence on the actions and perceptions of individuals (Vaezi et al., 2019). Feelings of sadness and the lack of interest in different activities are the products of depression, along with causing numerous other physical and emotional challenges (Vaezi et al., 2019).

Reference

Vaezi, A. et al. (2019) ‘The association between social support and postpartum depression in women: A cross sectional study’, Women and Birth, 32(2), pp. e238–e242.

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