Psychosocial History:
Patient recently had her first child two months ago. Currently married; stay at home mother after working in community library for 5 years. Grew up with her mother after her parents divorced when she was 16; has two sisters in Troy, Alabama. Completed education through bachelor’s level, majoring in English Literature. Prior to having her baby, patient enjoys writing and could write for hours at night. No previous suicidal gestures.
Medical History:
· Current Medications: Trandate 100mg twice daily for treatment of hypertension, admits to missing doses due to forgetting.
· Allergies: PCN
· Reproductive Hx: Patient is married with one child but says that she currently has no sex drive.
ROS:
· GENERAL: she has gained weight and feel bloated with lines on her face.
HEENT: Head: the patient denies having ever been injured in the head. Eye: No visual loss, blurred vision, double vision, or yellow sclerae. Ears, Nose, Throat: No hearing loss, sneezing, congestion, runny nose, or sore throat, or difficulty swallowing.
· SKIN: Skin is not smooth, has pimples and lines that are associated with the recent childbirth.
· CARDIOVASCULAR: Refutes experiencing tachycardia or chest pains. No chest pressure or chest discomfort, no palpitation or edema.
· RESPIRATORY: Denies shortness of breath and cough.
· NEUROLOGICAL: No headache, dizziness, syncope, paralysis, ataxia, numbness, or tingling in the extremities. No change in bowel or bladder control. No previous suicidal gestures, currently seems to have a distorted thinking pattern and cites suicidal thought.
· MUSCULOSKELETAL: the patient refutes experiencing joint pains
· HEMATOLOGIC: the patient says that she has never experienced anemia or hemorrhage.
· GENITOURINARY: No burning on urination, urgency, hesitancy, or odor.
Objective:
Physical exam: T- 98.6 P- 88 R 18 154/92 Ht 5’1 Wt 230lbs