Spaces:
Running
Running
Date: 2/12/2024 | |
History: the patient is a 45 yo F here for nervousness. A few weeks ago she noticed that she was feeling more nervous than usual and that it has been worsening. It is exacerbated by family and work. She feels espeically nervous on Sunday night and Monday morning when she is preparing for the week. She is unable to fall asleep and doesn’t want to eat anything, though she does make herself eat. Nothing helps her nervousness. She otherwise denies significant changes in appetite, weight loss, or overall wellbeing. She denies fevers, chills, nausea, constipation, diarrhea, skin changes, racing heart, shortness of breath, dizziness, headaches or rashes. | |
ROS: otherwise negative | |
PMH: None; PSH: None | |
Meds: Tylenol for occasional HA | |
FHX: Father had an MI, died at 65yo | |
Allergies: NKDA | |
SH: Lives at home with husband, mother, and youngest son. Is an english literature professor at a local college. | |
Has 2 drinks/mo, no tobacco or drug use. | |
Physical Examination: | |
VS: Blood Pressure: 130/85 mm Hg | |
Heart Rate: 96/min | |
Gen: No acute distress, conversational, thin | |
Neck: No thyromegaly, no lymphadeopathy | |
Heart: RRR, no murmurs, rubs or gallops. Radial pulses +2 bilaterally | |
Lungs: Clear to ascultation bilaterally, no wheezes | |
Psych: Well-groomed. Non-pressured speech, linear though process. | |