Subjective
CC (chief complaint): I have been having difficulty sleeping and anxiety.
HPI: Patient is a 18-year-old African American woman with history of hypertension presents with experiencing anxiety symptoms and difficulty sleeping. Patient states symptoms of anxiety has gotten worse over the years, her jitteriness, chest pain, feeling of impending doom and anxiety get worse when she drinks caffeine or waiting for lab result, its gets bad she has to run for cover sometimes. She says her lack of sleep makes her irritable and hard for her to concentrate or function the next day. Patient states was prescribed Lexapro, Benadryl and Ambien in the past by PCP, not on any medication currently, she has two children, no legal issues, pastor wife, denies hallucination, denies suicidal ideation.
chest pain, diarrhea, increase heart rate, excessive worrying, difficulty sleeping, shaking trembling
Severity is estimated to be medium based on patient risk of morbidity without treatment and her description of interference with functioning
Past Psychiatric History:
●General Statement: The patient states that she has been experiencing anxiety and difficulty sleeping and panic for years. She states the following as her prevalent symptoms. Chest discomfort or chest pain when under stress, diarrhea, sleep disturbance that is, difficulty falling or staying asleep, increase in heart rate, excessive worrying, and shaking or trembling. The patient states that these symptoms occur daily.
●Caregivers (if applicable): family
●Hospitalizations: None
●Medication trials: Lexapro, Benadryl, Ambien.
●Psychotherapy or Previous Psychiatric Diagnosis: Has history with anxiety symptoms.
Substance Current Use and History: None
Family Psychiatric/Substance Use History: The patient’s mother had anxiety.
Psychosocial History: Patient was born in Nigerian and migrated to the America years ago, patient has history of hypertension anxiety symptoms, mother diagnosed with anxiety. She is married with four children including twins. Patient is a nurse practitioner by profession, she has no legal or criminal issues, she is a Christian and a pastor’s wife, denies substance use, smoking or drinking, denies physical, sexual, or emotional abuse, denies suicidal ideas or intention, denies homicidal intention or ideas.
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