SAMPLE HISTORYandPHYSICAL

HistoryandPhysicalExaminationofP.R.T.

PerformedinEmergencyDepartment,3/19/062:00PM
SourceofInformation:Patient

Identifyingdata:Patientisa24yearoldsingleCaucasionwoman,currentlyafulltime
studentattendingcollegeoftheMainland,selfreferredtoE.D.forevaluationofanxiety
andlowmood.

CC:Ijustfeeloverwhelmedandcanttakeitanymore

HPI: PRTisa24yearoldwomanwhoreportsthatshehashaddifficultiesperiodically
withanxietyand lowmoodforagoodpartofherlifesinceage13.Shehasbeentreated
inthepastwith6monthsofcounseling(age15)andsertraline100mgqd(ages1623).
Hercurrentdifficultiesbegan9monthsagofollowingtheendingofa2yearrelationship
withman thatshehadhopedtomarry.Shereportsthatshehasneverfeltthisbadly
beforeandshedoesntknowifshewillrecover.Hercurrentsymptomsincludelow
moodmostoftheday,moredaysthannot,decreasedinterestformostactivitiesthat
sheonce enjoyed,bothinitialandterminalinsomnia,decreasedappetitewitha15lb
weightlossoverthepast9months,feelingsofworthlessness,decreasedenergy,and
markedfeelingsofanxietybutnotpanicattacks.Concentrationisintact,butherother
symptomsaremakingitverydifficultforhertofunctionadequatelyinschoolandshe
consideringdroppingherclasses.Shereportsfeelingsofnotwantingtolivebutdenies
activesuicidalideationhasnoplansandstatesthateventhoughshehashadsuicidal
ideationwhenshewasyoung(age15)shewouldneverdothatnowbecauseofher
parents.Shedeniesanycurrentorpastsymptomsofhallucinations,delusions,
decreasedneedforsleep,pressuredspeech,grandioseideations,flightofideas,or
excessiveirritability. Shestatesthatsheworriesagreatdeal,primarilyabouther
relationships,butdoesnotbelievethatherworryisexcessiveorabnormal.Shedenies
obsessivethoughtsorcompulsiverituals.Shedeniesahistoryofsignificanttraumaor
abuse. Aftertheonsetofhercurrentepisode,Herpsychiatrist,Dr.R.McDonald,tried
switchingherfromherlongtimedosageofsertraline100mgperdaytoescitalopram
10mg(6weektrial),paroxetine(1weektrial stoppedduetosideeffects),and
venlafaxine(startedon75mg2weeksago),butnoneofthesemedicationchangeshave
hadasignificantchangeinhermood.Sheisbecomingprogressivelymoredespondent,
andwonderingwhatotheroptionsareavailable.HerdecisiontocometotheE.D.today
waspromptedbythefactthatthisupcomingweekendistheanniversaryistheirfirst
date.Shereportsfeelingoverwhelmedwithgriefanddoesnotknowifshewilleverfind
anotherrelationshiplikethisoneagain.

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PastMedicalHistory:
Illnesses:PatienthasoccasionalmigraineheadachesforwhichshetakesExcedrin
Migraine
Hospitalizations:none
Surgeries:none
Allergies:noknowndrugallergies
Currentmedications:Venlafaxine75mgpoqd
Currentphysician:SeesDr.R.McDonaldforpsychiatricmeds
PCPisOb/gynphysician,Dr.SamCurryinTexasCity lastvisitwasin11/04
PastPsychiatricHistory

Patientfirstsawacounseloratage15for6months,withsomereliefofsymptoms.
Meds:Sertraline100mgqdages1523,withconsiderablereliefofsymptomsuntil
currentepisode
Nohospitalizations
Diagnoses:unsure,exceptanxietyanddepression
Suicidalgesturesorattempts:none

FamilyPsychiatricandMedicalHistory

Paternalgrandfatherabusedetoh
Paternalgrandmothersufferedfromdepression
Shedoesntbelievethereisanypsychiatricproblemsinmothersfamily,butsheis
unsure
Sisteralsohasanxiety,takesparoxetine
Reportsbothparentsaregenerallyhealthy,althoughmotherisoverweightandwas
recentlytoldshewasprediabetic
Siblings(1sister,age28,2brothers,ages26and22,areallhealthy)

Socialhistory
ThepatientwasborninNorman,Oklahoma,the3rd of4childrenwith1oldersister,an
olderbrotherandoneyoungerbrother.HerfatherisaC.P.A.andhermother stayedat
homewhileshewasgrowingupandcurrentlyworksasanassistantinaveterinarians
office.Shedescribesherrelationshipwithherparentsaswarm,andreportsthatsheis
particularlyclosetohermother.Shestatesthatbothherparentsare relativelyshy
people,andhaveasmallcircleofcloseknitfriends.Theywereactiveintheirchurch
(Methodist)andcontinuetobeso.Sheusedtoenjoygoingtochurchwhenshewas
young,butasshegotolderfounditlessmeaningfulandnowrarelyattends. Sheis
uncomfortablearoundpeopleshedoesntknowwell,andwouldratherstayhome. She
reportsthatsherememberslittleaboutherearlychildhood,butdoesnotbelievethat
therewasanythingremarkableaboutit.Shedidokinelementaryschool,andwas
particularlyclosetoonefriend.Herdifficultiesfirstbeganinmiddleschoolwhenher
familymovedfromOklahomatoTexasandshefeltoutofplaceinhernewschool.She

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reportsthatshewasextremelyshyandhatedtobecalledonin class.Shewouldblush
easily,andwouldbecomeparalyzedwithanxietywhenshewasaskedaquestionor
requiredtogiveapresentation.Shestatesthattheotherkidswouldpickonherandas
aresultshebecamewithdrawnanddepressed,evencontemplatingsuicide.Herparents
referredhertocounselingatage15,whichhelpedalittle,butdidntmakemuch
differenceintermsofovercominghershynessorimprovinghersocialsituationat
school.Atage16shebegantoskipschooltoavoidtheanxietyassociatewithinteracting
withotherkids,andeventuallyshedroppedoutofschool.Howeverstayingathomeall
thetimedidnothelphermood,especiallysincehermotherbegannagginghertogoget
ajob.Atthatpointintimeshedevelopedadeepeningdepression,andsoshewentto
seeDr.McDonaldandwasstartedonsertraline100mgqd.Thishelpedherconsiderably.
SheeventuallygotherG.E.D.,andgotajobdoingsomeclericalworkforalocal
insuranceagency.Sheremainedthereuntil2yearsago,whenshedecidedtoreturnto
returntoschoolfulltimeattheadviceofherfatherwhoencouragedhertopursue
accountingsoshecouldjoinhiminhisfirm.Sherarelydateduntilthreeyearsagowhen
shemetherboyfriend,aclientattheinsuranceagencywheresheworked.Heisalsothe
first(andonly)manwithwhomshehadbeensexualactive.Therelationshipended9
monthsagoafterhedecidedhewasnotreadytogetmarriedandwantedtoseeother
people.Sincethenshehasbeenuninterestedindatinganyoneelse. Shereportsthat
shefeelsunattractiveandhastroublebelievingthatanyonewouldbeinterestedin
her.Shestatesthatshewantstohaveanotherrelationship,butshedoesntbelievethat
isreallypossible,andshecantseemakingherselfvulnerableagain.

Currentlyshelivesathomewithherparentsandheryoungestbrother(age22).Inthe
pastsheenjoyedreading,surfingtheinternet,andspendingtimegardeningandtaking
careofherpets(2catsand1dog).Nowsheisuninterestedinhobbies.Shehasone
friendatschoolthatshesometimesgoesoutwith,butshehasntbeenseeingherlately.
Shereportsherfamilyissupportive.Shedeniesuseofalcohol,illicitdrugs,ortobacco
products.

MentalStatusExamination:

Patientisaslenderwhitefemale,appearingyoungerthanherstatedage,dressedina
plainwhitetshirtandjeans,hairpulledneatlybackintoaponytail,facepalewithno
makeup,cooperativebuttearfulduringtheinterviewwithonlyoccasionaleyecontact.
Speechislowandsoft,sheisarticulatebutattimesdifficulttounderstandbecausethe
volumeissolow.Therearenoneologisms,blocking,orlatencyofresponse.Affectis
blunted,moodisdepressed.Shedeniessuicidalideationbutadmitsthat sometimesshe
wishesthatshewouldjustnotwakeup.Denieshomicidalideation.Thoughtprocesses
areclearandgoaldirected.Shedenieshallucinations,delusions,thoughtinsertion,
thoughtwithdrawal,thoughtbroadcasting,orideasofreference.Cognition:Sheisalert
andorientedX3,sheisabletodoserial7squicklyandaccurately.Immediate,short
termandlongtermmemoryareallintactasisevidencedbyherabilitytoremember3
or3objectsafter5minutesandherabilitytogiveagoodhistory.Fundofknowledge:

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Sheisabletonamethepresidentandlast4presidents.Vocabularyisconsistentwith
levelofeducation(somecollege).Calculations:wasabletoaccuratelycalculate5X5=25,
5X9=45,5X13=65,and5x65=115,Abstractions:wasabletointerpretproverbsand
similaritiesinanabstractfashion.Constructionalability:Wasabletocopyathree
dimensionalfigureaccurately.Insightisgoodasisevidencedbyherrecognitionthatshe
issufferingfromdepression.Judgmentis intact.

ReviewofSystems:

Gen:Positivefor15lbweightlossover9months.Deniesweakness,fatigue,fever,chills,
nightsweats,heatintolerance.
Skin:Denieschanges,pruritis,rash,orchangesinhair.
Head:Positiveforoccmigraineheadaches.
ENT:Deniesvisualchanges,eyepain,hearingloss,tinnitus,vertigo,earpain,ear
discharge,epistaxis,nasaldischarge,sinusitis,teethproblems,abnormaltaste,sore
throat,orspeechdifficulty
Neck:Deniesneckswelling,pain,stiffneck,goiter,ormasses,nodes.
Cardiopulmonary:Deniescough,dyspnea,wheezing,hemoptysis,chestpain,
palpitations,orthopnea,P.N.D.,murmurs,edema,claudication,syncope,hypertension
GI:Positivefordecreasedappetite.Negforn/v,hematemesis,melena,dysphagia,
heartburn,flatulence,abdominalpain,jaundice,changeinbowelhabits,diarrhea,
constipation,hematochezia,orrectalpain.
GU:Agemenarche:12.regularmenses.G0,P0.Currentlyonnocontraceptives.Hasused
condomsinthepast.Deniesdysmenorrhea, menorrhagia,metrorrhagia,dyspareunia,
pelvicpain,sexualdysfunction(althoughcurrentlyhasnosexualpartner),discharge,
STD,breastmasses,pain,ortenderness,Nodysuria,frequency,nocturia,hematuria,
urgencyincontinenceorpolyuria.
MS:Deniesbackache,jointpain,stiffness,
Heme:Denieslympadenopathy,bleeding,bruising,anemia.
Neuro:Deniesseizures,paralysis,muscleweakness,parasthesia,sensationchanges.
Reportsoccasionaltremors(whenanxious),andproblemswithheadache.
Psych: NoteHPI.

PhysicalExam:
VitalSigns:
Height:63inches
Weight:115lbs
Temp:37C.
RR:16
BP:110/62
Pulse:82BPM

Appearance:Slenderwhitefemale,slightlypale,appearingyoungerthanstatedage in
moderatedistress,neatlydressedandgroomed.

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Skin:soft dry skin,nolesions.Nailbedspinkwithnocyanosisorclubbing.
Hairfine,scalpwithoutlesions
Eyes: Visualacuity20/20withoutcorrectivelenses. Pupilsequal,roundandreactiveto
light,Extraocularmovements intact.Conjunctivapinkwithnorednessor
exudates. Eyelidswithoutlesions. Sclerawithouticterus.Fundi discssharp.
Vesselswithouthemmorragesorexudates .
ENT: Hearing grosslyintact. Externalauditory canals patent,freeofcerumen, auricles
withoutlesions, tympanicmembranesintact withvisablelandmarks. .Nares
patentandmucusmembranesmoistwithouterythemaorexudates.Nosinus
pain topalpation.Mouth:Dentitionwithoutlesions.Lipsdryandchapped.Gums,
tongueandmucosawithoutlesions.Tonsilsslightlyenlargedbutnot
erythematousandwithoutexudates.Pharynxclear.
Neck:Fullrangeofmotion.Thyroidnotpalpable. Tracheaatmidline.No
lymphadenopathy.
Breasts:Examdeferred.
Pulm: Chestsymmetrical expansion. Nodeformatiesonposteriorchestwall. Lungs
clear toauscultationandpercussion, withoutadventitioussounds.
CV: NoJVD. Nodeformatiesonanteriorchestwall. PMIat5th intercostalsspace,
midclavicularline.HeartsoundsRRR, Normal S1and single S2. NoS3,S4,
rubs,ormurmurs.Carotids2+bilaterallywithoutbruits. .
Abd: Noscars,inspectionunremarkable.Bowelsounds normoactive Nopainto
superficialordeeppalpation. Liverspan7cmatthemidclavicularline.Spleen
notpalpated. GUexamnot performed
Musculoskeletal: Fullrangeofmotion. nopain,edema,or deformity.
Pulsesfullandequal.Nocyanosis,clubbing,oredema.
Neuro:CranialnervesIIVIIintact, Musclebulkisappropriateinupperandlower
extremities.Motorstrengthis5/5inupper andlowerextremitiesbilaterally.
Sensationintacttolighttouch,temperature,andpinprick. DTRs2+inbiceps,
triceps,quadricepsandankles. Gaitfullwithoutimpairment.Coordinationable
todo rapidalternatingmovementswellandfingertonosetestwellwitheyes
openandclosed. Babinskiresponsesdowngoingbilaterally.Rombergnegative.

Assessment:

Patientisa24yearoldSWFwithalonghistoryofsocialanxietydisorderwhichappears
tohaveimpactedherlifeinasignificantway, leadingtoacurtailmentinher
developmenteducationally,sociallyandoccupationally.Thisledeventuallyto
depressionwhichwassuccessfullytreatedwithsertralineforsometime,untilshewas
overcomebythegriefoflosingasignificantrelationship inherlife,thatofherfirstreal
boyfriend.Thedegreeofhersocialanxietyissoprofoundispossibleshemayevenmeet
criteriaforavoidantpersonalitydisorder.Currentlyhermostsignificantproblemisa
majordepressiveepisodeof9monthsduration,whichisnotrespondingtoachangeof
medications.Todateshehasonlyhadonedecenttrialofanalternatemedication
(escitalopram)intermsoflength,butsincethemedicationwasnotincreasedtoits

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maximumdosage(20mg)wecannotbesurethat itwouldnothavebeeneffectiveata
higherdosage.Thetrialofparoxetinewasnotagoodtrialbecauseofineffectivelength
(1week)andshehasnotbeenonthevenlafaxinelongenoughtoseeifitwillbe
effective.

Diagnosis:

AxisI:MajorDepressiveDisorder,Recurrent,Severe
SocialAnxietyDisorder
Ruleoutgeneralizedanxietydisorder
AxisII:R/OAvoidantPersonalityDisorder
AxisIII:MigraineHeadaches
AxisIV:Mild:Havingdifficultygoingtoschoolandconsideringdroppingout
AxisV:GAF=55

TreatmentPlan:Sincethepatientisnotacutelysuicidalatpresent,andsheisnot
psychotic,shedoesnotcurrentlymeetcriteriaforhospitalization.Thereforewill
attempttotreatherasanoutpatient.

1.WillrecommendthatsheincreaseherVenlafaxineto150mgqdfor7days,thengo
upagainto225mgqdfor7day,andthento300mgqd.Forthenoradrenergicreuptake
propertiesofvenlafaxinetotakeeffect,thedosagemustbeincreasedtoatleast225mg
perday,andpreferably300mgperday.Thepatientshouldbewarnedaboutthe
potentialsideeffectsofgoingupincludingnausea,insomnia,andincreasedblood
pressure.

2.Forsleepproblems,willprescriberozerem8mgpoqd.Thismedicationhasthe
advantagethatitisamelatoninreceptoragonist,andhasnoaddictivepotential.

3.Willrefertoapsychotherapistforcognitivebehavioraltherapytohelpaugmentthe
somatictherapies,toassistwithhergrievingoverherendedrelationship,andtoassist
herwithanxietyso thatshemightbebetterabletocopeandachievetheattainmentof
futuregoals,

4.Willrecommendthatshefollowupwithherpsychiatristwithinaweektodiscuss
theseplans,butthatifshefeelsworse,orbecomessuicidal,thatsheshouldreturnto
theE.D.toreevaluatehersituationorbeconsideredforhospitalization.

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