SH Tina mental health [13305 ] PDF

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I D:Ti naJonesi s28y oAAf emal e.Sel fr epor t . I D:Ms.Jones28y oAf r i canAmer i canf emal e. Rel i abl e.I nsur ed.Es t abl i shed.Dat eandt i meof Pr i mar ysour ceofi nf or mat i on.Rel i abl e. vi s i t:3/ 7/ 205PM CC:Iam s t r essedoutand Es t abl i shedpat i ent .I nsur ed.Chi efCompl ai nt : can' tf al l asl eepatni ghtduet oupcomi ngt es t . Di ffic ul t ysl eepi ngx1mont h.HPI :Ms .Jones HPI :Ms .Jonesi sa28y oAAf emal ewho pr esent st ot hecl i ni ccompl ai ni ngofdi ffic ul t y pr esent edt ot hecl i ni cwi t hcompl ai nt sof sl eepi ngwhi chshenot est ohav es t ar t ed1 di fficul t ysl eepi ngst ar t edamont hago.Shec/ omont hago.St at est hathersl eepi s“ shal l owand di fficul t yf al l i ngasl eepatl east4or5ni ght sper notr es t f ul ” .Compl ai nsofdi fficul t yf al l i ngasl eep week.Repor t sonl ysl eepi ng45hour sani ght atl east4or5ni ght sperweek,Shei sabl et o whenshepr ef er s8hour sandawak ensat8am s t ayasl eepwi t houtdi fficul t y .Onav er ageshe dai l y .sheal sos t at edt hatt hequal i t yofsl eepi ng sl eeps4or5hour sperni ghtandawak ensat hasbeendecr eased.Shedoesnott ak eany 8: 00am dai l y .Hasaf ai r l yconsi st ents chedul e pr esc r i pt i onorov ert hecount ersl eepai ds . onweek day sandweek ends.Doesnott ak eany Li mi t ssc r eent i mepr i ort obedanddoesnot pr es cr i pt i onorov ert hecount ersl eepai ds . dr i nkcaffei neaf t er4pm dai l y .Shedoesnot Li mi t ssc r eent i mepr i ort obedanddoesnot f eelr es t edi nt hemor ni ngandhasbeenf at i gue i nges tcaffei neaf t er4pm dai l y .Sheendor ses ( 7/ 10)dur i ngt heday s.Hasr aci ngt hought st hat decr eas edf eel i ngsofsl eepi nessov ert hepast mak esheranxi ousandi nt er f er eherwi t hsl eep. mont h.Deni esdi fficul t i esawaki ng,butdoesnot Di s t r act i onf r om t het hought st hatcauses t r ess f eel r est edi nt hemor ni ng.Hasday t i mef at i gue r el i ev esherst r es sal i t t l e.shedoesnott ak e ( r at es5/ 10s ev er i t y ) ,r est l essness ,and napsdur i ngt heday .PMH:Ast hmadi agnosed i r r i t abi l i t y( r at es2/ 10sev er i t y ) .Doesnott ak e whenshewas2.Type2di abet esdi agnosed naps .PMH;As t hma,Type2di abet es ,El ev at ed whenshewas24.Deni essl eepdi sor der sor BP.Deni esPMHoft hy r oi ddi seas e.Nopast ps y chi at r i cdi sor der s .Medi cat i ons :Fl ov entt wo sui ci deat t empt s.PSH:None( ALWAYSask puffsBI Df orast hma.Pr ov ent i lPRNf orast hma aboutOTC,Vi t ami ns,Her bal s ,OCsand at t ack.Al l er gi es:Cat s; i t chyey es ,Peni ci l l i n; suppl ement s . )Medi cat i ons :Pr ov ent i l i nhal er -2 r ashesSoci al Hx :Hassomes t r essr el at edt o puffsq4hr spr n,Fl ovent2puffsBI D.Al l er gi es : herupcomi ngex ami nat i onsandheri mpendi ng Peni ci l l i n-r ash.Cat sanddus tc auseast hma. j obsear ch.Shel i v eswi t hmot herandsi st erand Nof oodorseas onalal l er gi es.Soci al Hi st or y : hasas t r ongsuppor ts y st em madeupoff ami l y Hassomest r es sr el at edt oherupcomi ng andf r i ends.Goest ochur ch.Fat herdi edi na ex ami nat i onsandheri mpendi ngj obsear ch caracci dent2y ear sagot hatmadeher upongr aduat i on.Shehasast r ongsuppor t depr essedatt hi st i me.Jobatacopyand s y st em madeupoff r i endsandf ami l yandshe shi ppi ngst or eandpr epar i ngf orCPA i sact i v ei nherchur ch.Shecopeswi t hst r es sby cer t i ficat i on.Deni esdi ffic ul t ymaki ngdeci si on s . s t a y i ngor gani z ed.Enj oysr eadi ngandwat chi ng Goesoutdanci ngwi t hf r i endsont heweek end t el evi si on( 12hour sperday) .Herf at herdi edi n f orf un.Shecopeswi t hst r es sbyst ayi ng acaracci dentay earandahal fago,whi chwas or gani z ed.Deni esuseoft obaccoori l l i ci tdr ugs . di ffic ul tf orherandsheexper i enceds ome Shedr i nk sappr oxi mat el y1012al cohol i c di ffic ul t i eswi t hsl eepatt hatt i me.Deni esuseof bev er agespermont h,buti tdoesnotnot eany t obacco.Appr oxi mat el y1012al cohol i c i mpactonhersl eep.Deni esdr i nki ngand bev er agespermont h,butnev ermor et han3 dr i vi ng.hasusedmar i j uanaev er yweek endi n persi t t i ng.Not esnoi mpactonhersl eep.Has t hepast .Las tmar i j uanawaswhenshewas20 usedmar i j uanai nt hepast ,nocur r entuse. or21.Deni esphy si cal orsexual abuse.Deni es Deni esot heri l l i ci tdr ugs .Doesnotex er ci se sui ci dal at t emptorsel fhar m.Deni esvi ol ent r egul ar l y ,butst at est hatherj obi ssomewhat t hought ,angr yout bur st sorpas tt r auma.Deni es act i veandshewal ks515mi nut esdai l y .Dr i nks

hi st or yofpr escr i pt i ondr ugabuse.Nev erser ve 13di etcol asperday .Li v eswi t hmot herand i nmi l i t ar y .Deni escur r enti nt i mat er el at i onshi p si st er .I mmuni zat i ons:Upt odat e.Nofl uvac ci ne orsexual act i vi t y .Deni esanyfinanci al t hi sseasonFami l yHi s t or y :Deni esanyhi st or y di fficul t i es .Wor ks32hour saweekanddeni esofknownsl eepdi sor der sorps y chi at r i c mi ssi ngt i mef r om wor k.I mmuni zat i ons :Tet anus di sor der s .NoFHoft hyr oi ddi sor der s .( ALWAYS boost eray earago,Hav en' thadafl uv acci ne as kaboutpossi bl epr egnanc yanddocument t hi sy ear ;bel i ev ei tseemsnoteffect i v e.no LMP)Repr oduct i v eHx:G0P0,LMP:3weeks r eact i ont ov acci nes .Fami l yHx:Deni esany ago.Notcur r ent l ysexual l yact i v e.* * Cr i t i cal hi st or yofknownsl eepdi sor der sorpsy c hi at r i c Thi nki ngMoment :Donotwr i t e/documentt hi s di sor der s .Repr oduct i v eHx: LMP:Thr eeweeks ony ourSOAPnot e. * *Thi nkofy ourdi ffer ent i al ago.i r r egul arcy cl e.heavymenst r ualfl ow.No di agnosest ogui dey ourROSandEx am:Do chi l dr en.G0P0A0.Di et :Abl ueber r ymuffinf orNotMi ss :Depr essi on,al coholabuse.Ot her s: br eakf as t .Notmoni t ors al ti nt ak e.Saf et y:wear acut eemot i onal st r ess ,st i mul antuse,poor seat bel t .ROS:Gener al :l ost23poundsbut sl eephygi ene,s l eepdi sor der ,medi cat i onsi de deni esmaj orchangesi nwei ght .Deni esf ev er s , effect s,t hyr oi ddi sor der .REVI EW OF chi l l sandni ghtsweat s.c/ oi ncr easi ngday t i me SYSTEMSGener al-Deni eschangesi nwei ght , f at i gue.Neur o:Deni esl ossofsens at i on.Deni es weakness ,f ev er ,chi l l s,andni ghtsweat s .+ sei z ur es,numbness ,t i ngl i ng,t r emor s ,par al ys i s i ncr eas i ngdayt i mef at i gue.Respi r at or y-No orbl ack out s .Head:Deni esr ecentheadt r auma. cough,SOBorwheez i ng.As t hmai snot Ey es:c/ obl ur r yvi si onnot edov ert hepastf ew i nt er f er i ngwi t hsl eep.Hasnotusedr escue mont hs .Lastey eex am waswhenshewasa i nhal erf or9mont hs .Car di ac-Noches tpai nor ki d.Ear s :Nohear i ngl oss ,v er t i goordi zz i ness . pal pi t at i ons.Neur ol ogi c-Deni esl ossof Respi r at or y :noSOB,cough,hemopt ys i s, sens at i on,numbness ,t i ngl i ng,t r emor s , emphy semaort uber cul osi s .Car di ac:f eel st he weakness ,par al y si s ,f ai nt i ng,bl ack out s,or hear ti sr aci ngwhenshewasanxi ousand sei z ur es.Endor seschangesi nconcent r at i on s t r essouti nt er mi t t ent l y .Butdeni esmaj orhear t andsl eep.Deni eschangesordi fficul t i esi n pr obl emsoramur mur .GI :Deni eschangesi n coor di nat i on.Endocr i ne-Noheatorcol d bowel habi t s .Deni eshear t bur n.GU:c/ o i nt ol er ance.Posi t i v epol yur i a,pol ydi psi a, pol yur i aandnoct ur i a.Endocr i ne:nocol d pol yphagi a.Ps y chi at r i c-St at est hathermood i nt ol er ance.get swar m somet i mesbutdeni es hasbeen“ off”ands hedoesnotf eel l i k eher sel f . maj orpr obl emswi t hwar mi nt ol er ance. Compl ai nsofi ncr eas edanxi et yr el at edt o Ps y chi at r i c:Ref ert oHPI upcomi ngex amsandj obsear ch.Shehasno hi s t or yofdepr essi on.Doess t at et hatshef eel s hel pl essandnot esherper f or manceatwor k andschool i sbegi nni ngt odecl i ne.Deni es t ensi onormemor yl oss .Deni essui ci dal or homi ci dal i deat i on. As sessment

1Sl eepdi sbur gancer el at edt oanxi et yand s t r ess .2el ev at edbl oodpr es sur e3.Type2 di abet es4.Ast hma

1.Sl eepd Di abet es El ev at ed

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Di agnost i cs:noneatt hi st i meMedi cat i on: I ni t i at emel at oni n1mgpoatni ght ,t ak en30 mi nt uesbef or esl eep.Educat i on:Encour age

( Pl anwi l l nor mal l ya ( AL WAYS

Ms .Jonest ocont i nuet omoni t ors ympt omsand l ogherpei sodesofi nsomni aandanxi et y .Br i ng l ogt onextvi si t .Encour agehert odecr eas e caffei nei nt ak eandi ncr easei nt ak eofwat er . Educat eheronanxi et yr educt i onst r at egi es suchasdeepbr eat hi ng,r el axat i on,orgui ded i mager y .Educat eont hei mpor t anceof mai nt ai ngr egul arsl eepandwak eschedul e. Educat et ol i mi tal coholc onsumpt i on.Educat e t oseekemer gentcar ef oranysui ci dal t hought s. Educat et omoni t orBPandk eepl og.Br i ngl og t onextvi si t .Di scus st heneedt omai nt ai n heal t hybl oodpr ess ur eandl i f es t y l eEducat et o moni t orbl oodgl ucoseandk eepBG l ogand br i ngi tt onextvi si t .Di s cusst heneedt ocont r ol hi ghbl oodsugarandi t scompl i cat i ons .Educat eas t hmai nhal erusedai l yandr escue i nhal er .Di scus st opr ev entast hmaat t ackby avoi di ngt r i gger s .Ref er r al :ment al heal t h cons el l i ng.Fol l owup: Revi si tcl i ni ci n2week s f orf ol l owupandev al uat i on.

t hepat i en Di agnost i Ther apeu t hi st i me. mont hs.E cons umpt ot herfl deepbr ea Mai nt ai n caffei ne l i mi ts cr ee pm.Geto t heni ght . f ur t heror s el f har m changest Revi si tcl i eval uat i on Ret ur nt o di abet esc soci al wo i nt er v ent i o Educat i on...