Patient: Smith, Jane
DOB: 06/ 13/ 1985
Date of Interview: 02/05/2010
Date of Report: 02/06/2010
IDENTIFYING INFORMATION: Ms. Smith is a 24 year old white woman currently residing in Vancouver, WA. She is employed as a hairstylist and currently lives in an apartment with two friends and their newborn son. Ms. Smith has been seen for mental health symptoms previously as a teenager, and was referred again on this visit by a colleague. The following report information is based on information collected from my interview with the patient, her medical chart, and psychological testing. CHIEF COMPLAINT: “I feel like sometimes my life is too much to handle. It makes me sick to think about things and I am not sure I can stand much more. I feel like there is no hope. I am all alone and I think I will always be alone.” HISTORY OF PRESENT ILLNESS: Ms. Smith says she frequently suffers from anxiety attacks and is often times unable to cope with stress while at work. She states she feels sweaty, weak and dizzy when thinking about life. Over the last two years she has been unable to relax, often has difficulty falling or staying asleep, and often feels ill and tired. She says her primary way of coping is alcohol. When unable to drink she reports her anxiety levels being “unbearable” and tries to stay away from social interaction. She also reports that her anxiety increases after nights of drinking as she feels like everyone is watching her. Ms. Smith has been diagnosed with high blood pressure which may be caused by her weight gain over the last three years. SOCIAL HISTORY: Ms. Smith is currently single and has no children. She was living with her father until she was forced to leave after a domestic dispute caused a no contact order between them two years ago. Her mother and father separated four years ago and her mother moved out of their house into her own apartment. She states that until the separation she heavily relied on both parents for social and financial...
Please join StudyMode to read the full document