Nursing Evaluation Summary
Evaluation Summary
Ann is a 28-year-old Caucasian female who resides in Vancouver, BC. She is a married woman with no children. She came in for counselling because her husband wanted her to. He stated that she has bouts of crying, teariness, and is exhausted often. He feels she is grieving over the loss of her coworkers and friends who completed suicide. Ann reported feeling very sad and confused. The mental status exam, CAGE questions, and PHQ-9 suggests that Ann has moderately severe depression. She hopes to return back to her normal functioning.
Demographic Data
Ann is 5-foot, 7 inches, 120 pound, adult female of Caucasian heritage. She is a Canadian woman who has been married to her husband for seven years. Her socioeconomic status is middle class. She works as a secretary at a law firm. Her husband works at a technical support company as an IT specialist. She does not have family close by. The closest family to them is her husband’s family who resides in the United States of America.
Date of the Assessment
Ann came in for counselling on January 30, 2016 her appointment was at 10:30am.
Reason for Referral
Ann was referred to counselling by her husband. He claimed that she was experiencing bouts of teariness, sadness, and exhaustion for six months.
Key Signs, Symptoms, and Relevant Background Information
At the time of …show more content…
Her family history also did not show any concerns for mental health or physical illness. Ann only visits the doctor when is really sick with the flu, a virus, or an annual physical health check up. She visits her doctor about three to four times a year. Her last visit to her family doctor was two months ago. She went to see the doctor for her annual health check up. She does not consume any substances aside from her morning coffee and social drinking with friends. Her alcohol consumption during social events is one or two drinks at
Ann is a 28-year-old Caucasian female who resides in Vancouver, BC. She is a married woman with no children. She came in for counselling because her husband wanted her to. He stated that she has bouts of crying, teariness, and is exhausted often. He feels she is grieving over the loss of her coworkers and friends who completed suicide. Ann reported feeling very sad and confused. The mental status exam, CAGE questions, and PHQ-9 suggests that Ann has moderately severe depression. She hopes to return back to her normal functioning.
Demographic Data
Ann is 5-foot, 7 inches, 120 pound, adult female of Caucasian heritage. She is a Canadian woman who has been married to her husband for seven years. Her socioeconomic status is middle class. She works as a secretary at a law firm. Her husband works at a technical support company as an IT specialist. She does not have family close by. The closest family to them is her husband’s family who resides in the United States of America.
Date of the Assessment
Ann came in for counselling on January 30, 2016 her appointment was at 10:30am.
Reason for Referral
Ann was referred to counselling by her husband. He claimed that she was experiencing bouts of teariness, sadness, and exhaustion for six months.
Key Signs, Symptoms, and Relevant Background Information
At the time of …show more content…
Her family history also did not show any concerns for mental health or physical illness. Ann only visits the doctor when is really sick with the flu, a virus, or an annual physical health check up. She visits her doctor about three to four times a year. Her last visit to her family doctor was two months ago. She went to see the doctor for her annual health check up. She does not consume any substances aside from her morning coffee and social drinking with friends. Her alcohol consumption during social events is one or two drinks at