PSYCHOSCE - Ku @00124854 Grace Ku OMS-I ID# @00124854 Psych...

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Ku @00124854 Grace Ku OMS-I ID# @00124854 Psych OSCE CC: DG is a 32 y/o female who comes in complaining of lower back pain as a result of a car accident. HPI: She states that on May 19, 2007, at 11am, she went to Coco’s restaurant and ate a salad and had two glasses of wine before picking up her car from the mechanic. She later awoke in the hospital where she was informed that she had been involved in a car accident, which resulted in a rear-end collusion of the car in front. She does not remember being in or causing the accident, and claims she must have “blacked-out.” She was later given a DUI by the police for causing the accident. She has been in pain since the accident, and states that it is an annoying/gnawing that is localized to her lower back and does not radiate. She has been taking her husband’s Tylenol with Codeine (unknown dose) with no relief of symptoms. She rates the pain as a constant 5+/10. PMI: When questioned about her prior medical history, patient states that she suffered a fall in her home 3 years prior and broke 3 ribs. She suffered no head trauma from the fall. She could not recall how the fall occurred, and again states that she must have blacked-out. She and does not have a history of past surgeries or pregnancies, does not take any regular medications, and claims an otherwise unremarkable medical history. Past Psych Hx: Patient states that she has never been hospitalized for any past psychiatric problems. Patient denies any medication or other therapy for any psychiatric problems. While assessing her depressive state via SIGECAPS questions, she states that she has had a hard time sleeping, and has had frequent nightmares since the accident. She has not been motivated to do much, due to her back pain and feelings of guilt over causing the accident. She has had a hard time concentrating and feels a constant need to unwind and relax. Family Hx Patient states that she has 2 brothers and that both parents are living. She claims an unremarkable family medical history for all members, and denies any familial history of neurological problems, seizures, psychological illness or history of suicide attempts. Substance Abuse:
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This note was uploaded on 05/20/2008 for the course PSYCH. 1 taught by Professor Chart during the Spring '08 term at Western University of Health Sciences.

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PSYCHOSCE - Ku @00124854 Grace Ku OMS-I ID# @00124854 Psych...

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