Social History: She states that she has some stress related to her upcoming examinations and her impending job search upon graduation. She states that she has a strong support system made up of friends and family and she is active in her church. She states that she copes with stress by staying organized. She enjoys reading and watching television (1-2 hours per day). She states that her father died in a car accident a year and a half ago, which was di ﬃ cult for her and she experienced some di ﬃ culties with sleep at that time as well. She denies use of tobacco. She drinks approximately 10-12 alcoholic beverages per month, but never more than 3 per sitting and does not note any impact on her sleep. She has used marijuana in the past, but no current use and denies other illicit drugs. She does not exercise regularly, but states that her job is somewhat active and she walks 5-15 minutes daily. She drinks 1-3 diet colas per day. Family History: Denies any history of known sleep disorders or psychiatric disorders. Review of Systems: • General: Denies changes in weight, weakness, fever, chills, and night sweats. Does complain of increasing daytime fatigue. • Neurologic: Denies loss of sensation, numbness, tingling, tremors, weakness, paralysis, fainting, blackouts, or seizures. Endorses changes in concentration and sleep. Denies changes or di ﬃ culties in coordination. • Psychiatric: States that her mood has been “o ff ” and she does not feel like herself. She does complain of increased anxiety related to upcoming exams and job search. She has no history of depression, but does state that she feels helpless and notes that her performance at work and school
Resp: Denies di ﬃ culty breathing Psych: Denies having suicidal and homicidal ideation. Denies having panic attacks. Denies a history of bipolar, depression, anxiety, OCD and schizophrenia. Reports not being able to sleep due to excessive worrying about life. Reports a decrease in performance at work and school due to lack of sleep. is beginning to decline. She denies tension or memory loss. No past suicide attempts. Denies suicidal or homicidal ideation. Assessment Anxiety- patient states that she is constantly worried. Sleep disturbances secondary to anxiety- patient states that she is having di ﬃ culty sleeping due to stress and worrying. Substance withdrawal- possible withdrawal from ca ff eine intake. Sleep disturbance related to anxiety Plan Diagnostics: None at this time. May consider a sleep study if the insomnia persists for an extensive amount of time.
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- Summer '19
- mental health, denies, OBJECTIVE DATA COLLECTION, Student Performance Index, sleep aids