Assignment: Write a comprehensive H&P including the mental state exam 

 

CC: boyfriend called 911 as her girlfriend loss of consciousness while eating x 2 hours ago

 

HPI:

Emma is a 23 years old female with no PMHx was brought to the ER by EMS for losing consciences. Pt was eating lunch with her boyfriend while she started to feel a choking sensation as pt believes the food got stuck in her throat. Pt states along with choking, she was experiencing extreme sweating, trembling and  SOB. Pt describes her situation as “I started to sweat like crazy, I could not breath and my surrounding was turning black”. Patient states she felt similar SOB and sweating episode like a month ago while walking her dog. Patient states she went outside to walk her dog and suddenly she started to experience extreme chest pain, difficulty breathing, sweating, numbness in her arms. Pt describes that situation, “My heart started to pound so hard I thought it might explode out of my chest. My knees felt weak – it seemed like my whole body was shaking, then my arms went numb. Everything went dark next to me”. She describes the chest pain as sharp, non-radiating.  She rates the pain 10/10 at its worse and 8/10 at its best. Pt shares that she started to feel weird sensation for the last 6 months and she has intense fear of being alone. Pt is really anxious about her career, relationship and this weird episode that making her feel like she is going insane. Pt admits to chills, headaches, dyspnea, chest pain, palpitation, syncope, generalized fatigue and specific phobia to snake and spiders. Pt denies fever, night sweats, recent weight loss or gain, loss of appetite, hallucinations, delusions, suicidal or homicidal ideations. Pt was referred from the medical ER to the CPEP and she is currently alone.

 

PMHx: none

Surgical Hx– none

Medications: multi-vitamins

Family Hx:

Father- Bipolar disorder which was diagnosed 10 years ago

Mather- DM and HTN

Sister- OCD

 

Social Hx:

Emma is single graduate students who lives with her boyfriend. She describes her relationship with her boyfriend to be changing as recently he became more violent.

Habits – denies drinking, smoking or illegal drug use

Travel – Pt denies any recent travel.

Diet – Pt admits to eating meats and rice. Pt rarely eats fruits and vegetables. Exercise – Pt denies any form of exercise.

Sexual Hx- Pt is sexually active with one partner and denies use of contraceptives

 

Allergies: PCN à rash

 

ROS:

General: admits to chills and generalized fatigue. Denies fever, night sweats, recent weight loss or gain, or loss of appetite

Skin, hair, nails – Denies changes in texture, excessive dryness or sweating, discolorations, pigmentations, moles/rashes, pruritus or changes in hair distribution.

Head – Denies headaches, vertigo or head trauma.

Eyes –Denies lacrimation, pruritis, visual disturbances, or photophobia.

Ears – Denies deafness, pain, discharge, tinnitus or use of hearing aids.

Nose/sinuses – Denies discharge, obstruction or epistaxis.

Mouth/throat – Denies bleeding gums, sore tongue, sore throat, mouth ulcers, voice changes or use dentures. Last dental exam unknown

Neck: denies stiffness or swelling/swollen glands

CVS: admits of having chest pain, palpitations and syncope but denies ankle swelling, PND, Orthopnea or known heart murmur

Pulmonary: mild SOB and sometime wheezing. denies cough, hemoptysis, or cyanosis

 

GI: admits of Nausea and mild abdominal pain. Denies diarrhea, constipation, changes in Bowel Movement, bloating, anorexia, blood in stools, hemorrhoids

GU: Denies incontinence, dysuria, nocturia, urgency, flank pain, hematuria, urethral discharge

MSK:  Denies muscle/joint pain, deformity or swelling, redness or arthritis

Neurologic: admits to having frequent headache, dizziness, loss of consciousness, loss of strength, tremors, weakness, paresthesia. Denies memory issues, slurring speech, paresis

Peripheral vascular system – Denies intermittent claudication, coldness or trophic changes, varicose veins, peripheral edema or color changes.

Hematological system – Denies anemia, easy bruising or bleeding, lymph node enlargement, blood transfusions, or history of DVT/PE.

Endocrine system – Denies polyuria, polydipsia, polyphagia, heat or cold intolerance, excessive sweating, hirsutism, or goiter

Psychiatric: Denies depression, anhedonia, nightmares, suicidal or homicidal ideation

 

Initial Differential Diagnosis: 

• MI
• Panic Attack
• Generalized anxiety
• Somatoform disorder

PE:

 

VS:

BP 120/ 70 mm Hg seated, right arm

T 98.2, oral

HR 86bpm regular

RR 16 unlabored

SpO2 100% on RA

Ht 68”, Wt 135 lbs, BMI 21.1

 

Gen: Well-developed female. Alert and oriented x 3, Not in any apparent Distress, Compliant to exam. Dressed and groomed appropriately.

Skin: Warm and dry, good turgor

Head: Normocephalic and atraumatic

Eyes: clear sclera and conjunctivae, PERRLA, EOMs full without nystagmus

Ears: hearing intact to whisper test, clear canals.  Slight cerumen present in both canals, but TMs visualized and without lesions.

Mouth/Throat: Oral mucosa moist and pink. Mild periodontal disease noted. Tonsils are normal in size, free of exudates. Oropharynx normal.  Tongue midline.  Uvula rises symmetrically, tongue protrudes in midline

Neck: supple, no JVD, No thyromegaly, no adenopathy. Carotids 2+ without bruits.

Lymph nodes: No lymphadenopathy

Heart: RRR, Normal S1 and S2, no Murmur/Rubs/Galaps noted

Lung: Clear to auscultation, no accessory muscle use

Abd: soft, non-tender.  No masses, lesions, or pulsations noted.  No organomegaly.  Liver edge firm. No guarding or rebound tenderness

GU: No inguinal adenopathy, no suprapubic tenderness.  Genital and rectal exam deferred

MSK: Grossly normal with good ROM all 4 extremities.  No joint swelling or deformity

CN: a V1-V3 intact, no facial asymmetry, equal elevation of palate

Motor: normal bulk and tone.  Strength symmetric. No tremors.  No pronator drift

Sensory: to pinprick intact all 4 distal extremities

DTR’s: 2+ throughout.  No clonus. Toes down-going, Gait normal

Extremities: No edema, clubbing, cyanosis

 

Mental Status Exam:

1. Appearance – tall, well developed female, good posture, dress appropriately to age and weather, well-groomed, good hygiene and cooperative with the examination.
2. Attitude – Pt is cooperative and pleasant.

• Behavior – Pt makes good eye contact but seems little frightened, restless and worried as he keeps looking around the room. She is voluntarily shaking his legs. She is responding to questions and can follow requests.

1. Level of Consciousness – Pt appears worried and nervous in her surroundings.
2. Orientation – Pt is oriented to person, place, and time.
3. Speech and Language – pt speaks in full sentences in clear, normal audible voice. Pt is fluent in English

• Mood: “I am worried… am I dying. or going crazy. Please tell me what’s going on”.
• Affect -Pt affect is anxious, consistent with mood and thought content.

1. Thought Process/Form – Pt’s thought processes exhibit perseveration about anxiety and she is extremely worried about dying .
2. Thought Content: – Thought content exhibits and phobias. There are no observed hallucinations, delusions.
3. Suicidality and Homicidality: Pt denies suicidal or homicidal thoughts.

• Insight and Judgment: -pt is trying to understand the seriousness of the issue. Even though she realize she is young to have severe cardiac issue but she is anxious of dying.
• Attention Span: -Pt is easily distracted. Pt cannot be redirected to an unrelated topic, about politics for example.
• Memory: Pt was able to answer all questions correctly.

1. Intellectual Functioning: Pt has full intellectual functioning.

Assessment:

23 years old female with no significant PMHx came to the medical ER for loss of consciousness, who was referred to CPEP for evaluation of Panic disorder. Pt exhibiting symptoms of recurrent panic attacks for the past 3 months.

 

Plan:

Acute Panic Attack:

• Stabilize the patient using a Xanax or Klonopin
• Can discharge the patient with SSRIs
• Explain the situation to the patient and inform about the panic attacks
• Advise the patient to follow up with outpatient Psychiatry