PMHNP with worries about a number of health problems
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Jill is a 50-year-old woman who lives with her husband and two children (aged 20 and 18). She has come to see her PMHNP with worries about a number of health problems including extreme tiredness, agitation and pains in her chest. Past history Jill has been a frequent attender at the practice over the years, often with concerns about her or her children’s health. She experienced postpartum depression with her second child. She has a history of GAD and Depression and has been on and off antidepressants for the past 30 years. When she was 23 she took an overdose following the break-up of a relationship. She had some sessions of counseling about 10 years ago that she found helpful. She was referred to a primary care mental health worker in the practice two years ago for help with anxiety and low mood. She had some sessions of individual guided self-help, but she found that this made no difference. She was put in touch with a voluntary sector self-help group for people with anxiety around this time – but did not pursue this. She has no other health history or complaints today related to medical health, no military history. She currently takes no medications and has no allergies. She considers herself healthy as she eats a vegan diet and does walk 2 times a week around the local lake.
On examination Jill says she has always been a very ‘nervy’ person who finds dealing with everyday stresses difficult. She worries a lot about herself and her family and easily gets “in a state” and assumes “the worst” – for example, if family members are unwell or if they are late coming home. Sometimes things get so bad that she needs someone around her constantly to reassure her and feels that she can’t be left on her own. The intensity of these problems has varied over the years, but has become worse again during the past eight months following her husband’s diagnosis of heart problems. She has been drinking wine most evenings to try to calm herself down. More recently things have become so bad that she has sometimes felt that if she were left on her own she might harm herself. Her family has been very supportive and stayed with her during these periods until she calmed down, but is now finding this difficult to manage. Last night she had an extended period of feeling like everyone would be better off without her. She describes a plan “to drink alcohol, take some of her husband’s pain medications, start her car in the garage and pass out.” She states the only thing that every helps her is to walk and hum to herself and in the winter she sometimes knits.
Vitals:
BP: 122/68
HR: 74
R: 18
T: 97
O2: 99%
Pain: 2 on 0–10 scale
Wt.: 147
Ht.: 66”
Initial Assessment:
Patient Name: Jane Dolly
MRN: X12674799
Date of Service: 05/12/2024
Start Time: 10:00
End Time: 11:02
Billing Code(s): 90837 90791
Accompanied by: Husband
CC: “I’m extremely tired and agitated. I sometimes have chest pains and I’m worried about my health”
HPI: Patient is a 50-year-old female with hx of GAD, MDD, and past suicide attempt presenting with worsening anxiety, depression, passive SI, and increased alcohol use in context of husband’s recent heart condition diagnosis. Symptoms escalated over past 8 months with plans of overdose/carbon monoxide poisoning. After giving birth to her second child, she experienced posttpartum depression. She has used antidepressants intermittently for the past 30 years and has a history of depression and GAD. She overdosed when she was 23 years old, after a relationship ended. She found some counseling sessions she had around 10 years ago to be beneficial. Two years ago, she was referred to the practice’s primary care mental health worker for assistance with anxiety and depression.
S- Long-standing struggles with anxiety, worry, difficulty managing stress. Catastrophizes minor issues, needs constant reassurance. Depressive symptoms of low mood, anhedonia, fatigue. Increased alcohol use to cope. Passive SI last night with plan to overdose but did not act on it. Positive supports include family and hobbies like walking, knitting.
Crisis Issues Patient denies current suicidal ideation or intent, but endorsed passive suicidal ideation with a specific plan to overdose the previous night, though she did not act on it. No access to firearms, but has access to medications, alcohol, and car in the home which could be used for an attempt.
Reviewed Allergies: NKA
Current Medications: None
ROS: no complaints
O-
Vitals: BP 122/68, HR 74, RR 18, T 97F, O2 99%, Ht 66″, Wt 147 lbs
Labs: Deferred
Results of any Psychiatric Clinical Tests: None
MSE:
Jill is a 50-year-old woman who appears her stated age. She is casually dressed in slacks and a sweater. She makes good eye contact and is cooperative with the interview. Her psychomotor activity is increased, fidgeting frequently in her chair and unable to remain still. Her mood is anxious and depressed, rating her mood as “3/10”. Her affect is constricted in range but congruent with her depressed and anxious mood. Her speech is generally regular rate and rhythm, though at times becomes pressured with rapid, uninterrupted speech. Her thought process is circumstantial, going off on tangents frequently before being redirected. Her thought content is notable for excessive worry about minor matters, catastrophizing, and somatic preoccupations. She denies any current auditory or visual hallucinations. No overt delusions are evident. She is oriented to person, place, time, and situation. Her attention and concentration are mildly impaired due to anxiety. Her short and long-term memory appear grossly intact. Her insight is fair,
At the initial assessment you decided that the best interest of the patient and safety would be admission to the psychiatric unit. The patient remained for six days in the inpatient psychiatric unit. During her stay, she attended group meetings, was started on Zoloft for anxiety and depression and was stabilized. Upon discharge, the patient agreed to attend psychotherapy treatment and continue with her prescription for 50mg Zoloft PO daily.
This is your first follow-up appointment with your patient, Jill, two weeks after her hospital discharge. The goal of today’s appointment is to assess her as follow-up and to develop a psychotherapy treatment plan to continue treatment.
Use the Individual Psychotherapy Treatment Plan template in Course Documents. You are required to use APA format with evidence-based references to support your treatment plan.