Chief complainants
VC is a twenty-eight Asian—American female nursing student and also working as a Cna. She stated that she has stress and anxiety that is related to her workload. Her stress and anxiety began after she joined the nursing school. She feels more stressed and anxious during exams and check-offs. When having stress and anxiety attacks, she feels her heart racing and her palms becomes sweaty. When she has elevated stress and anxiety levels, she loses weight. VC believes that her stress and anxiety levels will decline when she finishes nursing school.
The patient came for her annual physical examination and to do some blood work to examine her blood sugar level. Her gynecologist recommended she see a primary care provider annually to prevent further health concerns.
Current medication
None.
Allergies
No known food or allergies.
Past medical History
VC received all her vaccinations and immunizations. Recently, she received her annual flu shot. She has no childhood illness, no history of surgery, accident or hospitalization. The patient recently had a non-cancerous mole removed by the dermatologist. The patient also has an active intrauterine device inserted three years ago after an abortion. The patient states that she only suffers from anxiety and stress but not other neurological disorders.
Medical History of the family
The patient says that there are a lot of illnesses in her family. Her paternal grandfather died of old age without any health condition. Her maternal grandmother died at the age of ninety-two with colon cancer. Her father, a sixty-five-year-old medical doctor in Taiwan, has diabetes, which he manages with medication. On the other hand, her mother, a sixty-one-year-old nurse who had Hashimtot thyroid. She had surgery to remove her thyroid glands. Her maternal uncle has lung cancer, and he is currently on radiotherapy. Currently, all her family members are in Taiwan, and she hasn’t visited for the last five years.
Social History
VC is an Asian-American who has resided is in the United all her life. She lives in San Francisco, California, with her mother after she divorced her father. Previously, she attends school in Texas but moved to her birthplace a few months ago. English is her primary language; however, she understands a little mandarin. Her father lives in Taiwan with the other family members. She frequently visits Taiwan to see her father. The patient has not been in any romantic relationship for the past three years. She is the only child and has no social relationship with her friends. Her only friend is miles away, which strains their communication. Currently, she is working on new hobbies to deal with her stress and anxiety levels.
The patient went to therapy after her parents’ divorce. She has a gym membership, but she does not attend due to schooling.
System review
HEENT:
Head: the patient denies having headaches, syncope, vertigo or head injuries.
Eyes: the patient denies any eye problem and says an eye specialist an eye ago.
Ears: the patient denies any tinnitus, vertigo, infections, discharge, and earaches
Nose:
Voice: The patient reports having no voice alteration.
Neck: The patient denies any neck pain or enlarged nodes.
Nails: The patient denies any change in shape, color, or brittleness in nails.
Respiratory: The patient denies any history of lung conditions, coughing, and shortness of breath.
Cardiac: The patient denies cyanosis and a history of a heart murmur.
Gastrointestinal system: The patient denies numbness and tingling, coldness, and ulcers. The patient denies heartburn, abdominal pain, appetite, and vomiting blood. The patient denies incontinence, retention and flank pain.
GU: the patient has an active intrauterine device inserted three years ago after her abortion.
Neuromuscular: The patient denies joint stiffness and muscle weakness. The patient denies excessive bruising.
Emotions: has a History of stress and anxiety.
Rheumatic: no history of arthritis or lupus.
Endocrine: The patient denies intolerance to cold or heat and excessive sweating.
Dermatological: the patient had a non-cancerous mole that was removed.
Physical Examination
Vital signs: temperature 99.6F, BP110/60, respiration 18bmp, oxygen saturation 99%
Facial structure: symmetric with movement, no piercing or tattoos.
Head: normal cephalic, no lesion or infection in the scalp.
Eyes: symmetric, no lesion, no infestation of the eyebrows, eyelashes or eyelids. No color change, white sclera, pink conjunctiva with no lesion, swelling or discharge. The pupil is equal round, reactive to light and accommodates.
Ears: no lesion, swelling, redness or discharge. No skin breakdown
Nose: midline, symmetric, and bilateral patency. No lesion, drainage, foreign bodies or a deviated septum.
Lips: pink, moist, aligned, no lesion. Gum, tongue, pink and moist.
Skin: tone matches ethnicity, no lesion, incision, wound, rashes or tattoos.
Formulation
The twenty-nine-year-old patient with a history of stress and anxiety disorder and previous abortion. When examined, she was found with porous bones due to malnourishment and a poor body built and contours.
Impression
Stress and anxiety disorder.
Porous bones.
Plan
The patient needs education on nutrition and living a stress-free life. Her nutrition needs dense foods to have strong bones and maintain an ideal weight. She needs to start going to her gym frequently for exercise, go for walks. She should also attend social functions, go to dinner with friends, and practice self-care and have self-time.