Full Name: L.V.

Date of Birth: XX/XX/1967

Age: 54

Date and Time: 11/24/2021 10:00 AM

Location: Amazing Medical Services, Jamaica, NY

Source of Information: Self

Reliability: Reliable patient 

Mode of Transport: Private Vehicle

Chief Complaint: depression x 11 months

History of Present Illness: 

54 y/o F, with a PMHx of asthma and left knee osteoarthritis, who presents for depression for eleven months. Patient states her husband died of COVID-19 last year after going into the hospital for heart surgery. Patient reports she is currently residing with her daughter and has a support system at home, but states she is having difficulty coping with her grief. Patient states it has worsened in the past month as she approaches one year since his passing. She states she has not been sleeping well, reporting she has difficulty falling asleep and staying asleep. Patient reports she was previously prescribed Trazadone to help sleep, with relief. She also reports decreased appetite. She denies suicidal ideation. Patient is requesting a referral to a psychiatrist.

Patient also reports right knee pain for four months. She describes the pain as sharp and stabbing and reports it has been worsening. She does not take anything for the pain. Patient reports walking exacerbates the pain and resting alleviates the pain. Patient reports the pain is a 9/10 at times. Denies fever, chills, chest pain, shortness of breath or leg swelling.

PHQ-9:

• Little interest or pleasure in doing things: Nearly every day
• Feeling down, depressed, or hopeless: Nearly every day
• Trouble falling or staying asleep, or sleeping too much: Nearly every day
• Feeling tired or having little energy: Nearly every day
• Poor appetite or overeating:  Several days
• Feeling bad about yourself-or that you are a failure or have let yourself or your family down: Nearly every day
• Trouble concentrating on things, such as reading the newspaper or watching television: Nearly every day
• Moving or speaking so slowly that other people could have noticed. Or the opposite- being so fidgety or restless that you have been moving around a lot more than usual: Not at all
• Thoughts that you would be better off dead, or of hurting yourself in some way? Not at all
• Total Score: 19, Interpretation: Moderately severe depression

Past Medical History:

• Asthma

Past Surgical History:

• Gastric Bypass 2010, no complications
• Hernia repair 2011, no complications
• Right knee replacement 2018, no complications

Past Hospitalizations:

• Denies hospitalizations

Family History:

• Father – deceased, DM
• Mother – alive
• Sister – alive
• Brother – alive
• Spouse – deceased, COVID-19
• Daughter – alive

Medications:

• Singulair 10 mg PO once a day
• Albuterol sulfate (2.5 mg/3ML) nebulization solution 3 mL as needed inhaled every 6 hours
• Symbicort 160-4.5 MCG/ACT aerosol, inhale two puffs twice a day
• Montelukast sodium 10 mg PO once a day

Immunizations:

• Up to date

Allergies:

• No known drug, food, or seasonal allergies

Social history:

• Widowed female who lives with daughter in private home. Patient does not work.
• Denies past or present alcohol, tobacco, or illicit drug use.
• Nutrition: Reports to decreased appetite. Daughter cooks healthy meals.
• Sleep: Reports difficulty falling asleep and staying asleep.
• Sexual history: Denies being currently sexually active.

Review of Systems: 

General: Unable to do usual activities, decreased appetite. Denies fever, chills, night sweats, fatigue, weakness, weight loss/gain. 

Skin, hair, nails: Denies changes in texture, excessive dryness or sweating, discolorations, pruritis or changes in hair distribution.

Head: Denies headache, dizziness, or head trauma. 

Eyes: Denies blurry vision, double vision or loss of vision. 

Ears: Denies hearing loss, discharge, tinnitus, ear pain. 

Nose/Sinuses: Denies nasal congestion, nasal discharge, sinus pressure/pain, or loss of smell.

Mouth/throat: Denies sore throat, bleeding gums, mouth ulcers. 

Neck: Denies localized swelling/lumps or stiffness/decreased range of motion.

Respiratory: Denies cough, shortness of breath, wheezing, sputum production. 

Cardiovascular: Denies chest pain, palpitations, leg edema, hypertension, syncope or known heart murmur. 

GI: Denies abdominal pain, nausea, vomiting, hematemesis, diarrhea or constipation. 

GU: Denies heavy vaginal bleeding, dysuria, hesitancy, flank pain, frequency, hematuria or urgency. 

MSK: Denies any muscle or joint pain, redness or stiffness. 

Neuro: Denies weakness, dizziness, lightheadedness, headaches, sensory disturbances. 

Psych: Admits to depression. Denies suicidal ideations, homicidal ideations, or hallucinations.

Physical Exam: 

VS: T 98.4 F, BP 105/71, HR 62 bpm, RR 16, O2 sat 98%, Ht5’3”, Wt 210 lb, BMI 37.20

Gen: Alert and oriented to person, place and time, in no acute distress. Well-nourished with good hygiene. Sitting comfortably in chair.

Skin: Warm and moist, no rash, bruises, or scars.

Head: Normocephalic, atraumatic 

Eyes: PERRLA. Sclera non-icteric. Conjunctiva pink, sclera white. No discharge.  

Ears: Pinna, tragus and external canal non-tender. No lesions or swelling of bilateral ear canals. Normal tympanic membranes

Nose: Nasal septum midline.

Throat: Mucous membranes moist. No erythema or exudates. No tonsillar enlargement. Uvula midline. 

Neck: Supple. No thyroid enlargement, no lymphadenopathy.

Cardiovascular: Regular rate and rhythm. S1 and S2 with no murmurs. 

Pulmonary: No respiratory distress. Clear to auscultation bilaterally. Non-labored breathing.

Abdomen: Flat and symmetric. Soft, nontender, nondistended.

Extremities: No edema. 2+ DP/PT pulses bilaterally.

MSK: No edema, erythema, discoloration, or deformity. Pain with extension and flexion of right knee with tenderness to palpation over anterior knee at medial and lateral joint lines. No warmth noted. Negative anterior/posterior draw test and negative McMurray’s test.

Neurological: CN II-XII grossly intact. Gross sensation intact.

Psychiatric: Sad, tearful. Good eye contact.

Assessment: 

54 y/o F with a PMHx of asthma and left knee OA, who presents for depression for eleven months and right knee pain for four months. Patient is sad and tearful on exam. Right anterior knee pain to palpation with painful range of motion. Findings most consistent with depression and right knee osteoarthritis.

Plan: 

• Adjustment disorder with depressed mood
  • Will start Sertraline HCl 50 mg PO once a day for thirty days until patient can be seen by psychiatrist.
  • Discussed patient should stop Trazadone while taking Sertraline.
  • Will send referral for psychiatrist.
  • Patient will follow up in one month to assess.
  • Medication side effects discussed with patient. Patient will stop trazadone.
• Right knee pain
  • Likely due to osteoarthritis.
  • Will order XR right knee
  • Patient can take Tylenol for pain as needed.
• BMI 37.0-37.9
  • Discussed diet and exercise with the patient.
• Patient will follow up in office in one month.
• Patient agreed with plan and all questions were answered.

Differentials:

• Adjustment disorder with depressed mood, major depressive disorder
• Osteoarthritis, bursitis, tendonitis