This my patient case study
CC: I have trouble forcing
Patient is 38 years African American female seen today Via telehealth for evaluation and treatment of her illness Reason for todays visit is I have been having problem focusing, back pain, Past medical history of ADHD, Anxiety at work most especially with her boss.
Allergic Hydrocodone (give her stomach problem) Steroids (Causes Visual Hallucination)
No Hospitalization
Pain management by primary care provider.
Family Hx : Substance abuse from mother side(mother sister Alcohol Abuse) Father side is Undiagnosed. Both mother & Father have issues with substance abuse. Patient recovery from Alcohol. Patients have Hx of substance abuse & nicotine since age 14years old. Both parents are still living. Have one sister-6years older than her with good relationship. And, with mother and father
Patient was born and race in Newborn North Carolina a lot of moving overseas.
Marital status: Engaged (Have 2 dogs and 3 cats)
Education: Almost finishing her Bachelor (3 semester away)
Trauma: Oldest cousin abuse her when she was 14years
Patient stated because of her manager she was lay off from her job because of her ADHD and anxiety its hard for her to focus. Patient Stated she goes into panic attack when she makes mistake at work especially around her boss, she has all this symptoms of shortness of breath, upset stomach, bowel issues, panic and crying.
Questionnaire: Personality problems, no feeling of sadness, Overall energy is ok, cannot sleep comfortable because of her back pain, Appetite is ok, No OCD, Irritability-Yes. Denies any psychological symptoms. Any sign of hopeless- Because of chronic back pain for the past 2weeks. The back pain from lifting at job & degenerative joint disease from family Hx
Medications: Lyrica 150mg BID, Wellbutrin 150mg Daily, Cymbalta 40mg
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