Outpatient Office Visit
Patient Case Number: OPOV28-Morris, Heather (established pt)
Patient Name: Heather Morris | DOB: 05-16-65 | Sex: F
Date of Service: 11-01-XX | Physician: Stanley Banks, MD

# Chief Complaint: “I feel like I am becoming my mother”

# History of Present Illness:

Several weeks ago, the patient reports that she got very depressed again, was crying, and hardly functioning. Her sleep is still very poor, energy is low. Endorses a lot of PTSD symptoms, particularly when she has to have some kind of hospital procedure. Anything reminding her hospital is causing flashbacks, anxiety, and nightmares. She talks about how high functioning she used to be before her mother’s death. She even unable to complete disability paperwork without assistance of her husband. He helps with her depression some, but not much. She complains of tolerance, focus, and the inability to get things done.

# Medications:

Klonopin 1.0 mg qhs, Xanax XR 0.5 mg prn, Acidophilus, digestive enzymes, Fexofenadine, Tylenol, Ventolin, Vit D 2000U

# Review of Systems

# Constitutional: low energy, fatigue. No appetite, she forces herself to eat. Ears, Nose, Mouth, Throat: recurrent staph infections, pharyngitis Genitourinary: 6 months ago, she started bleeding, had one bleed in September Musculoskeletal: weakness in her both legs,

# Gastrointestinal: no appetite. Now the problem is diarrhea, not constipation. Unable to leave house due to of diarrhea

# Skin/Breast: hair loss

# Psychiatric: as above

# Endocrine: started having hot flashes recently, after 3 years of menopause

# Hematologic/Lymphatic: very low Iron

# Mental Status Examination

General appearance, orientation

Alert, oriented, no signs of agitation/retardation. Eye contact is good. Comes on time. No make-up.

Gait

stable.

Speech

clear, goal oriented, normal tone and amount

Language function

not affected

Thought process/ content/ associations/ perceptual disturbance

well organized, no signs of psychosis.

Suicidal ideation

Denies

Judgement/ insight/ future orientation

Fair

Mood / affect

mood is sad, affect is tearful

Memory / attention / concentration

Impaired

Fund of knowledge

Average

# Assessment:

# Axis I: MDD, recurrent, Anxiety, PTSD, chronic complicated 1bereavement, idiopathic hypersomnia

# Axis II: Deferred

# Axis III: Iron deficiency anemia

# Electronically Signed By: Stanley Banks, MD

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