Problem: Can you provide me with a sample of a mental status exam of the following patient?
20-year-old college student who returns for psychiatric follow-up while experiencing significant life stressors and grief. She was increased to 100 mg of sertraline at her last appointment approximately three weeks ago and continues taking trazodone 100 mg, one to two tablets as needed for sleep.
Since her last visit, the patient has been dealing with multiple stressors including graduation preparations while taking 20 credit hours, a family friend's recent suicide, and her dog being ill with vomiting for the past 24 hours. The family friend was a former neighbor from Colorado who had moved to Fayetteville and provided significant support to the patient during her college years, particularly when she was 17 and during her sophomore year when her own dog died. This represents her first experience being close to someone who died by suicide, and she reports the impact has not fully hit her yet. Her father is currently in town, and her mother is arriving tomorrow with two dogs including a new puppy.
The patient reports struggling with sleep, which has not improved since the sertraline increase. She attributes this primarily to current stressors rather than medication ineffectiveness, noting difficulty shutting her brain off at night, particularly last night due to worry about her sick dog. She continues taking two tablets of trazodone for sleep. She describes experiencing primarily sad emotions related to both grieving and general sadness about college ending, including receiving her cap and gown and attending her last mom's weekend and red dress gala. Yesterday she received notification that she was not accepted to one of two radiology schools she applied to in Colorado, with results from the second school pending until spring break in two weeks.
The patient denies anxiety attacks, panic, feelings of hopelessness or worthlessness, suicidal thoughts, and self-harming thoughts. She reports actively avoiding isolation by staying with her father and visiting the affected family daily, though she took the week off from her internship to be present for support. She has not seen a therapist in over a year after negative experiences with two previous therapists who repeatedly failed to show up for appointments while still charging for sessions.
She continues taking birth control, Synthroid 88 mg, vitamin D3, and Zyrtec. Her last menstrual period was several months ago, around October, with a previous period lasting a month between September and October. She denies starting any new medications or supplements. Need Assignment Help?