Document Preview

Subjective:

CC (chief complaint): Recurrent depression and relapse into disordered eating over past several months.

HPI:

J.M., a 29-year-old Caucasian female presents for psychiatric evaluation for what she described as a return of depression and binge/purge eating behaviors over the past several months. It is unclear to her which started first because "they go together." She states that she was 122 lbs at her discharge from an Eating Disorder (ED) facility about a year ago and was 95 lbs when she weighed herself yesterday. She estimates that she binge-eats and self-induces vomiting about 10-15 times per day currently. She denies laxative or diuretic use. She states that she has been sleeping poorly and feeling generally hopeless about her ability to get well and maintain her health. She has been having frequent suicidal ideation, and has been "stockpiling" medications including opiates prescribed for family members. She contemplated overdose and looked up what would be a lethal dose of medication. She has not rehearsed or attempted the overdose, but did tell her therapist six months ago - who then emergency petitioned her. She spent 8 days in the ED facility. Pt denies physical symptoms including abdominal pain, nausea, constipation or diarrhea. She was anxious and endorsed PDW but denied SI. She denied having current urges to self-harm. She reported her current mood as "hopeless."……….. Continue