Saturday, September 6, 2008

Diagnosis X

Pt: Jennifer M. Welch
DOB: 04/15/1981 ..
Sex: F .
Marital Status: Married .
Occupation: mother, wife, student, nurse, housekeeper, cook, dog walker, full time looney ..

Chief complaint: Pt c/o feeling "like my brain and soul are being slowly sucked out of my body".

Dx #1: Disturbed Sleep Pattern r/t waking at night to care for infant, staying up late studying, fear of failing D&S exam AEB verbal complaints of less than adequate sleep, awakening earlier than desired, interrupted sleep, puffy under eyes, irritability, yearning for naps, yawning, altered facial expression (e.g. blank look, fatigued appearance, ugly scowl).

Dx #2: Chronic confusion r/t oversaturation of educational information AEB altered interpretation/response to stimuli, progressive cognitive impairment, no change in level of consciousness, impaired memory (short-term and long-term), altered personality (sometimes referred to as bitchy).

Dx #3: Role strain r/t difficulty being in multiple places at once AEB unpredictable school schedule, knowledge deficit regarding studies, personal and social life is disrupted by educational demands, multiple competing roles, time and freedom is restricted because of studying, past history of poor relationship between pt and textbooks, social isolation r/t studying, no respite from educational demands, expresses negative feelings about being surrounded by dumbasses.

Key:
pt = patient
c/o = complains of
dx = diagnosis
r/t = related to
AEB = as evidenced by
D&S = dosage and solutions

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