Chief Complaint Feel Explained for Students (Easy Guide)

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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 what are the correct ICD 10 cm codes

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