Identifying Information: : LM is a 67 year old Caucasian woman accompanied by her male partner. LM has a business degree and worked as an office manager.

Identifying Information: : LM is a 67 year old Caucasian woman accompanied by her male partner. LM has a business degree and worked as an office manager.

First visit with PMHNP for diagnostic evaluation at the Outpatient Community Mental Health Clinic

Chief Complaint:
The client’s partner reports that LM has had increasing difficulty with memory and decision making, but what is even more troubling is an increasing difficulty with “know how” to complete simple tasks. He states, “she would call me at work because she couldn’t remember how to start the car.” LM states, “ I don’t know why you are making such a big deal out of this…. I just want to go back to the way we were. Can we go home?”

History of Present Illness:
LM had worked in a Doctor’s office up until 1 year ago when she left to work as a cashier at a local Target. LM’s partner reports that she had quit the cashier job when she began having a great deal of frustration over running the cash register. In addition she was reported as having had a car accident in which she was entering the intersection in front of an oncoming vehicle and was hit broad- side. When asked what had happened following the accident, LM was unable to say. LM apparently sustained no injuries but she did decide to quit her job at Target soon after this event. Over the next few months LM was reportedly irritable and angry much of the time which represented a change from her usually kind and calm personality. She, on one occasion, had called the police when she couldn’t reach her partner and was convinced that the locks had been changed on her house because she was not able to get in. The partner relates that he was beginning to fear for her safety after she left the burner on under an empty pan causing a fire on top of the stove. During much of the intake LM sits with her head down, affect is angry at times and at other times sad. LM reportedly used to drink but has not had a drink in over a year that he knows of.

Marital History: LM was married for 22 years and has two daughters from that marriage. She has been with her current partner for 10 years. There is apparently conflict between the partners and LM’s partner.

Past Psychiatric History:LM has no prior psychiatric history per client’s partner as well as client.
Medical History:
History of hypertension, well controlled with Norvasc. Examination following the automobile accident revealed no injury. She has no other health issues or concerns and is considered to be in overall good health.

Surgical History:

Family Medical History: LM reports both of her parents are deceased.

Family Psychiatric History:
There is little known about LM’s family’s psychiatric history. LM’s partner reported that LM had told him that her mother had died in a nursing home when she was still fairly young.
Medical Review of Systems:
General: Denies any weight gain or loss

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