Personal Information Name: Thomas Sykes Gender: Male Age: 17 Marital Status: Single Weight: 240 pounds (108.86 kg) Height: 5 ft. 11 in. (71 inches) Occupation: High School Student Address: New York, USA Race: African American Religion: Baptist Allergies: None Known Immunizations: Up to date Major Support Name: Keisha Sykes, age 31 Relationship: Sister Phone: 577-666-7890 Attending Provider/Team: Susan Henretty, DNP, CRNP, PPCNP-BC Past Medical History: Significant for chronic obesity and depression. History of Present Illness: Thomas was recently discharged from an inpatient psychiatric program for suicidal ideation. He has undergone group therapy, individual therapy, and is taking an SSRI antidepressant medication (escitalopram). Upon discharge he was feeling somewhat less depressed. He is continuing in counseling and states it is helping. He is working on a healthy eating weight-loss plan and was instructed on keeping a food log. Social History: Thomas lives with his sister, Keisha, and her 3-year-old son Torrey. Keisha has been Thomas’ legal guardian since their mother passed-away 10 years ago from complications associated with uncontrolled diabetes and obesity. Thomas’ father is not involved in his life. About a year ago, Keisha, Thomas, and Torrey moved for Keisha’s new job in the local battery plant. Her shifts rotate between days and evenings, requiring Thomas to care for Torrey when Keisha has to work the evening shift. Last year, Thomas was in his junior year of high school and had been planning to graduate with his classmates, so the move for Keisha’s work has been difficult for him. Thomas did not make friends at his new school and spends most of his time alone playing video games or watching television with Torrey. Primary Medical Diagnosis: Obesity and Depression Surgeries/Procedures & Dates: No previous surgeries Medications: Drug: Escitalopram Dosage: 10mg Route: po Frequency: Daily Hours/Date of Administration: 9:00am Discuss the clinical manifestations evidenced during your assessment. How would you explain these manifestations?
Personal Information
Name: Thomas Sykes
Gender: Male
Age: 17
Marital Status: Single
Weight: 240 pounds (108.86 kg)
Height: 5 ft. 11 in. (71 inches)
Occupation: High School Student
Address: New York, USA
Race: African American
Religion: Baptist
Allergies: None Known
Immunizations: Up to date
Major Support
Name: Keisha Sykes, age 31
Relationship: Sister
Phone: 577-666-7890
Attending Provider/Team: Susan Henretty, DNP, CRNP, PPCNP-BC
Past Medical History: Significant for chronic obesity and depression.
History of Present Illness: Thomas was recently discharged from an inpatient psychiatric program for suicidal ideation. He has undergone group therapy, individual therapy, and is taking an SSRI antidepressant medication (escitalopram). Upon discharge he was feeling somewhat less depressed. He is continuing in counseling and states it is helping. He is working on a healthy eating weight-loss plan and was instructed on keeping a food log.
Social History: Thomas lives with his sister, Keisha, and her 3-year-old son Torrey. Keisha has been Thomas’ legal guardian since their mother passed-away 10 years ago from complications associated with uncontrolled diabetes and obesity. Thomas’ father is not involved in his life. About a year ago, Keisha, Thomas, and Torrey moved for Keisha’s new job in the local battery plant. Her shifts rotate between days and evenings, requiring Thomas to care for Torrey when Keisha has to work the evening shift. Last year, Thomas was in his junior year of high school and had been planning to graduate with his
classmates, so the move for Keisha’s work has been difficult for him. Thomas did not make friends at his new school and spends most of his time alone playing video games or watching television with Torrey.
Primary Medical Diagnosis: Obesity and Depression
Surgeries/Procedures & Dates: No previous surgeries
Medications:
Drug: Escitalopram
Dosage: 10mg
Route: po
Frequency: Daily
Hours/Date of Administration: 9:00am
Discuss the clinical manifestations evidenced during your assessment. How would you explain these manifestations?
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