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Nursing Case Studies Essay

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Amy is a 29-year-old here today for a followup regarding her anxiety and depression. She would also like to talk about some dysuria she is having and a breast lump she has noticed.
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The patient tells me overall she is feeling better from an anxiety and depression standpoint. She thinks the Lexapro has been helpful. She has been on a regimen of 10 mg daily since mid August. She tells me that her mood seems better. She is less irritable. She is less anxious about everything all the time, in her words. She initially had some nausea, as well as some tiredness, but those have resolved. Her energy level is good, except that she awakens in the night with her son which makes her somewhat tired. Her appetite is good. She is eating and drinking normally. Her weight is stable from her last visit. She is feeling well enough on this dose that she does not feel she needs to make any changes. She would describe herself as feeling 90+ percent improved. She still does struggle some with sleep. When we discussed this initially, it was unclear what the cause was, but with more discussion, it seems as though if her son were not waking her up, she would be able to sleep through the night. She is going to monitor that. They are going to work on trying to help him with his sleep issues and will
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She says just for last couple of days she has noticed that there is some burning with urination and perhaps an odor in her urine as well. She does have a history of kidney stones about five years ago and passed them on her own. She knows that she has some residual kidney stones and is not sure if that is the issue. She is not having any urgency. She has not noticed frequency. She does not feel as though she is incompletely emptying her bladder. She has not had a discharge. No concerns for STDs. She is about a week away from the start of her menstrual cycle. No concerns for pregnancy at this time or STD at this
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