Ugonna Mbaegbu

Zenith Mental Wellness Centre-Ph:- Subjective Notes: Patient Name: Jane Doe Gender: Female Date of Birth(DOB): March 14, 1985 Contact Number: - Email:-Appointment Date/Time: August 15, 2025 -10:00 AM Reason for Visit: Follow-up consultation – weight management and binge eating concerns Chief complaint: There hasn’t been any improvement since the last visit. I felt better in the first half of the week when I was away from sugar and flour. My son was home from school because he had a head injury. We baked brownies, ate a whole pan, and a couple of unhealthy foods like hamburgers, french fries, and candies, which triggered episodes of binge eating. Jane reports feeling overwhelmed by her weight and shares that she experiences episodes of emotional eating. She states, "I eat even when I'm not hungry, and then I feel terrible afterward." Emphasized that food feels like slavery and has control over her. Jane describes her clothes not fitting and feels sad about it. She rated her confidence to change as 10/10 and the importance of change as 0/10. She listed Chocolate, Hershey bars, and Hershey kisses as other problematic foods, stating how she tried to stop eating chocolate, which was unrealistic. Reported she could start small changes like stopping the consumption of Skittles, but was skeptical that it won't solve the larger problem. Although she has recorded success with stopping nail-biting in the past. Zenith Mental Wellness Centre-Ph:- Objective: -Patient appears anxious but engaged during the consultation. -Patient feels sad, disgusted, and frustrated. -Emotional state: Moderate anxiety, appears mildly distressed when discussing binge eating. - Thought content: Hopelessness -Behaviour: Recurrent binge eating episodes with a preference for calorie-dense sweet and fried foods No physical examination or vitals were done in this session. Assessment: Jane's emotional eating is contributing to her weight gain. She acknowledges the need for change but feels stuck in a cycle of emotional eating. She has a history of failed weight loss attempts, likely due to the lack of a structured support system. Jane is in the contemplation stage of change, as she recognizes the issue but is not yet ready to commit fully to a structured treatment plan. Possible Comorbid Depressive thought given hopeless statement(“I feel like giving up”) Low self-esteem despite high motivation for change. Access to food and environmental factors contribute to recurrent binges. Plan: Discuss and explore strategies to address emotional triggers for binge eating. Refer Jane to a registered dietitian for nutritional guidance and meal planning. Zenith Mental Wellness Centre-Ph:- Recommend cognitive-behavioral therapy (CBT) to address binge eating and emotional issues Encourage daily journaling to track eating habits and emotional states. Follow up in 4 weeks to evaluate progress and adjust the plan if necessary. Electronically signed by: Dr. Todd L. Grande (08/15/2025)