My First Psychiatric Report
History of Present Illness: Ms. **** is a 23-year-old mother of four who was referred for Psychiatric Evaluation after Child Protective Services became involved in assessing her household situation. Ms. **** began today's session by stating, "I'm having problems with CPS and a social worker ordered me to be here. I don't think I need any help. I have a clutter problem, but they thought I was depressed--I guess anybody would be depressed if their child was taken away." Ms. **** denies any sustained periods of sadness or dysporia. She denied any depressive symptoms post-partum (her youngest child is two months old). She reports that as of July 1, 2002 she gave temporary custody to her four-year-old child's father. The child was then taken to Maine. She notes that CPS became involved in her life earlier this calendar year because of report that her home was cluttered. She states, "I don't have any furniture and so I guess things are a little cluttered." She believes that a neighbor originated a call to Child Protective Services. She further believes that a neighbor may have been jealous of her relationship of a mutual friend and then, by Ms. *****'s Report, the neighbor sent her sister to Ms. ****'s apartment in a harassing way and then immediately after that she believes her acquaintance called CPS to make a report. Ms. **** notes that social workers involved with her care were concerned about depressive symptoms. She reports an increase in appetite since her child was taken away. She also reports there are times when she purposely stays up until 3:00 to 4:00 a.m. two-to-three times per week in order to "have time to myself." She notes that her sleep averages between five and seven hours per night. She denies a significant sense of fatigue, though reports at times she will "catch up" on sleep. Her concentration is without significant change. Her interest in activities is well maintained. She reported concern regarding well-being of her other children (including evaluation for possible ADHD or diabetes of her six-year-old child, as well, concern regarding her two-year-old child's medical condition). Ms. ****strongly denied any thoughts of self-harm or harm towards others. No information was provided from CPS regarding specific concern. The case worker who accompanied Ms. **** expressed her concern about Ms. **** to the reception staff, but did not wish to meet with this author.
Past Psychiatric History: Ms. **** reports evaluation approximately 10 years ago at which time she was prescribed Zoloft for a several-month period. She was in foster care at the time and states, "my foster mother thought that I needed some medicine for depression. Well, I was taken away from my family and I was a little depressed." She denies any change with medication and notes that she took the medication only because she was observed taking it and it was necessary for her to "move forward in the system." She denies any history of inpatient hospitalization. She denies any history of suicidal thinking, suicidal behavior, or violence. She has no prior H-** *** evalutions. She denies any significant episodes of panic and denies any traumatic or PTSD symptoms. She denies any significant symptoms of manic episodes, specifically denying irritability, euphoria, decreased need for sleep (see above; Ms. **** reports that on occasion she has endured one-to-two nights of limited sleep if necessary which is followed by a need to "catch up" on sleep). She denies any history of increased energy or talkativeness in periodic fashion (she acknowledges a lifelong history of talking more then others. She also relates this to a family trait.) She denies any impulsive behaviors.
Past Medical History: Ms. ***** denies any significant ongoing medical problems. She has a history of anemia during pregnancy. Her primary care Physician is Dr. **** *****. She is on no prescription medications. She reports an untoward reaction to Doxycycline which led to first-degree burns after brief sun exposure. She denies any history of head injury, loss of consciousness, or seizure.
Substance Abuse: Ms. **** denies any history of drug use. She reports drinking alcohol for the first time at age 20. She reports having no alcohol problems and that she "rarely" has consumed alcohol. Last alcohol intake was approximately a year ago.
Social History: Ms. **** is a native of ****. She lived in Hawaii for a two-year period. Her parents were divorced when she was three years old. She has five full and half siblings. She reports some "mental abuse" by her stepfather. She has had a poor relationship with him over time. She was in a detention home and foster home during her youth. She was first pregnant at the age of 16. She has four children by four different fathers. She notes there is currently a question of paternity regarding at least one of her children. Her children are ages 6 years, 4 years, 2 years and 2 months. She has obtained a GED. There is no history of military service. There is a history of charges for petty larceny in the distant past. Charges were dismissed. She has never been married. She in unemployed. Ms. **** reportedly was assaulted in Jan. of this year. Family history is noted for no significant history of substance abuse, suicide, or psychiatric problems. Her oldest child is currently being evaluated for possible ADHD.
bravenet.com