Subjective:
CC (chief complaint): Husband is worried about her
HPI: AT. is a 27-year-old African American female who was referred to the clinic by
... [Show More] her
husband for psychiatric evaluation. The patient does not know why she was sent by her
husband for evaluation and treatment. She lives at home with her husband and
newborn child Jessica. Her husband is concerned about her mental health and is
worried about her. She is not currently prescribed psychotropic medications. AT recently
had her first child two months ago and feels like she is stuck with the baby. She said her
life has not been the same since she gave birth. She said the baby cries all the time and
she cannot sleep because she must attend to the baby. She also has difficulty falling
asleep after caring for the baby. She feels hopeless and blames herself for everything.
She easily gets upset, yells a lot and her behavior has affected the relationship with her
husband. She is not sexually active, does not go out with friends, does not enjoy
activities she used to like reading and watching movies, and nothing gives her pleasure.
She admits to having suicidal ideations.
Past Psychiatric History: No psychiatric history
Substance Current Use and History: She denied drugs/alcohol
Family Psychiatric/Substance Use History: Brother was addicted to
methamphetamines and committed suicide via GSW.
Psychosocial History: AT was raised by her mother after her parents divorced when
she was 16 years old. She has two sisters in Troy, Alabama and a deceased brother
who committed suicide via GSW. She is married and lives at home with her 2-month-old
daughter Jessica and her husband. She completed education through bachelor’s level,
majoring in English Literature. She has no hobbies and no longer enjoys the things she
once had pleasure in doing, like reading and watching movies or socializing with friends.
She is a stay-at-home mother after working in community library for 5 years but recently
quit her job to take care of the baby. No reports of childhood or adult history of trauma
and no violence history. Worth noting is that the brother was addicted to
methamphetamines and committed suicide via GSW.
Medical History:
• Current Medications: Trandate 100mg twice daily for HTN
• Allergies: None noted
• Reproductive Hx: Married with one child. Not sexually active currently. “Pushes
husband away”
ROS: [Show Less]