Subjective:
CC (chief complaint): “I am just here out of a courtesy”
HPI: I.F. is a 47-year-old Caucasian female who was referred to the clinic by
... [Show More] her
husband Greg for psychiatric evaluation. Her husband reported a recent school
shooting nearby 3 weeks ago “flipped a switch” in her. She is concerned about her
children’s safety, and she believes something bad may happen to them. She cites
cases of serial rapists, gun deaths and missing children and must check regularly on
her children to make sure they are safe. She is watching the news 24/7, barely sleeping,
and even when she does, it is only a few hours, Appetite is decreased.
Past Psychiatric History: No psychiatric history
Substance Current Use and History: She denied drugs/alcohol
Family Psychiatric/Substance Use History: No family history of substance abuse.
Her parents were killed in a car accident by a drunk driver when she was 19.
Psychosocial History: I.F. was born and raised in Northern Ireland, parents brought
her and her one sister to U.S. when she was 15 to go to U.S. university where she met
her husband. They live in Charleston, SC. She obtained her master’s degree in
education. Her husband reported a recent school shooting nearby 3 weeks ago “flipped
a switch” in her. She pulled her children from public school and started home schooling
them 1 month after the shooting. She reported having a fight with the husband because
of that. She does not want to lose her children. The school shooting brought back
memories of the car accident that killed her parents, and she is still traumatized by the
thoughts. She has made a promise to herself not to lose anyone she loves, especially
her kids. She is watching the news 24/7, barely sleeping, and even when she does, it is
only a few hours, Appetite is decreased.
Medical History: No medical history
• Current Medications: None noted
• Allergies: None noted
• Reproductive Hx: hysterectomy
ROS:
• GENERAL: No weight loss, fever, chills, weakness, or fatigue.
• HEENT: Eyes: No visual loss, blurred vision, double vision, or yellow sclerae.
Ears, Nose, Throat: No hearing loss, sneezing, congestion, runny nose, or sore
throat.
• SKIN: No rash or itching
• CARDIOVASCULAR: No chest pain, chest pressure, or chest discomfort. No
palpitations or edema. [Show Less]