Presenting Problem: PT is seen for medication monitoring.  She made similar excuses for missing her appt.  Just that she is so stressed out and forgetful that she doesn't remember she had an appt. she has stopped taking sleeping pills because she did not like the side affects.  It made her light headed with tingling on her finger tips.  She feels just as depressed as when she came here in May.  She has returned home on 07-01-00.  She had difficulty cooking, cleaning, stays in bed a lot.  She is impatient but not angry.

09-25-00  PT missed her appt. again.  Signed by Psychiatrist.

11-20-00  called for appt.  I told her I thought she has stopped coming and not in need of services.  She offered bunch of excuses and said she is taking wellbutrin and her PMD gave her alot of samples.  Signed by Psychiatrist.

 

 

05-18-00

28 y. w. married Caucasian female TCC of depression, feeling overwhelmed. I need help.

On 2-29 had third child.  Right after that I have been depressed have marital problems.  Husband has bi-polar disorder.  on Monday I left him.  I felt I needed to get away from him and the kids.  I lost my father on 05-28-99 and I am sure it bothers me too.  

Ever since my father died I see ghosts, nothing scary or threatening .  I have overwhelming feeling that I am going to die.  I am afraid that my kids will be alone.  

My husband has been verbally abusive when he is not well.  

Children are 4, 2, and 10weeks.

PT is at mother's house.

PT reports she has suffered from depression in the past 

She seen from Heburn for a while

Her mother is also Bi-Polar and has received ECT in the past.  There are alot of other family members who have suffered from mood disorder.

Medical history is non contributing

Denies substance abuse.  Admits to drinking 2 beers a day to lower her anxiety.

Family physician gave her paxil

Pt. was born in Neptune NJ, raised in Barnegat, moved to Brick 10 years ago.

Leftschool at 16, went back at 18 and left because father was sick.  She didn't like school.  

She married in 95 to a man 11 years her senior.  They have 3 children.

Husband is a chef.

 

 

PT is the youngest of 3.  Has 31 & 29 brothers.  Older brother is fine and works well.  29 y. brother is severely depressed self medicated.

Mother is 54 yo still grieving, in therapy.  She was recently hospitalized.  She also has medical problems.  PT is staying with mother and brother.  

M.S. 28y Caucasian female appeared younger then stated age. 5'2" tall, 153 lbs., casually dressed, clean, adequately groomed

She was cooperative with good eye contact.

Mood was depressed anxious.  She was crying and shaking.

She was soft spoken.  Speech was good directed.  There was no thinking disorder.

She stated that her childhood was very painful.  Her mother was in and out of mental hospitals.  She has witnessed mother making suicide attempts twice.  She is very close to her mother and will die without her.  She stated she sees ghosts every day, but denied hallucination, delusion, suicidal or homicidal 

Poor Concentration and short term memory.

Insight and judgment adequate.

 

 

06-12-00

PT is seen for medication monitoring.  She states that she is not feeling well, and it takes away every bit of energy to take care of her children.  She realizes that she is going to end up divorcing her husband.  She can't take care of herself, children and him. He doesn't take responsibility for himself and wouldn't see psychiatrist.  He blames her for their problems.  

She is financially stranded and yet can't get her husband to child support because he only makes $300 on the books.  

Her brother has accepted her being there but resents supporting them.  She has to get a job but she is not ready for it.  

She also can't afford babysitter.

PT was well dressed, well groomed, cooperative with good eye contact.  She was tearful stating "I am afraid I am going to crack."  

She feels it is getting easier to stay in bed rather then getting out of bed.  She has 3 beautiful children and they don't deserve it.

PT denied suicidal ideas.

06-29-00

Pt missed her appt. on 06-26-00

She stated that I am rolling, I am in high gear, my thoughts are racing.  I am screaming, yelling acting like a lunatic to my children.  I am having nightmares, real weird stuff.  

When I am waking up I am not rested.  I am hurting my children

Presently,  is seeing Rhonda Batlas for mental therapy.

PT was clean, neat, cooperative with good eye contact.  Mood was lubile and she was tearful.  Speech was pressured, over productive 

There was no thinking disorder.  Denied hallucination, delusion, suicidal and homicidal ideas

was recommended meds..

07-17-00 

Failed appt.

08-21-00

Missed appt.

 

 

11-27-00

PT missed her last appt. she states there is a lot wrong with her life.  Her 8 month old girl just got out of the hospital.  She was having 105 degrees tyl.- Her 3 year old son has severe asthma and may need to go to the hospital.  

Her husband is mad at her for sleeping all the time.

He is not much of a help.  They have a lot of financial problems.  He goes to work.

Her mother met a man and moved to VA and getting married

PT lost support system.

12-28-00 

Failed appt.

 

 

01-04-01

PT called stating she has reduced paxil to 30mg 1/2 tab 

Now she wants to reduce it further and discontinue.

Needs long paxil in order to do that.  Feels fine with wellbutrin

Called for RA paxil 

01-19-01

PT called stating she wants to dc paxil but she is not able to, she is having withdrawel symptoms and doesn't know what to do-even with long she has a problem

I suggested that she stays on paxil for a while she is not ready to dc she was not happy about this.

Shortly after called demanding something has to be done and there has to be a way.

I told her I had no other recommendations and she either has to stop and tolerate the symptoms or continue with paxil.  She was very unhappy.

I also brought to her attention that she has not been compliant with her visits.

If she is not satisfied she should call her insurance and ask for another psychiatrist for a second opinion.

Signed by psychiatrist