![]() |
DEMOGRAPHIC IDENTIFICATION, SOURCES OF INFORMATION AND REASONS FOR EVALUATION |
---|
![]() |
HISTORY OF PSYCHIATRIC AND GENERAL MEDICAL ILLNESS |
---|
![]() |
FAMILY, DEVELOPMENTAL AND SOCIAL HISTORY |
---|
![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() |
---|
She grew up in a lower middle-class neighbourhood and was raised as a Catholic, attending church every Sunday with her family. Her mother had to work hard in order to support all the children and was therefore often absent from home, but devoted all her available time to her children.
Ms Y completed high school and then went to work as a secretary for a large company in town. She assumed increasing responsibilities within the company and achieved the position of supervisor for a whole floor. She stayed with the company for a total of 6 years.
Ms Y met her husband through her job while he was doing business with her company. They dated for 2 years and finally decided to marry when the company went bankrupt after the devaluation of the Mexican peso in 1994. Her family approved of the marriage, following which the couple moved to the USA.
Ms Y lives with her husband in a rented house. Her husband is self-employed and works in the construction business. She describes her husband as hard-working and very traditional in his views of marriage, and denies any type of abuse from him. She states that she is happy with her marriage although she recognises that they have some problems. She feels that marriage is forever, and that she needs to work on making it better. She is taking oral contraception but has been discussing with her husband the possibility of having children. They are currently saving all the money they can to buy a house.
Ms Y has been working as a maid for a family for the past year and she enjoys her job, stating that her employer is very supportive and encourages her to learn English. However, she has been unable to attend any classes because of lack of time. She keeps contact with her family in Mexico, but has not made them aware of her job situation because she is concerned that they would be upset if they knew that she was working as a maid. She misses her family, particularly because they were very close to each other, and remembers fondly getting together every Sunday.
Her current social relations are limited (restricted to the friend who accompanied her to the emergency room), owing to her inability to drive. She does not have a driver's licence because her permit to stay in the USA has expired and she is afraid of detection by the immigration service. Her husband is a legal resident in the USA and she wants him to volunteer to take the steps to make her stay legal. He has not offered to do this so far, and she has not explicitly requested it because she does not want him to think that all she wants is a green card. They have no health insurance.
![]() |
SYMPTOMS AND MENTAL STATE EVALUATION |
---|
Her speech is spontaneous and somewhat slow. Her thought processes are coherent, logical and goal-directed. There is no evidence of hallucinations, delusions, flight-of-ideas or loose associations.
Her mood is moderately depressed and she expresses multiple worries. She does not voice any homicidal or suicidal ideation. She moves her hands nervously.
She is alert and oriented to place and time. Her concentration and memory are somewhat impaired. Her intellectual functioning is in the average range as suggested by the vocabulary she uses. Her judgement and insight on having clinical problems are good.
![]() |
PHYSICAL EXAMINATION |
---|
![]() |
SUPPLEMENTARY ASSESSMENTS |
---|
![]() |
DIAGNOSIS AND TREATMENT |
---|
|