IDENTIFYING AND BACKGROUND DATA: The patient is an (XX)-year-old Caucasian girl with a history of several placements in foster homes and long-term conflicts with her biological mother, who was cited for neglect regarding the patient and her sister. The patient is here for psychiatric evaluation.
Staff and the patient both feel the best disposition plan for her is to be referred to foster care, though she has been visiting her mother and still considers that an option upon discharge.
She has not been on psychotropic medication though it has been considered and recommended in the past for depression. She has a history of, at times, being out of program and oppositional to authority figures and is described as easily influenced by her peers seeking positive reinforcement from adults that was not forthcoming at home.
The patient was evaluated by us MM/DD/YYYY. At that time, plans were to eventually attend foster care, and psychotropic medication was not indicated, as she had been in reasonable control.
For further history and background information, please refer to the record and past psychiatric evaluation.
PSYCHIATRIC INTERVIEW: The patient was friendly in the interview, and her mood was upbeat. She denied any recent depression and stated she had no appetite or sleep disturbances.
She said at this time the plan was to be referred eventually to a foster home or possibly to her mother. She said she hoped to be discharged within two months.
She said her behavior had been in reasonable control, and she had been doing well in school. She denied any substance abuse. She denied any suicidal or assaultive ideation.
She stated that she had a few friends here, and no romantic relationships currently, but this was not important to her at this time.
She stated her main hobby at this time is music, and in the future, she hopes to have a job as a radiologist. Her thinking was goal directed, and there was no presence of hallucinations or any psychotic phenomenon.
DIAGNOSTIC IMPRESSION:
AXIS I: Adjustment Disorder with Mixed Disturbance of Emotions and Conduct, Improved.
AXIS II: Deferred.
AXIS III: No major medical illnesses other than acne.
AXIS IV: Past Stressors – Severe, conflict with mother, history of maternal neglect, repeated failed foster home placements.
Current Stressors – Moderate, upcoming plan for discharge from (XX) to probable foster placement.
AXIS V: GAF in current institutional setting: 60.
RECOMMENDATIONS: The patient continues to be considered for referral to foster care.
Upon discharge, she should receive supportive counseling, which would include giving her vocational direction in her area of interest and ongoing meetings to stabilize her relationship with her mother.
Psychotropic medication is not currently indicated, but should be considered in the future if mood or behavioral behaviors worsen.
