General Mental Wellness Intake

Chief Complaint (CC):

Patient reports feeling "really, really low" since a few weeks after the birth of her baby, Michael, who is now four months old.

 

History of Present Illness (HPI):

The patient describes persistent low mood beginning a few weeks postpartum, characterized by feelings of hopelessness and a sense that the situation is "never ending." She reports a marked decrease in interest and pleasure in usual activities such as cooking, reading, and socializing. Sleep is significantly disrupted due to the infant’s poor sleep patterns, resulting in frequent nighttime awakenings. Appetite is irregular but maintained due to breastfeeding demands. The patient and her husband are worried about the baby's sleep and feeding adequacy. She experiences pervasive feelings of inadequacy and guilt related to her maternal role, stating she often feels she "can't measure up" and is "not a good mom." There is no mention of any treatments tried or their effects.

 

Review of Systems (ROS – mental health):

Mood: Depressed, low mood most days since postpartum period began.

Anxiety: Excessive worry about infant’s sleep and feeding.

Thought processes: No evidence of psychosis or disorganized thinking reported.

Sleep: Poor quality sleep with frequent awakenings due to infant care.

Concentration: Not specifically addressed.

Energy: Markedly decreased energy, feeling tired "all the time."

Motivation: Low motivation; prefers to lie in bed when not caring for baby.

Appetite: Variable appetite, maintained primarily for breastfeeding.

Other: Feelings of guilt and worthlessness related to parenting.

 

Functional Impact:

Symptoms interfere with engagement in previously enjoyed activities and social interactions. The patient’s low energy and mood limit her ability to participate in self-care and leisure activities. She expresses significant distress related to her perceived parenting inadequacy, which may impact family dynamics.

 

Current Medications & Therapies:

No current medications reported. No mention of psychotherapy or other treatments.

 

Safety & Risk:

No suicidal ideation, self-harm, or harm to others reported or indicated.