Community Health Centre
8 January 2019
Re:Ms Britney Wahlberg, aged 21
Ms Britney Wahlberg is a 6 weeks of pregnant lady, who has the tendency to stop smoking and alcohol abuse and she has the history of self-harm. She requires assistance and advice after being discharged today.
Ms Wahlberg was self-admitted on 6 January 2019 due to concern towards her pregnancy , which was confirmed a day before on 4 January. However, her presenting complains was lower back pain, 6kg of weight loss over the last 2 months, tingling sensation in the feet and difficulty in sleeping. In addition, she has the history of depression, suicidal thoughts along with self-harm but she never consulted to psychiatrist.
Ms Wahlberg lives at Wiltshire with a friend in rental accommodation. She has the habit of smoking, drinking and substance abuse since teenage. However, she has no contact with her parents. Moreover, as she used to share infected equipments for drugs, she was adviced for investigation of HIV/AIDS as well as she also received health education on nutrition, related to pregnancy and rehabilitation to regarding substance abuse.
Ms Wahlberg wishes to continue living with her friend. So , it would be greatly appreciated if you could arrange a psychiatric consultation for her depression and methadone program for Alcohol Anonymous Meetings. In addition, she needs an appointment at maternal health clinic with first trimester ultrasound report.
Pertaining to the above information, if you have further queries, please do not hesitate to contact me.
Prinstine Women's Refuge Centre