Ms. Lucy Wan
Community Health Nurse
8 January 2009
Re:Ms Amy Vineyard,aged 21
I am referring 6 weeks of pregnant Ms Amy Vineyard, who has been suffering from pregnency substance abuse. She requires ongoing care and assistance after being discharged today.
On 6 January 2009,Ms Vineyard has been self-admitted due to concern towards her pregnency which was confirmed a day before admission and desire to cease drug abuse and alcoholism. Lower back pain, sleeping difficulties, tingling sensation in feet and weight loss has been reported. In addition, she found to have hallucinations and memory loss.
Ms vineyard lives with her friend and having no contact with her parents. She has been having habits of substance abuse, smoking and drinking since teenage. She has had a history of self-harm due to depression but never consulted to psychiatrist.
During hospitalization, blood test has been sent and educated her regarding the risk of HIV/AIDS and STDs as she used to share infected needles for drug abuse. In addition, counselling has been provided in order to maintain healthy pregnency and nutritious diet. It would be greatly appreciated if you could assist her by arranging psychiatric support, informing alcohol anonymous program and appointment at maternal health clinic. Please note, she has no desire to cease smoking.
In case of additional information, please do not hesitate to contact me.