Psychiatric Assessment

Full Name: Mrs Katherine Penelope Lawrence (nee White)
Date of Birth/Time: 2.2.2242 / 7.43 pm
Star sign: Aquarius
Occupation: Housewife
Appearance and behaviour: Black, obese female, BMI 32, slightly dishevelled but appropriately attired. Made poor eye contact. Appeared older than stated. Evidence of psychomotor retardation – very little spontaneous movement. Scar noted on leff-hand. Some agitation.
Affect: Anxious and at times fearful though somewhat flat and frequently vague about exact nature of fears.
Mood: Subjectively felt to be OK, objectively low.
Speech: Soft and monotonous, difficult to understand, but perfect annunciation, not slurred or dysphasic.
Thought: Intermittent suicidal ideation. History of self-harm. Severe laceration to third digit leff-hand requiring surgery. Described her action as unpremeditated and impulsive with no intent to kill herself. Has displayed outbursts of a violent nature eg. kicking doors, throwing things, but they occur without her realising it until the crash of the falling object is heard, then she
realises what she’s done. Admits to feeling angry when under stress but, ’the
rest of me feels blank.’ She felt she sometimes loses track of time. Some
slowness of thought. Denied once drinking half a bottle of bleach, ‘to kill the
germs’ inside. Denied homicidal ideation.
Perception: Admitted to occasionally hearing her own voice in her head in
the form of a 2nd person auditory hallucination saying, ‘you’re ok, you’re ok’
Not unpleasant voice. No visual hallucinations. Direct questioning revealed that she was hearing a running commentary of her actions and that there appeared to be mild thought echo.
Sleep/Appetite: Sleep distressed with frequent interruptions through the
night. Spends large part of the day in bed. Possible chronic fatigue syndrome8
mental and physical lethargy.
Drug and alcohol history: Overdose on 24 Nurofen and a can of lager.
Poisons unit said no physical treatment required.
Physical Examination: 1 termination of pregnancy, history of a/uterine
prolapse repair. Refused to remove undergarments for physical eflamination
but blood tests revealed:
Haemoglobin 13.4, white count of 10.3, Platelet 284, mcv 88.8, sodium 139,
potassium 4.8 urea 6.1, creatine 72, calcium 2.23, phosphate 1.33 billyrubin
3, alkaline phosphate 142, alt 20, rbc folate 221 ug/l, serum folate 4 ug/l (All
normal).
Cognitive function: Cognitively her memory was impaired, especially
short-term memory and her concentration was poor. No biological symptoms
of depression.
Insight: She described being able to enjoy some things like television, superficially, while feeling blank, and not knowing her feelings makes it difficult to respond to people in social situations. But she said, ‘that’s just me, I can’t help it.’