Reflection writing

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PsychotherapyPatients.docx

1. Hx: ER is a 36 years old Caucasian woman married with two kids, who came in to the center today with CC of : Repeatedly having night mares that will not let her go back to sleep and fear that bad things could happen to her when she closes her eyes, Patient was in the military prior to her honorable discharge and has went on deployment to middle east couple of times (per patient’s statement) which makes her remember lots of bad things that will give her panic attack , sleepless nights , low mood at most times. no safety concerns noted. Diagnosis: PTSD, Anxiety disorder, Major Depression Disorder (Unspecified). Intervention: Pharmacological intervention and Therapy: Cognitive-therapy, Behavior therapy, and Psychotherapy. Goal: get patient back to functioning level, refer to Social Service for placement and follow up with occupational therapy.

2. Hx: JM is 23 years old African American lady who presents to the center with CC of; Low mood, loss of interest in almost everything and will sometimes sleeps 72hrs without stop. Patient stated that “Since I lost my brother last month, everything doesn’t seem to be the same anymore. Patient has no other medical history. Dx: Acute stress disorder. Intervention: Pharmacological intervention with, grief counseling therapy and cognitive behavior therapy.

3. Hx: TM is a 21- year- old African American Male who come in to the center with CC of; Suicide ideation through auditory Hallucinations with plan that does not correlate with homicidal Ideation. Patient demonstrates some poor impulse control by screaming on top of his voice to the wall” leave me alone, no, no, “I won’t do it John” Go and do it yourself John! “Patient does not comprehend well to questions and sometimes will just be staring. Diagnosis: Schizophrenia. Intervention: Hospitalization is imminent, to provide safety and make sure patient is no danger to self or others. Psychotropic medication to be initiated. To put patient back on medication. Encourage patient to participate in group therapy, provide psychotherapy upon visits. Refer to social service for placement and appointment set up.