Comprehensive psyc eval

Referred by another doctor to be seen by a psychotherapist.  Was attacked by a resident Nursing and Rehabilitation about a year ago.  Resident was in the locked unit.  Resident asked her to help him change.  Punched her in her face, down her arm, down her back.  She was 5'3" and 110# at that time.  Nurse was on break.  Coworker on the other side of the glass.  He called her a n _ _ _ _ r.    Worked the 11 p.m. to 7 a.m. shift.

Has seen a neurologist, had a severe concussion.  Has post-concussion syndrome, dizziness.  Has tingling in her fingers, wrist.  The side of her face also has continuing pain.  Has sharp pain in her left ear.

Had an MRI and CT scan.  Was found to have Venus thoracic outlet syndrome.

Workers Comp, Thomas Swonger, works for Davies Claims Solutions, and is downplaying her continuing symptoms.  Car stopped working, so she could not get to physical therapy.  Was discharged, rather than having transportation arranged.

Was seen by a surgeon, who states that the condition may be able to be corrected by surgery.

She is not able to lift more than 10 pounds.  Her cat died in August 2024.  He was a "support animal."  At that time she was in a toxic relationship.

Her children are aged 5 and 7 years.  They are in Kindergarten and 1st grade.

Speech is also effected by the incident.

ENT doctor diagnosed assymetric hearing loss, left ear.

She is out of work currently until after she has surgery.  Neurologist had cleared her to go back to work.  He put her back into the care of an orthopedic doctor.  She could not lift clients, and was put on light duty.  Residents became angry with her for sorting out their closets, which was the light duty.

Resident who assaulted her was still in her workplace.

She is working with an attorney on the case.  Resident who hurt her was never supposed to be in the rehab in the first place.

She helps herself by attending church and being involved with the photography team, young adult team.

Didn't want to bring this up, but she attempted suicide at age 12-17. Tried cutting, pills, hanging. Didn't want to be here anymore.  Did not see a future for herself.

Has tachycardia, and takes meds for that.  Has thyroid disease, she learned 3 years ago, and is also medicated for that.

Has had dreams/premonitions.

Patient presents for initial evaluation.

Anxiety and depression due to long standing relationship, emotionally, verbally and physically abusive.  Stalked her after they broke up.  She had 2 children from this relationship.  Primary custody with client.  Supervised visitation every other weekend, with client's mother being the supervisor.

Oldest sister has bi-polar disorder.  She, and mother, were abused by mother's previous husband.  Mother felt she was "attention-seeking."

In childhood her sister "tried to kill me."  Pillow over her face, threatened with a hammer, iron thrown at her, etc.

"Hates" being around her family.  Feels protective of her 2 daughters, and of herself.  She is afraid that mother will try to take her children, as she had her nephew.

The patient was born in Frankfurt, Germany. Father was in the service.. The patient is the third of three. Throughout school the patient had been teased by friends. The patient completed and CNA, Certified Medical Assistant, would like to be a midwife in the future

The patient's speech was normal, sharing conversation with normal laryngeal efforts. Appropriate mood and affect were seen on exam. Thought processes were logical, relevant, and thoughts were completed normally. Thought content was normal with no psychotic or suicidal thoughts. The patient's judgement was realistic with normal insight into their present condition. Mental status included: correct time, place, person orientation, normal recent and remote memory, normal attention span and concentration ability. Language skills included the ability to correctly name objects. Fund of knowledge included normal awareness of current and past events.

Tests

None at the present time.

Client has experienced a high degree of trauma from a workplace incident about a year ago.  She is working with an attorney to file a Worker's Compensation claim.

Post-traumatic stress disorder

Depression and anxiety

Client would benefit from ongoing individual therapy, especially as she deals with the Workers Comp claim from 1 year ago.

Referred by another doctor to be seen by a psychotherapist.  Was attacked by a resident Nursing and Rehabilitation about a year ago.  Resident was in the locked unit.  Resident asked her to help him change.  Punched her in her face, down her arm, down her back.  She was 5'3" and 110# at that time.  Nurse was on break.  Coworker on the other side of the glass.  He called her a n _ _ _ _ r.    Worked the 11 p.m. to 7 a.m. shift.

Has seen a neurologist, had a severe concussion.  Has post-concussion syndrome, dizziness.  Has tingling in her fingers, wrist.  The side of her face also has continuing pain.  Has sharp pain in her left ear.

Had an MRI and CT scan.  Was found to have Venus thoracic outlet syndrome.

Workers Comp, Thomas Swonger, works for Davies Claims Solutions, and is downplaying her continuing symptoms.  Car stopped working, so she could not get to physical therapy.  Was discharged, rather than having transportation arranged.

Was seen by a surgeon, who states that the condition may be able to be corrected by surgery.

She is not able to lift more than 10 pounds.  Her cat died in August 2024.  He was a "support animal."  At that time she was in a toxic relationship.

Her children are aged 5 and 7 years.  They are in Kindergarten and 1st grade.

Speech is also effected by the incident.

ENT doctor diagnosed assymetric hearing loss, left ear.

She is out of work currently until after she has surgery.  Neurologist had cleared her to go back to work.  He put her back into the care of an orthopedic doctor.  She could not lift clients, and was put on light duty.  Residents became angry with her for sorting out their closets, which was the light duty.

Resident who assaulted her was still in her workplace.

She is working with an attorney on the case.  Resident who hurt her was never supposed to be in the rehab in the first place.

She helps herself by attending church and being involved with the photography team, young adult team.

Didn't want to bring this up, but she attempted suicide at age 12-17. Tried cutting, pills, hanging. Didn't want to be here anymore.  Did not see a future for herself.

Has tachycardia, and takes meds for that.  Has thyroid disease, she learned 3 years ago, and is also medicated for that.

Has had dreams/premonitions.

Patient presents for initial evaluation.

Anxiety and depression due to long standing relationship, emotionally, verbally and physically abusive.  Stalked her after they broke up.  She had 2 children from this relationship.  Primary custody with client.  Supervised visitation every other weekend, with client's mother being the supervisor.

Oldest sister has bi-polar disorder.  She, and mother, were abused by mother's previous husband.  Mother felt she was "attention-seeking."

In childhood her sister "tried to kill me."  Pillow over her face, threatened with a hammer, iron thrown at her, etc.

"Hates" being around her family.  Feels protective of her 2 daughters, and of herself.  She is afraid that mother will try to take her children, as she had her nephew.

The patient was born in Frankfurt, Germany. Father was in the service.. The patient is the third of three. Throughout school the patient had been teased by friends. The patient completed and CNA, Certified Medical Assistant, would like to be a midwife in the future

The patient's speech was normal, sharing conversation with normal laryngeal efforts. Appropriate mood and affect were seen on exam. Thought processes were logical, relevant, and thoughts were completed normally. Thought content was normal with no psychotic or suicidal thoughts. The patient's judgement was realistic with normal insight into their present condition. Mental status included: correct time, place, person orientation, normal recent and remote memory, normal attention span and concentration ability. Language skills included the ability to correctly name objects. Fund of knowledge included normal awareness of current and past events.

Tests

None at the present time.

Client has experienced a high degree of trauma from a workplace incident about a year ago.  She is working with an attorney to file a Worker's Compensation claim.

Post-traumatic stress disorder

Depression and anxiety

Client would benefit from ongoing individual therapy, especially as she deals with the Workers Comp claim from 1 year ago.