clinical write up - for seek the geek only

Clinical Write Up Example

ID: Joseph Smith, 35 years old, male, Caucasian, referred to o/p clinic by wife.

CC: Ct was referred to o/p clinic p having an emotional outburst in Walmart p the fire alarm went off while he was next to the broom aisle. Ct states he is, “embarrassed” and “my wife wants me to come in…it has never been this bad before”.

HPI: Precipitant was 9/11; ct worked in downtown New York City on the city maintenance team for five years (swept the streets, fixed buildings, painted, ect.). The morning of 9/11 ct was street sweeping on the same block as the Twin Towers. He stated he could, “see the dark black, grey smoke, and hear people screaming. I saw people horrifically injured, dead, and trying to escape. I tried to help.” Pt reports sx: reoccurring and distressing memories of 9/11 (“I can sense everything I can smell the burning, hear the screaming, see the building coming down”), recurrent dreams (1x a week) about the events on 9/11, distress c exposure to external cues that symbolize the trauma (in Walmart when the fire alarm went off the ct happened to be next to the broom aisle, and he grabbed a broom and starting yelling and screaming for people to leave and tried to evacuate the other shoppers), avoidance of external reminders (p 9/11 he quit his job, has no contact with old coworkers, and moved to Alaska. If anything related to NYC appears on television, internet, or in the newspaper he immediately gets upset and turns off the electronic device or closes the paper. Ct reports he constantly feels the, “world is dangerous, especially NYC, so I had to move far away”. He is constantly in a state of fear, and feels like he cannot trust others, so he is very detached from relationships, per ct report. He has switched jobs 12 times since 9/11 because he cannot seem to concentrate on his work, and was showing up to work late due to difficulties falling asleep. Ct notes it usually takes about an hour to three hours on average to fall asleep. Ct reports initially he only had a few sx that were bothersome and initially he could not remember what happened, only little details. However, as time has passed he noticed more and more sx and distressing reactions to remembering the events of 9/11. When asked about SI, ct reports, “no, but I do see darkness from time to time”.

SH: Lives c wife (married for 16 years), no children. Ct reports he does not have friends anymore, and he does not like to do much except watch old movies. Ct reports he use to be part of a softball team c his friends, and loved to ride mountain bikes. Currently, he does not play on the team anymore or ride bikes. Ct states he prefers to be alone. Ct works part time at a deli. Ct reports he thinks he is close to his wife still, but if you ask her there is, “distance and misunderstanding between them”.

SAHx: Ct denies previous problems c substance abuse and states, “I may have one beer one weekend a month, but I don’t really like the taste”. Ct reports his dad was an alcoholic and died from liver complications so he, “does not touch the stuff really”.

PH: Ct denies any previous problems c psychiatric hx.

FH: Ct reports other than his father abusing alcohol he is unaware of any other mental health issues in his family.

MH: Ct states he is healthy, and not currently taking any rx. He had a physical exam six months ago. Ct is allergic to trees, dust, dogs, and cats. Mother is on thyroid medication, per ct report.

MSE: Ct was wearing casual attire (jeans and t-shirt), normally groomed, and neatly shaven. Very cooperative, but did not make much eye contact while describing intrusive memories. Ct speech was NR&V, at times there was rapid speech when describing traumatic events of 9/11. Ct described his mood as, “down and embarrassed”. Ct affect was blunt. Ct scored 27 on the Folestin MMSE. His cognitive fx was A&Ox3. Thoughts were in normal production range. No bizarre thoughts, per ct report. Ct content was normal c no production of abnormal form. Ct offers no evidence of psychosis. Judgment was intact, and he seemed to recognize that this behavior was not normal and was not reflective of what he use to be like prior to 9/11. Ct insight is fair. Ct denies suicidal or homicidal ideation.

Assess: Evidence of Posttraumatic Stress d/o precipitated by ct being involved in the events of 9/11. Ct reports intrusive sx, persistent avoidance of stimuli, distress, avoidance of stimuli associated with 9/11 and NYC, and negative cognitions and mood starting p the exposure to the traumatic event. Ct notes he has difficulty sleeping and concentrating, and these sx cause impairment in social and occupational areas of fx. Risk assessment low, ct denies SI.

Dx:

309.81 Posttraumatic Stress Disorder, c delayed expression

V62.89 Victim of Terrorism

Plan: Ct will be assigned a clinician for o/p therapy as soon as possible. Ct will also be referred for a medication evaluation and couples therapy.