Client was well groomed with an average build. She was able to attain stable eye contact, her speech was clear and her activity was average. She did maintain normal body postures and her facial expressions matched the feelings she was verbally expressing. Patient denied experiencing delusions, hallucinations, self-abusive behavior, or aggressiveness. Her thought process was logical but her mood was anxious. She had full affect and her behavior was cooperative. She did not have any cognitive impairments and her intelligence seemed average. Client did state, “I’m anxious, I’m anxious now, just about being here”. Her activity was average but she did appear anxious as she was fiddling with her hands and picking her nails. Patient denied suicidal
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Patient also reported physiological symptoms of dizziness, shakiness, difficulty sleeping, and restless. Patient stated, “I often have a hard time sleeping because when I lay down to go to sleep my mind won’t shut down and all I do is worry”. Client worries about her family most often. She worries that her parents will die or something horrible will happen to her siblings. She also worries about her social life and keeping relationships. She states that, “I often worry about keeping my friends and when I hang out with them I tend to withdrawal because the worrying makes it hard to have fun with them”. She also worries that she will get in trouble at her job even though she is not doing anything wrong and that her grades will decline. Client expresses that there are no triggers or current stressors that are associated with her …show more content…
She denies getting any other kind of psychiatric treatment for her issues and reports that her family members have also not received any psychiatric treatment either. She denies any hospitalization, medications, psychotherapy, or counseling services for her presenting problems. Patient denies that she has any psychiatric or substance abuse disorders in her blood relatives. Her father did experiencing a minimal stroke when she was a child but has not had any other medical issues since then. Patient claims that other than her father, no one in her family has experienced major medical disorders.
Relevant Medical History Patient denied having any recent hospitalizations. Client did state that she was hospitalized as a child for the flu and was suffering from dehydration. Patient denies any major medical illness. Client’s current health status is deemed healthy. Client stated, “I feel healthy physically but just mentally I can’t seem to get my worrying under control”. Client is not taking any medications at this time but does see her Primary Care Physician. Dr. Thomas, for checkups when necessary. Dr. Thomas can be reached at 434-355-6789.
Developmental
Patient also reported physiological symptoms of dizziness, shakiness, difficulty sleeping, and restless. Patient stated, “I often have a hard time sleeping because when I lay down to go to sleep my mind won’t shut down and all I do is worry”. Client worries about her family most often. She worries that her parents will die or something horrible will happen to her siblings. She also worries about her social life and keeping relationships. She states that, “I often worry about keeping my friends and when I hang out with them I tend to withdrawal because the worrying makes it hard to have fun with them”. She also worries that she will get in trouble at her job even though she is not doing anything wrong and that her grades will decline. Client expresses that there are no triggers or current stressors that are associated with her …show more content…
She denies getting any other kind of psychiatric treatment for her issues and reports that her family members have also not received any psychiatric treatment either. She denies any hospitalization, medications, psychotherapy, or counseling services for her presenting problems. Patient denies that she has any psychiatric or substance abuse disorders in her blood relatives. Her father did experiencing a minimal stroke when she was a child but has not had any other medical issues since then. Patient claims that other than her father, no one in her family has experienced major medical disorders.
Relevant Medical History Patient denied having any recent hospitalizations. Client did state that she was hospitalized as a child for the flu and was suffering from dehydration. Patient denies any major medical illness. Client’s current health status is deemed healthy. Client stated, “I feel healthy physically but just mentally I can’t seem to get my worrying under control”. Client is not taking any medications at this time but does see her Primary Care Physician. Dr. Thomas, for checkups when necessary. Dr. Thomas can be reached at 434-355-6789.
Developmental