Identifying Information: Client is a 68-year-old Caucasian male from Washington, NC. Client presents to Navigate for individual counseling and meditation group.
Appearance (e.g. overweight, dresses appropriately, etc.): Client is overweight and of average height. Client dresses casually and appropriate for sessions.
Benefits (Food Stamps/SSI/Medicaid/VA): Medicare
History of Presenting Problems: Client presents to Navigate with depression and anxiety. Client describes a lack of meaning, usefulness, and direction. Client states that since his retirement he has not been able to see past the “wall” and that he is currently stuck. Client reports not having anyone to talk to or hold him accountable for getting out of the roadblock he is currently …show more content…
According to client’s medical records he as been diagnosed with coronary artery disease, hyperlipidemia, high blood pressure, benign prostatic hyperplasia, and is in remission from chronic lymphocytic leukemia.
Medications: Client is currently taking: Aspirin 81mg, Voltaren 75mg, Vasotec 20mg, Proscar 5mg, Fish Oil, Flaxseed Oil, Glucosamine, Prilosec 20mg, Zocar 40mg, and Flomax 4mg.
Psychoactive Substance Use and Abuse: Client reports not using psychoactive substances and never having a substance abuse problem.
Psychological: Client reports anxiety, depression, and a lack of motivation.
Mental Status: Client is oriented to person, place, time, and event. Thinking is clear. Memory appears excellent and affect is congruent with stated feelings.
Social, Relationships, and Cultural: Unknown
Marital and Family History: Client reports being married to his wife, LW. Client reports experiencing communication issues with his wife. Client states that his wife has a “hearing problem” and that sometimes their schedules do not align, causing problems in communication. Client has two older sons, one of which lives 2 hours away and the other lives about 20 minutes away from “home”. Client is active in his children’s life and states that “we watch sports together and sometimes take family
Appearance (e.g. overweight, dresses appropriately, etc.): Client is overweight and of average height. Client dresses casually and appropriate for sessions.
Benefits (Food Stamps/SSI/Medicaid/VA): Medicare
History of Presenting Problems: Client presents to Navigate with depression and anxiety. Client describes a lack of meaning, usefulness, and direction. Client states that since his retirement he has not been able to see past the “wall” and that he is currently stuck. Client reports not having anyone to talk to or hold him accountable for getting out of the roadblock he is currently …show more content…
According to client’s medical records he as been diagnosed with coronary artery disease, hyperlipidemia, high blood pressure, benign prostatic hyperplasia, and is in remission from chronic lymphocytic leukemia.
Medications: Client is currently taking: Aspirin 81mg, Voltaren 75mg, Vasotec 20mg, Proscar 5mg, Fish Oil, Flaxseed Oil, Glucosamine, Prilosec 20mg, Zocar 40mg, and Flomax 4mg.
Psychoactive Substance Use and Abuse: Client reports not using psychoactive substances and never having a substance abuse problem.
Psychological: Client reports anxiety, depression, and a lack of motivation.
Mental Status: Client is oriented to person, place, time, and event. Thinking is clear. Memory appears excellent and affect is congruent with stated feelings.
Social, Relationships, and Cultural: Unknown
Marital and Family History: Client reports being married to his wife, LW. Client reports experiencing communication issues with his wife. Client states that his wife has a “hearing problem” and that sometimes their schedules do not align, causing problems in communication. Client has two older sons, one of which lives 2 hours away and the other lives about 20 minutes away from “home”. Client is active in his children’s life and states that “we watch sports together and sometimes take family