S: S.E is a 35-year-old A.A female whose health record shows that she has had a chronic history of numerous physical complaints since her early 20s. She has sought frequent medical treatment for the various physical complaints affecting multiple body systems. In the last five years, she has presented to her PCP with various vague symptoms such as muscle, joint, and back pains, abdominal pain, headache, altered bowel patterns, food intolerance, sore throat, and heavy menstruation. The client states that the physical symptoms have significantly impaired occupational and social areas of functioning.
O: The client is neat and appropriately dressed for the weather. She appears mildly anxious and maintains minimal eye contact. The self-reported mood is depressed,’ and affect is full range and appropriate.
A: Psychological distress with comorbid depression.
P: Continue with weekly CBT sessions.
S: W.D is a 34-year-old male client on follow-up for GAD. He was diagnosed with GAD after presenting with symptoms of excessive worry about his job. The excessive worry began after he got a job promotion to the editor-in-chief in a media company six months ago. He reports having immense pressure to perform and meet the job’s expectations. The client reported that she has been unable to control her worries for the past six months.
O: The client is neat and appropriately groomed. He is alert and oriented. He maintains adequate eye contact throughout the session. His speech is clear and he demonstrates a coherent thought process. GAD-7 score: 11
A: Improved anxiety symptoms compared to the previous session.
P: Initiate Prozac 20 mg PO once daily.
S: A.B is a 77-year-old client who presented with persistent preoccupation with having a severe illness that the PCP has not diagnosed. The PCP could not persuade her that she had no major illness even after conducting numerous diagnostic studies. The client’s preoccupation with having a severe illness began when she was diagnosed with PUD 7 months ago. She was prescribed Omeprazole, which has alleviated the symptoms. However, the client believes that the epigastric pain was due to stomach cancer since her father had the same condition.
O: The client is alert, oriented, and maintains adequate eye contact. The self-reported mood is nervous, and the affect is blunt. She is preoccupied with thoughts of having stomach cancer and beliefs that it might spread to her lungs.
A: The client has abnormal illness behavior. She has high anxiety levels.
P: Refer for psychotherapy for possible CBT and cognitive and exposure therapy.
S: O.H is a 35-year-old female client referred for assessment after developing marked distress after losing her job in an insurance firm eight weeks ago. She reports facing difficulties adjusting to life after the job loss and considers it a major failure in her life. She also feels guilty for disappointing her employer, who had put much trust in her to do the job as expected. The client stated that in the past four months, she has had an excessive worry, anxiety, sleeping difficulties, and is constantly angry.
O: The self-reported mood is anxious, and affect is appropriate. She demonstrates a coherent thought process. No obvious obsessions, phobias, hallucinations, delusions, or suicidal ideations.
A: Disruption in social functioning. Occupational impairment.
P: Fluoxetine 10 mg PO OD.
S: A.D is a 42-year-old male who reports he has been having difficulty falling asleep at night for the last two months. He reports he stays awake almost throughout the night and denies sleeping during the day, being stressed, and taking drinks with caffeine. He reports he wakes up too early and does not feel well-rested after a night’s sleep. Additionally, he reports having daytime tiredness, making it difficult to pay attention and remember. He says that the symptoms have made him more irritable and anxious, with an increased propensity to errors.
O: The patient is alert, anxious and well-groomed. He is irritable and has a coherent thought process. His memory and judgment are intact.
A: The patient has insomnia and worries about his sleep pattern.
P: Initiate Fluoxetine 10 mg PO OD.
S: D.S is a 24-year-old female on follow-up for cocaine addiction. She reports using coke since she was 15 years after she was introduced to it by her friends. She became addicted to heroin after the fourth use. She is forced to increase the dose of the drug every day to get high and cannot stop herself. The client reports that she experiences body aches, severe anxiety, sweating, nausea, vomiting, and muscle cramps when she stops using coke. She has been to rehab twice in the past year but has had a relapse after each program. The client is currently on detoxification and is being administered daily Methadone, which has effectively reduced the cravings for coke.
O: The client is alert but appears anxious and fidgets on the chair. Her self-reported mood is nervous, and her affect is constricted. Her speech is clear with normal volume and rate. She has a coherent and logical thought process with no noted hallucinations, delusions, or phobias. Limited attention span and concentration levels.
A: Cocaine-induced anxiety.
P: Continue with Methadone.
S: M.D is a 5-year-old AA on follow-up for Autism Spectrum Disorder (ASD). The boy presented with ASD features of developmental regression, abnormal social interactions, repetitive abnormal reactions to environmental stimuli, stereotyped behavior, and lack of symbolic play. The mother reported that the boy had normal developmental milestones until two years of age, when she noticed deficits in the child’s verbal and nonverbal communication skills. The mother reported that the child has odd responses to auditory stimuli such as loud music and car hooting. He also has a high pain threshold
O: He is alert but maintains minimal eye contact. The boy was uncooperative at the beginning of the session but became cooperative with time. Speech abnormalities and language delays were noted. The patient has no social smile when greeted and has an exaggerated stimulus to touch. He has abnormal motor movements with an odd walk. Symbolic play and Protodeclarative pointing were absent. The child has self-injurious behavior, like teeth banging and head punching.
A: Self-injurious behaviors. Deficits in executive function.
P: Prozac 10 mg orally OD.
S: C.M is a 17-year-old who reported being preoccupied with intrusive thoughts and beliefs of being contaminated after she became positive for the COVID-19 virus three months ago. The thoughts of being contaminated repeatedly intrude in her conscious mind. This compels her to wash exposed parts of her body, such as her hands and face. She reports that she has tried to resist the thoughts but has been unable.
O: The client is well-groomed and alert. She maintains minimal eye contact but frequently looks at her hands. Her self-reported mood is ‘nervous,’ and her affect is broad. She has a coherent thought process. Obsessions on contamination were noted.
A: OCD-Washers type. Anxiety secondary to fear of contamination.
P: Prescribe Clomipramine 25mg PO OD.
S: Z.P is a 12-year-old female who reported having an intense fear of public occurrences, such as speaking in class, eating in a restaurant, and speaking in public. She fears that she might do or say something embarrassing while being watched. Consequently, she avoids being in public or acting in a manner that will make her a center of public attention. She experiences intense anxiety when in public places, which interferes with her ability to socialize with others. She experiences episodes of profuse sweating, palpitations, and increased urinary frequency while in a public place or when asked to speak in class.
O: She is alert but appears nervous. She maintains minimal eye contact and occasionally fidgets on her chair. Her speech is clear with normal rate and volume. She exhibits a coherent thought process. Social phobia is apparent.
A: Avoidance behavior has interfered with her academic and social functioning.
P: Refer for psychotherapy.
S: D.D is an 8-year-old female referred for psychiatric assessment. The mother states that the child develops an intense fear when being separated from her. She also becomes anxious when going to school and cries a lot when the mother or father drops her off at school. Besides, she insists on sleeping in the same room with her parents, which is becoming a growing concern. When she sleeps in her room, she gets nightmares and cries afterward. The child has a persistent and excessive fear of being left alone at home without a close family member.
O: The girl is alert and leans close to her mother throughout the session. She appears anxious and maintains minimal eye contact. Her self-reported mood is nervous, and his affect is appropriate. She talks in low volumes and talks minimally.
A: School refusal. Physical symptoms from separation anxiety.
P: Initiate family CBT and training of somatic management skills.
S: W.F is a 17-year-old White female client who presented with uncontrollable worries about her child’s health and well-being. She is a first-time mum and had delivered a live male infant nine weeks ago. The client states that she developed a feeling of intense sadness and despair four weeks after delivery. She also reported being tearful most of the day and unable to experience the pleasure of activities she enjoyed before delivery. The client also states that she had sleeping difficulties and was constantly fatigued during the day.
O: The self-reported mood is sad, and the affect is flat. Her speech is clear with normal rate and volume, and she demonstrates a coherent thought process. No apparent delusions, hallucinations, obsessions, phobias, or suicidal ideations.
A: Insomnia, adjustment difficulties, and difficulty coping with daily stressors associated with motherhood.
P: Zoloft 50 mg oral OD.
S: A.L is a 16-year-old female who presented with a depressed mood, suicidal ideations and felt unworthy. Additionally, she reports she has not been eating and has lost about 10 pounds. She reports she has been experiencing insomnia despite feeling fatigued the whole day. She reports that the symptoms have affected her studies as she has lost interest and cannot concentrate in class as she previously could.
O: Patient is alert, oriented, and well-groomed. She reports a low mood. She has a coherent thought process but with suicidal ideations. There are no hallucinations and delusions, but with good judgment and insight.
A: The patient is concerned that the symptoms are affecting her studies, and she needs help to mitigate the effects.
P: Initiate Zoloft 50 mg oral OD.