Conduct an initial assessment on one of the following clients as though you were seeing them at your clinical site, including taking history, conducting a mental status exam, and assessing attachment and cultural beliefs. Starting next week, you will complete similar clinical write ups on clients you see in your practicum setting. Of course, your write ups will be more thorough for those clients. See Clinical Write Ups Overview for details.
Â· (Alcohol addiction) P. J., a 34-year-old, comes in for therapy. Patient states that she has been drinking a fifth of vodka and club soda every day for the past three months, following a horrible divorce. Patient is seeking therapy because she recently was pulled over while drinking. Patient states that she has been using alcohol to cope. Patient states that she drank socially prior to the divorce, but it was never a problem. No other history of mental illness or substance abuse.
Â· (Depression) K. L., a 15-year-old, comes in with her mom for therapy. Patient’s mom states that she recently found out that patient was cutting herself. Patient’s mom noticed that patient has been isolating in her room, she quit the volleyball team at school, and doesn’t seem to enjoy the things she used to do. Patient states that she just doesn’t feel happy and thinks about suicide often, especially when she is alone.
Â· (PTSD) W. M., a 43-year-old, comes in with his wife, U. E., for therapy. Patient’s wife states that patient is always nervous and worried about things. Patient’s wife states that patient will not go to any of their kidsâ€™ sporting events because he is afraid of the crowds. Patient states that any time he hears a loud noise he has a flashback of when he was overseas in the military. Patient’s wife states that patient will scream and yell in his sleep and patient states that he wakes up after having horrible nightmares.
Â· (Borderline personality disorder) N. G., a 24-year-old, comes in for therapy. Patient states that she hates being alone and will constantly try to be with random men and women, for fear of being by herself. Patient feels like people are always picking on her and when she gets mad, she gets overly emotional and angry. Patient states that she likes creating drama with her friends because she feels the chaos helps calm her.
Â· (Depression) P. A., an 88-year-old, comes in for therapy after losing his wife of 40 years. Patient states that he has no appetite, can’t sleep, and has thoughts of hurting himself. Patient states that he has never had mental health problems before, but he can’t function.