III

Date: 09/07/2011

 

[DEPRESSION]
Patient stated his mood was stressed, annoyed, angry, apathetic, guilty, frustrated, shame, depressed, lonely, bored, anxious, jealous, and exhausted. He said he’s been getting less than 4 hours of sleep and wakes up 3 times a night but goes right back to sleep. Patient has been using ‘large amounts’ of Nitequil since Jan/Feb to help him sleep but it isn’t working. He says he sleeps better during the day than night and is suffering from insomnia. When asked about his sex life, he stated that he has never enjoyed sex and that it wasn’t what he expected it. He believes it comes from his learning about sex at a very early age and the effects it had on him mentally. He said he felt guilty about alot of things and that he was feeling borderline hopeless. Patient stated that his energy is low and his concentration and focus was horrible. He said his mind was racing and that it’s always been that way. He said he does not pay attention to detail and is having memory problems.

 

[Mania]
Patient stated he will do impulsive behavior when he knows he shouldn’t. He said he gets an attitude really quick and will shut doen so that people can not speak to him.

 

[Anxiety]
Patient stated that he is irritated and nervous. He said he is nervous about getting married. He does not like to be in a crowd of more than 6 persons. He said that he doesn’t feel like he fits in or is different. He said people are not like me, they don’t think like me.

 

[PTSD/ASD]
Patient denied any life threatening experiences. He says he has dreams of Deji vue and they scare him. He does not avoid things and is startled easily but is not hyper-vigilent.

 

[OCD]
Patient is afraid of being figured out and loneliness.

 

Impression:

Patient talked slower and softer as intake progressed. He was unwilling to reveal what he was guilty about. He was unwilling to state who his abuser was. He was disassociating slightly at the end of the interview. As he was leaving the provider rubbed his shoulders trying to reground him and he appeared to return to a better state. He used the NASW feelings chart when asked about his mood to describe himself. Patient does not think he has ever been happy and he is not certain what happiness is. He indicated that he is living in a world of gray. Patient has poor nutritional patterns that could lead to health problems. He has problems with focus, anxiety, stress, energy, fatigue, mind racing, disorganized in planning, slight psychomotor retardation, irritability, disrupted sleep pattern, and poor self-esteem. Discussed antidepressant medications with him and he is unsure.

Reviews

[Coyote Poetry]

I like the description. Make me feel like I'm in the room with the patience. I like the detail and the solutions for the person to heal. Thank you for the outstanding chapter.
Coyote