Date of Exam: 06-Aug-2020
Time of Exam: 10:12:05 AM
Patient Name: Mr. WT
Patient Number: 010574
Mr. T shows an improved response to the treatment plan as of today. Although he continues to exhibit symptoms of Posttraumatic Stress Disorder (PTSD) such as fear when recalling the traumatic experience he went through, the intensity of his fear has significantly reduced and he can discuss his experience during the entire therapy session without exhibiting extreme distress signs. Mr. T. is still upset about the memory of his troop leader being killed and still blames himself for hesitating before shooting the attackers. He still experiences nightmares at least once every night of the attack on their camp and wakes up covered in sweat. Is still unable to talk about his experience outside the clinic setting.
No longer relies on medication to sleep at night. Falls back to sleep shortly after nightmares. Fells well rested by morning. Still uncomfortable in social places.
Content of Therapy: Mr. T acknowledged his discomfort in talking about his experiences with his family and stated that the clinic setting made him feel safe. He also admitted to feeling anxious in social situations. “I constantly feel like I am being watched.”
Therapeutic Interventions: The main therapeutic intervention approach used during this session involved discussing possible outcomes of the attacks while alternating the actions taken by Mr. T. During this session, the focus was to try to relieve Mr. T of the guilt by helping him understand that regardless of his actions the outcomes of the attack would have still been the same or worse. The patient will make positive affirmations about his service to the country.
MENTAL STATUS: Mr. T is slightly distressed, fully communicative, and casually dressed. He appears to be distracted by a pen on the table but responds to all questions directed towards him. His speech is at a normal rate, volume, and articulation. His language skills are intact. He appears to be in a slightly depressed mood. His affect is congruent with his mood. He exhibits no signs of hallucinations, delusions, or any other bizarre behavior that could be linked to psychosis during the session. Associations are intact, exhibits logical thinking, and thought process is normal. Convincingly denies having homicidal thoughts, dreams, or ideas. His cognitive functioning, arithmetic calculations skills, and general knowledge are age-appropriate and intact. Short and long-term memory of most things is intact. Unable to remember certain details about his mission that occurred shortly before the traumatic attack. He is fully oriented. Clinically, his IQ appears to be above the average. Aware of his mental health status and illness. Social judgment is impaired. The patient portrays signs of distress when questioned about his social anxiety.
DIAGNOSES: The diagnosis identified is based on current information based on observation and patients’ progress and may change over time if additional information is obtained.
Axis I: Posttraumatic Stress Disorder, 309.81 (F43.10) Active
Link to Treatment Plan problem: Trauma
Short Term Goals: Lessening of Mr. T. distress during clinical sessions and social anxiety by 50%.
Target Date: 30-Aug-2020 Mr. T. will exhibit reduced distress during clinical sessions and will feel comfortable discussing the events of the traumatic event without feeling stressed or fearful.
Target Date: 15-Sep-2020 Mr. T will exhibit significant improvement in walking around social places without feeling distressed.
Slight progress in resolving the patient’s distress was reached today. Recommend continuing the current interventions and focusing on the short-term goals. Continued use of prolonged exposure therapy is needed for the patient to recover fully.
Return One week or earlier if needed
90838 (psychotherapy w. E/M services)
Time spent conducting prolonged exposure therapy and coordinating care: 60 min
Session start: 9:45 AM
Session end: 10:45 AM
Dr. Christine, MD
By: Dr. Jones, MD
On: 6/Aug/2020 10:12:05 AM