Mental Health Case Study: Recent Exposure To Illness
Demographics:
The patient presented for this SOAP note is a 17 year old Caucasian female who comes into the clinic today with her father for a comprehensive mental health evaluation. This patient will be addressed as patient 003. She denies any religious or cultural preferences during the interview.
Recent Travel Outside U.S. - Recent Exposure to illnesses:
The patient and her father deny any recent travels outside the United States.
Chief Complaint:
The patient’s father reports that the patient seems to be anxious a lot more than usual. The patient expresses difficulty staying motivated and completing tasks. She states that she finds herself restless a lot, which affects her at school as well as her relationship with people.
History of Present Illness:
The patient 003 reports that managing tasks make her very anxious as she worries if her performance would be as expected. She states that she expects a lot from herself and becomes anxious when she does not exceed her goal. She worries about the future, especially when she does not know what to expect. For example, If she knows that it is trash day and she has to take out the trash for pick up, she finds such task overwhelming. She reports increased anxiety when she thinks …show more content…
The patient was also assessed by her school district in the same year and was reported to have an average verbal cognitive and nonverbal reasoning abilities with minimal working memory and processing speed. Hence, she qualified for special education services in school as she showed significant learning disabilities in math and written expressions. She started behavioral therapy with different therapists from 2006 to 2008 and has been with one therapist from 2011 to
The patient presented for this SOAP note is a 17 year old Caucasian female who comes into the clinic today with her father for a comprehensive mental health evaluation. This patient will be addressed as patient 003. She denies any religious or cultural preferences during the interview.
Recent Travel Outside U.S. - Recent Exposure to illnesses:
The patient and her father deny any recent travels outside the United States.
Chief Complaint:
The patient’s father reports that the patient seems to be anxious a lot more than usual. The patient expresses difficulty staying motivated and completing tasks. She states that she finds herself restless a lot, which affects her at school as well as her relationship with people.
History of Present Illness:
The patient 003 reports that managing tasks make her very anxious as she worries if her performance would be as expected. She states that she expects a lot from herself and becomes anxious when she does not exceed her goal. She worries about the future, especially when she does not know what to expect. For example, If she knows that it is trash day and she has to take out the trash for pick up, she finds such task overwhelming. She reports increased anxiety when she thinks …show more content…
The patient was also assessed by her school district in the same year and was reported to have an average verbal cognitive and nonverbal reasoning abilities with minimal working memory and processing speed. Hence, she qualified for special education services in school as she showed significant learning disabilities in math and written expressions. She started behavioral therapy with different therapists from 2006 to 2008 and has been with one therapist from 2011 to