Instructions: Read the case below which will help to formulate the treatment plan
This is a 15-year-old healthy female who present to the clinic with her mother for initial evaluation. Her mood is congruent with affect. Upon assessment the client verbalized being fearful of leaving the house after witnessing her friend hit and dragged by a car. The client is afraid another incident might happen, she reports isolative, irritability, racing thoughts, episodes of crying spells, insomnia, flashbacks, and intrusive thoughts. so, she avoids leaving the house, per mother, client spent a lot time alone and will not even go to the store with no one, she spent most time in her room. this She denies having any medical history.
Subjective:
CC (chief complaint):
HPI:
Substance Current Use:
Medical History:
- Current Medications:
- Allergies:
- Reproductive Hx:
ROS:
- GENERAL:
- HEENT:
- SKIN:
- CARDIOVASCULAR:
- RESPIRATORY:
- GASTROINTESTINAL:
- GENITOURINARY:
- NEUROLOGICAL:
- MUSCULOSKELETAL:
- HEMATOLOGIC:
- LYMPHATICS:
- ENDOCRINOLOGIC:
Objective:
Diagnostic results:
Assessment:
Mental Status Examination:
Diagnostic Impression:
Reflections:
Case Formulation and Treatment Plan:
References