The client has post-traumatic stress symptoms and depression as manifested irritability, lack of enough sleep, and suicidal ideation. He has been drinking and smoking frequently, a sign of mental disturbance. He also lacks basic living skills as he no hardly does his laundry, cleans his place, or t...
Name: Mr. Goodwell Preferred name: Mr. G Age: 69 Years Gender: Male
Current Symptoms/Presenting Problem(s): (Including symptoms that are affecting patient’s
functioning/behavior i.e. daily activities, medical condition, relationships, vocational, etc.).
The client has post-traumatic stress symptoms and depression as manifested irritability, lack of
enough sleep and suicidal ideation. He has been drinking and smoking frequently, a sign of
mental disturbance. He also lacks basic living skills as he no hardly does his laundry, cleans his
place or takes a bath. Mr. G has a history of mental health complication which has deteriorated
since he divorced his wife. He accents to having suicidal ideation, lack of enough sleep, anxiety,
irritability and appetite disturbance. Since his amputation, he has been reported to be incontinent
at times.
Treatment Diagnosis:1. Sleep- Wake disorders. The client amount of sleep is worrying
2. Trauma and stressor related disorder. The client has Posttraumatic
stress Disorder.
3. Anxiety disorders
4. Depressive disorder due to irritable mood and anxiety
Psycho-social Stressors (Z Codes):
1. Relationship difficulties. Mr. G has been divorced
2. Lack of social support
3. Previous work environment
4. Loneliness
5. Health problems
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