Focused Exam: PTSD (Part 3 of 4) C487 Psych/Mental Health Clinical - Aug 2018, C487

Focused Exam: PTSD (Part 3 of 4) C487 Psych/Mental Health Clinical - Aug 2018, C487 Return to Assignment Reflections Activity Description: Reflective writing develops your clinical reasoning skills as you grow and improve as a clinician and gives your instructor insight into your learning process. This reflection activity will help you think more deeply about your performance in the assignment. Use your documentation as you respond to the prompts at the bottom of the page. Documentation Review Mental Status Note Student Response Model Documentation Appearance clean, well kept normal for age Ms. Diaz is a 48-year-old Cuban American woman of average height. She appears overweight. Eye contact is direct. Her expression is tense and posture rigid. Her clothing is appropriate to her age and occasion. She appears well groomed. Attitude cooperative, engaged, open, relaxed Ms. Diaz is cooperative, but is anxious and appears guarded when asked about her social history. Motor Activity lack of eye contact, flat facial expression, no involuntary movements Ms. Diaz's motor activity appears agitated. She has a clenched jaw and clenched fists. She has a steady gait and continuous steps. Speech normal rate, volume, quantity, and fluidity Ms. Diaz's speech is rapid and she only responds to questions when asked. No observed problems with liveliness, volume intensity, or flow. Her speech is normal for her age, education, and general ability. Mood and Affect easily angered, obessive thoughts, sudden modd changes Ms. Diaz is guarded and appears to be moderately anxious. Her affect is appropriate to the situation but constricted. She appears stable. She is aware that she is anxious and tense. Thought Process normal Ms. Diaz's thoughts have no observable disordered behaviors. Her thoughts appear coherent, logical, and relevant. Thought Content suicidal thoughts, dpressve state, obessive thoughts Ms. Diaz has some passive suicidal ideation, reporting that she is not sure she can go on like this anymore because of her exhaustion and tension from PTSD. She appears paranoid, stating that she checks her doors and windows multiple times before she goes to sleep at night. She cannot sleep deeply because of her paranoia and fears. Perceptual Disturbances none Ms. Diaz has no delusions or hallucinations. There are no observable abnormal tendencies. Orientation and Level of Consciousness a/o x 3 A&O x 4 Cognition no noted difficencies No problems with serial 7s or abstract reasoning. Her memory appears normal and she is attentive and aware of the situation.