Oswin Session 1 Case Notes

[patterns_bloom]

Opening Note
A. Demographic Information
Oswin presents as a white female in her mid-twenties who currently lives in Milliways. Client is a former junior entertainment officer for the starship Alaska.

B. Chief Complaint
Oswin's presenting problem relates to dealing with a traumatic experience which violated her sense of identity, bodily autonomy, and personal freedom. Cl. presents with symptoms of PTSD and disassociation.

C. Symptomatology
Cl. experienced minor incidence of SI/HI flashbacks during session and required music from Carmen to calm down. Note: Assess whether cl. has difficulty sleeping. Tearful and labile during session, expressed shame in crying. Note: Assess social supports, exercise, history with A/D, best attempt to relieve symptoms.

D. History
Oswin states traumatic experience lasted for one year where she believed she was trapped in an escape pod. Client then was forcibly used by Daleks, creatures which glorify hatred. Cl. tries to shrug off concerns, but worries remain.

E. Mental Status
Oswin is oriented to person, place, and time. Thinking is clear and linear, though interrupted by SI/HI. Memory appears adequate. Affect is somewhat guarded initially, but quickly moves to tearfulness when describing difficulties with trauma. Cl. is generally focused with slight disruption in tracking.

PAIP
P: Oswin presents with PTSD symptoms due to excessive trauma lasting over a year on a hostile planet.

A: Cl. presents as cautious, tearful and labile. Cl. presents with SI/HI. Cl. appears to have coped re: Carmen.

I: Screened. Supported client in use of positive coping skills. Assess client's social supports.

P: Will see client in future. Will focus on coping skills, further assess reaction to trauma.