Athelstan session 1 case notes

[patterns_bloom]

Opening Note
A. Demographic Information
Athelstan presents as a white male who is separated from his loved ones under duress.

B. Chief Complaint
Athelstan's presenting problem is that he is a slave under a despotic king's whims, which violates his sense of identity, bodily autonomy, and personal freedom. Cl. presents with symptoms of PTSD.

C. Symptomatology
Cl. describes difficulty sleeping and eating, nightmares, excessive worry and fear, and visual hallucinations. Note: Assess social supports, exercise, history with A/D, best attempt to relieve symptoms.

D. History
Athelstan states that his traumatic experience will be over in the spring of his world, when Ragnar, his lover, will come to trade for his freedom.

E. Mental Status
Athelstan is oriented to person, place, and time. Thinking is clear and linear. Memory appears adequate. Affect is somewhat guarded initially. Client is generally focused.

PAIP
P: Athelstan presents with PTSD symptoms due to trauma including nightmares, hallucinations, hypervigilance, and poor appetite.

A: Cl. presents as calm and guarded, but can become upset. Some of his trauma remains a mystery, as client often trails off when speaking.

I: Screened. Supported client in use of positive coping skills.

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