A person who has experienced a crisis or trauma

Full Answer Section

  History of Present Illness: Sarah was driving her daughter to school when she was rear-ended by another car. The other car was going at a high speed and Sarah's car was totaled. Sarah and her daughter were both taken to the hospital. Sarah suffered a concussion and whiplash, and her daughter suffered a broken leg and a concussion. Sarah's daughter has been recovering well, but Sarah is still struggling with the emotional effects of the accident. She has nightmares about the accident, she is easily startled, and she has difficulty concentrating. Past Medical History: Sarah has no significant past medical history. Social History: Sarah is single and has no children other than her daughter. She works as an administrative assistant and has been with her current employer for 5 years. She is close to her family and they have been very supportive since the accident. Mental Status Exam: Sarah is alert and oriented. She is cooperative and pleasant. She is able to follow simple instructions. Her mood is anxious and her affect is restricted. She is tearful when talking about the accident. She has difficulty concentrating and her attention span is short. Diagnosis: Post-traumatic stress disorder (PTSD) Treatment Plan: Sarah will be treated with trauma-informed therapy. This type of therapy helps people to understand and process their traumatic experiences in a safe and supportive environment. Sarah will also be taught coping skills to help her manage her symptoms of PTSD. Resources:

• The National Center for PTSD: https://www.ptsd.va.gov/
• The Rape, Abuse & Incest National Network (RAINN): https://www.rainn.org/
• The American Psychological Association: https://www.apa.org/topics/ptsd/

Goals of Treatment:

• To help Sarah to understand and process her traumatic experience.
• To help Sarah to develop coping skills to manage her symptoms of PTSD.
• To help Sarah to return to her normal level of functioning.

Expected Outcomes:

• Sarah will be able to talk about her traumatic experience without becoming overwhelmed.
• Sarah will be able to identify and use coping skills to manage her symptoms of PTSD.
• Sarah will be able to return to her normal level of functioning.

Sample Solution

  Client Name: Sarah Age: 35 Gender: Female Marital Status: Single Occupation: Administrative Assistant Chief Complaint: Sarah is experiencing symptoms of post-traumatic stress disorder (PTSD) following a car accident that she was in 6 months ago. She was the driver of the car and her 10-year-old daughter was a passenger. Both Sarah and her daughter were injured in the accident, but her daughter was more seriously injured. Sarah's daughter spent 2 weeks in the hospital and has been recovering at home since then.