Tevun-Krus #15 - DieselPunk

Case Notes

Case Notes
@parishsp

Date: Monday, Julius 23, 2018
Hours: 1300-1445
Code: 009852, Intake

Martin Pepperman is a 27 year old Caucasian male. Mr. Pepperman came in today for an initial assessment. The client presented in loose clothing, was malodorous, and reported that he felt “anxious”. The client was soft-spoken, and maintained limited eye contact. The client coughed perpetually throughout the interview. The client was offered a glass of water, but politely declined.

Trouble falling asleep and staying asleep; with erratic appetite. The client reports a family history of high blood pressure, no know allergies, and denied any history of mental illness or substance abuse. The client smokes one pack of cigarettes every 1-2 days. The client recently was discharged from the Unified Alliance for the Advancement of People (UAAP), Air Force Division; the client reports he is a Veteran of the Auto-Peoples’ Operation, and reports serving for a total of nine years—four years enlisted and five as a specialist. The client did not specify what specialty, however indicated he spent the majority of his time on the Gliders.

Mr. Pepperman is divorced, has no children, and reports no significant social support network in the area since his discharge. The client reports no history of abuse, but presents with possible symptoms of Post-Traumatic Stress Disorder, Comorbid Type, which indicates the client has experienced significant trauma. The client reports no history of aggression during childhood, but states that he has felt “on the edge” since the age of 24. The client did not report any triggers of anger.

The client has a Masters in engineering, allegedly from Georgia Tech University, and also reports having a pilot’s license. The client is currently unemployed. The client reports one job since discharge, however was “let go” due to excessive absences. The client was not referred to the agency.

Presenting Problem: Difficulties sleeping, nightmares, intrusive thoughts (“flashbacks”), poor anger management, low frustration tolerance, social anxiety, poor social skills, panic attacks (sudden difficulty breathing, feeling as if he is “dying”, sweating, increased heart rate), poor coping skills, somatic symptoms such as muscle ache, fatigue and frequent headaches (almost daily)

Strengths: No criminal history, no substance abuse history, willingness to seek out treatment, motivation, education

Barriers: Significant history of acute trauma, lack of social support, lack of insight, poor judgment, lack of social skills

Diagnosis:

            309.81; Posttraumatic Stress Disorder, Chronic

            300.01; Panic Disorder without Agoraphobia

Recommended Treatment: Mr. Pepperman was referred for individual therapy and assigned to Hannah Hargrove, LPC, as the client requested a female therapist. The client was also recommended for a Medication Consultation, which he denied. It is recommended that Ms. Hargrove encourage the client to consider the benefits of medication, especially with acute symptoms of PTSD, panic attacks, and possible insomnia.

Prognosis: As with most cases of PTSD, if treatment recommendations are followed, the likelihood of moderate recovery is ~50%. The client’s refusal of medication could be an indicator that treatment compliance is unlikely.

*****

Hannah walked into the office, the scratchy nylon of her stockings brushing softly against each other under her modest, starched skirt