Case Summary
Client Y is a 33-year-old African-American female with two children aged 3 and 5, and married to a 39-year-old Hispanic male. Client Y presents following a referral by her sister, who thinks that she is under severe emotional distress. Symptoms at the time of presentation included a depressed mood, inability to concentrate, nightmares, sleeping difficulties, and heightened irritability. Client reported that symptoms began 4 months earlier, after a violent encounter with her husband that resulted in serious injury. Client Y was diagnosed with PTSD and placed on Sertraline (Zoloft) 25 mg once daily in addition to once-weekly CBT sessions. The goal of treatment is to ensure that client Y regains control over her life and develops skills to address her symptoms. Four weeks later, the client shows minimal response to treatment. PTSD symptoms are still present. No modifications have been made to the treatment plan this far.

Subjective Content

The client reports that she is still unable to concentrate, feels depressed most of the day, and has not noticed any improvement in regard to the nightmares. She reports feeling like a ‘ship lost at sea – afraid of a pirate attack at any time’ as she constantly fears that she could wrong her husband and attract another violent attack. The client reports that she is able to fall asleep more easily over the past two weeks and no longer experiences night chills and sweating, although she fears going to bed as the nightmares keep coming. She is ‘willing to do anything for the nightmares to go away and for her days and those of her family to be bright again’. The client is concerned that the prescribed medication is ‘working too slowly’.

Treatment Compliance

The client reports that she had been taking her medication as prescribed until a week ago, when she began feeling like it had ‘no impact’. She now takes the medicine only when she remembers. Client has not taken any other medication since she began treatment with Sertraline.

Relevant Psychosocial Information

The client’s relationship with her husband is getting worse as she ‘no longer loves her husband like she used to’. Her interactions with male clients have been severely affected and she fears that this is hurting her business. She is concerned that she may lose some of her key clients as she has had to halt associations with particularly male clients. Her relationship with her children has also suffered as she no longer takes time to cook nice meals for them or treat them during the weekends.

Safety Issues

The client does not report any safety concerns from her use of Sertraline. Client does not report heart palpations, chest pains, or breathing difficulties. No clinical emergencies have been reported.

Objective Content/Clinical impressions

The client is well-groomed, though irritable and distracted. She is fully communicative, although her speech rate is slow and incoherent. She constantly avoids eye contact and her reasoning and thought processes are at times illogical. She displays a depressed mood and is...…parent client is not a very social person and has few friends, there may be a need to encourage more communication and interaction with her parents, both of whom are alive. The parents could provide a listening ear for the client, thus minimizing the risk of piling things up and heightening stress/ depression. More communication with the parent clients’ parents and other couples that have had successful marriages could also be crucial in helping client Y change her mind set on how marriage couples need to interact with each other.

The progress note documents the client’s clinical progress and can be accessed by any authorized medical personnel. For instance, a therapist may share a progress note with another therapist as a way of acquainting them with the client’s medical history. Its main aim is to document a client’s clinical progress in the course of treatment. Conversely, a privileged note is private (Corley, 2013). As such, it would not include medication details, test results, treatment plan information, summary of diagnosis, or summary of clinical progress, all of which would be present in a progress note. Some of the information present in the progress note is excluded from the privilege note as privilege notes are private notes that are not subject to federal privacy protections. My preceptor uses privileged notes in their interactions with clients. The notes include subjective information such as the therapist’s personal observations about a client (family), hypotheses, questions for supervisors, and feelings or thoughts related to the therapy sessions.…