Behaviour and Appearance
The client appears neat, clean and well-groomed. His clothing is appropriate to his age and congruent to the weather. He was engaged with the doctor. However, at some instances, he appears to be withdrawn. He seems to be restless as he is constantly shaking his hand, and legs. He paced his hand to the face at regular intervals. He appears sluggish in the mid of the conversation occasionally. His speech was clear, volume and flow are normal. In addition to this, he often becomes slow and inattentive in the middle of the conversation.
Affect and Mood
The client’s emotion and his moods are appeared on his face. He is constantly shaking his legs and looking all around the room. His eye-to-eye contact with the doctor while conversation is not good. He is expansive and smiling while talking about his thoughts and views. His face appears tired and dull due to lack of sleep and food. The client states that he is very busy in his work which prevents him from taking proper sleep. He is not taking medication whose impact can be visible for his expression. At many instances, he was flat and shows restricted emotions may be due to lack of focus. He uses his body while interacting with the doctor and there is proper variation in the expression.
Thought content, Form, and Perception
The client is very clear that he has no intention of hurting himself. He believes that music calms him and does not consider that television is pushing him to take any action. However, he has left his job as he is not feeling appropriate to work in the food related industry. In contrast, client considered himself as a very busy person. He constantly stresses upon being too much busy in his plans, ideas and thought. He believes that he needs to bring his plans into action as there is very limited time left. He believes that he has so many things to think off which keeps him too much busy. He is consuming drugs as he believes that these drugs provide him energy. He considered his job monotonous.
Orientation
The client is very clear about the time, date and place. He is aware that his parents brought him to the doctor as he is too busy to eat or sleep. He believes that the visit is unnecessary as he is taking sufficient sleep.
Memory and Cognition
The client has poor recollection of his medication and when he had stopped taking his medication. He is being aware of coming to meet the doctor and who had brought him and why. He is aware of his situation.
Insight and Judgement
The client lacks the awareness of his condition or the impact which can occur on his health if he continuous with his current situation.
The risks associated with the client are
Behaviour and Appearance
The client appears neat and clean but not well-groomed. Her hair are not neatly tied, however her clothes appear to be congruent with the weather and her age. She is engaging and discussing her issue continuously. She is not making eye contact while communicating and appears very restless during the conversation. Her voice is clear and normal in volume. She is constantly sharing her remorse. The rate of her speech is also very normal.
Affect and Mood
The client emotions are appropriately matching with her facial expression and body language. She is crying and her facial expression shows guilt and remorse. She is very sad that she has lost her licence of six months due to drunk driving. She seems irritated by her situation and feeling helpless as she failed to manage her life. She is depressed (dysthymic).
Thought content, Form, and Perception
The client is suicidal. She thought that her death may not have any impact on others life. She often thinks about killing herself. She is feeling drifted. She is suffering from post-partum depression. She believes her life is completely changed after the birth of her baby. She has made herself isolated as she believes sharing her issues with friend may cause any burden or trouble. Her relationship is going difficult with her husband as they both are not communicating with each other. I think her poor communication with husband and her friends has developed suicidal thoughts in her. Her lifestyle has completely changed after birth of her baby and she is finding difficult to adjust with this changed lifestyle. She is under high stress and irritated with her current situation.
Orientation
The client is very clear about the time, date and place. She is aware of her visit to the doctor. She visited the doctor after suggestion made by child support service nurse. She wanted to improve her situation.
Memory and Cognition
The client has good memory about the events occurring in her life. She remembered the time when her situation developed and well-aware of the time when her condition become worsen. Apart from this, she has a good memory of past six months of her life.
Insight and Judgement
The client is completely aware of her situation. She knows that if her condition is continued, then she may lose her child to social service. Apart from this, she is aware that her relationship with her husband may ended if she failed to took control of her life.
Risks
The risks associated with the client are