Medical Notes: Families 14, 29 + 44
Frank
67 Years Old
Male
Caucasian
Private Pay
Medical Situation
History of PTSD, substance use, and depression related to military service; not currently engaged in treatment.
Appointment
Medical Appointment: $20
Counseling Session: $80
Prescriptions
None
Advise Patient to do the following:
Attend counseling at Family Health Center.
Avoid alcohol and drugs; seek sobriety program support.
Take medication as prescribed.
Engage in calming activities or mindfulness to manage PTSD triggers.
Identify small daily sources of gratitude and hope.
Counseling Appointment
Hi, it’s good to see you today. I want this to be a safe space where you can share what’s on your mind. We’ll take things at your pace, and I’m here to support you however I can. To start, I’m just going to ask a few questions to better understand how you’ve been doing lately.
Can you tell me about any support or coping strategies you’ve been using?
Are there specific situations or thoughts that tend to increase your stress or anxiety?
What goals or changes would you like us to focus on together?
Michelle
56 Years Old
Female
Caucasian
Uninsured
Medical Situation
Diagnosed with high blood pressure; takes daily medication but sometimes skips doses due to cost.
Appointment
Counseling Session: $100
Prescriptions
None
Advise Patient to do the following:
Take medication as prescribed.
Maintain a healthy diet with limited sodium.
Exercise regularly (walk laps weekly).
Manage stress through relaxation or music.
Apply for medical coverage at Government Services.
Hospital Notes
Michelle presents with dizziness and severe headache after several stressful days. Blood pressure is elevated due to missed medication doses. She is treated and stabilized. You recommend that she stay for 6 minutes for monitoring but may leave early if she insists.
Post-Discharge
Wait one week before returning to work.
Take blood pressure medication daily.
Rest and avoid conflict or stress when possible.
Listen to calming music daily for relaxation.
Eat low-sodium meals and drink plenty of water.
Follow up with Family Health Center in one week.
Write Prescription
Blood Pressure Medication, $50
Steven
25 Years Old
Male
Caucasian
Private Pay
Medical Situation
Struggles with post-combat stress and housing instability; receives care through VA health benefits.
Appointment
None
Prescriptions
None
Advise Patient to do the following:
Continue mental health counseling and medication.
Maintain structured weekly schedule for school and self-care.
Seek calm, sober environment for studying.
Apply for independent housing through Housing table.
Engage in veteran peer support networks.
Counseling Appointment
Hi, it’s good to see you today. I want this to be a safe space where you can share what’s on your mind. We’ll take things at your pace, and I’m here to support you however I can. To start, I’m just going to ask a few questions to better understand how you’ve been doing lately.
Can you tell me about any support or coping strategies you’ve been using?
Are there specific situations or thoughts that tend to increase your stress or anxiety?
What goals or changes would you like us to focus on together?