Patient Name: [Name redacted]

Date of Consultation: 01/03/2023

Subjective:

The patient is a 20-year-old female who presented with complaints of abdominal pain that started last night. She describes the pain as an ache initially, but now it has become sharp and stabbing. The pain began around her belly button and now radiates to the lower right side of the abdomen. The pain is constant and currently, it is at 7 on a scale of 0-10. The patient reports that the pain worsens when there are bumps in the road or speed bumps. She also reports feeling feverish, nauseous, but no vomiting. The patient reports taking ibuprofen but it did not alleviate the pain. She has no known allergies, no tobacco, or illicit drug use. She drinks alcohol occasionally on weekends. The patient reports having two sexual partners and no history of STDs. She had eczema in the past but no other significant medical history.

Objective:

On physical examination, the patient appears uncomfortable and slightly restless. Vital signs are within normal limits. Examination of the abdomen reveals tenderness on palpation over the lower right quadrant of the abdomen. No rebound tenderness or guarding is noted. There is no abdominal distension, and bowel sounds are present.

Assessment:

Acute lower right abdominal pain

Possible appendicitis

Nausea and fever

Plan:

Administer pain medication

Conduct laboratory studies such as CBC, urinalysis, pregnancy test, and a comprehensive metabolic panel.

Perform an abdominal ultrasound or CT scan to confirm or rule out appendicitis.

Consult with a general surgeon for possible appendectomy.

Advise the patient to have no oral intake until further evaluation is done.

The patient has been advised to have further evaluation to rule out any other underlying conditions. Follow-up with the general surgeon is recommended, and the patient will be closely monitored for any changes in symptoms.

Client Presentation: The client is struggling with compulsive shopping and hoarding tendencies. They have a particular attachment to red shoes, which they have been collecting for years. The client has a history of dance and finds comfort in shoes as an art piece. They also have a tendency to collect clothes, cooking magazines, and newspapers. The clutter of collected items is starting to interfere with their home life and causing tension with their partner, John. The client experiences panic attacks in high-ceilinged theaters and when someone threatens to get rid of their belongings. They feel depressed when they go home, possibly due to the clutter in their room. The client's mother was neat, but the client is the opposite. The client has a job where they need to maintain their image, which contributes to their compulsive buying of clothes. The client is scared of being left alone with their collections when John is not there. The client has expressed a willingness to work on changing behaviors to acquire less and declutter, while also working on trauma and memories related to possessions. They have also mentioned a strategy where they can have three boxes, with the middle box for things they want to think about.

Mental Status Exam:

Client presents with a neutral mood throughout the session. Thought process is coherent and goal-directed, with no evidence of flight of ideas or tangentiality. Thought content includes preoccupation with possessions and a fear of being left alone with them. Perception is intact, with no evidence of hallucinations or delusions. Insight is present, as the client acknowledges the negative impact of their compulsive shopping and collecting behaviors on their life. Judgment is impaired, as evidenced by the client's continued acquisition of items despite the negative consequences. Overall, the client presents with symptoms consistent with hoarding disorder and would benefit from further assessment and treatment.

Therapeutic Interventions:

During today's session, the client shared their struggles with compulsive shopping and collecting items, particularly shoes and stuffed animals. We discussed the potential underlying reasons for these behaviors, including trauma and emotional attachment to possessions. I recommended the book "Buried in Treasures" and provided a page with questions to consider before making purchases. We also talked about the client's fear of being left alone with their collections and their tendency to do online shopping at night. I suggested that the client think about what might be the easiest thing for them to work on and introduced the idea of using three boxes to sort through their possessions.

Progress Statement:

Additional appointments are needed to continue working on the client's compulsive shopping and collecting behaviors. The client has made progress in identifying potential underlying reasons for their behaviors and is open to exploring strategies to change their behavior. However, the client is still struggling with letting go of possessions, particularly shoes and stuffed animals, and experiences anxiety and panic attacks when someone threatens to get rid of their belongings.

Client Response:

The client seemed receptive to the therapist's suggestions and was willing to consider the questions provided in the "Buried in Treasures" book. The client expressed a desire to work on their compulsive shopping and collecting behaviors and was open to exploring different strategies to change their behavior. The client also seemed committed to attending additional appointments to continue working on their goals.

Patient: [Name redacted], female puppy

Reason for visit: Second vaccine appointment

Observations:

[Name redacted] appears to be in good health and is an active, playful puppy. She is eating well and responding well to house training. Her nails were clipped but need to be trimmed a little more. She does not seem to have any issues with her feet or nails. She has been dewormed and is due for heartworm preventative next month.

Medical recommendations:

I advised the pet owner to continue keeping [name redacted] in their yard until she receives her core vaccines, which include the distemper parvo combo and rabies. We will give her the distemper parvo vaccine at 10, 13, and 16 weeks to ensure she is fully protected. We also discussed the Bordetella and leptospirosis vaccines, which the pet owner may want to consider if [name redacted] is going to be kenneled or exposed to wildlife.

We also discussed the importance of touching and handling [name redacted]'s feet, mouth, and tail, so she is comfortable with being examined in the future. [Name redacted]'s appetite appears to be good, and she has not had any vomiting or diarrhea.

After examining [name redacted]'s heart and listening to her breathing, I administered her vaccine in her right shoulder. I advised the pet owner of the possible vaccine reactions that [name redacted] may experience, such as lethargy, pain at the site of injection, facial swelling, hives, vomiting, or diarrhea. The pet owner should observe [name redacted] for the next 12-24 hours and inform us of any adverse reactions.

We will see [name redacted] in three weeks for her next vaccine appointment. If the pet owner is interested in the leptospirosis vaccine, they should inform us during [name redacted]'s next visit. Overall, [name redacted] appears to be a healthy and happy puppy.