🩺 Record Detail
Patient Info
Transcript
Doctor: Okay Amazing. How did you find that one? A little bit easier? Good. Okay, last but not least Music to my ears. Give it a shot And then yeah, we will skip the ads. Yeah. Yeah Okay, we have to technically once we start this one Like this, we have to finish this one And then we can actually do this if you'd like the math better you can do Okay, this one I know it looks a little scary but very simple I'm going to show you two sentences and I'm going to ask you to combine them into one. That means the same thing So first one is good. That's the sentences are The car is red, the car goes fast. Combined sentence that means the same thing is the red car goes fast. Another combined sentence you could write Lucas would be The car is red and it goes fast, but that one's even better Do the first one and then we'll look at it together and then Well, we'll do the rest if we can Yeah, I just thought of something that would do this The dog has ferns so as the cat. You can write that if you'd like. Patient: Yeah, I'll do it Sorry Smarty pants When did you write? The dog has ferns so as the cat So as the cat and I see you used correct capitalization and punctuation And a sentence you can also use is The dog and cat have ferns It would still combine those two So that's another way you could do it But I want you to try number two and number three Yeah, you don't have to show me the other ones that you make Holy smokes, you're fast. Good good. You found them. Okay. Yeah, let me see Try the one where it says Mark has a sister named Ava. Ava is six years old Mark's sister Ava is six years old. Oh my gosh, you're pro now. Thank you Okay, so those next two they are the hardest sort of them because there's three sentences now, right? But you know what? Just try your best to combine those three sentences in two What did you write? Antonio won the best acting award for being the fastest runner and I heard he's a strong star Oh my gosh, cool. I like that sentence. That was creative Is the last one too hard or is it doable maybe Think about it. It's doable. All right, give it a shot and then we'll do maybe some of the math, right? Yeah Okay, I'll get that set up now Hmm I know I thought there was someone there but I guess not Hey Marie's new car I mean Marie bought a new car and her new car costs too much to repair um and Marie's new car is small Yeah, it's let me see Very good You're great The apostrophe. No, that's good. Um Now that I tortured you enough to break Shall we go back to math? Yes. All right, let's do it And it's on the ipad and you can use the back of this book But oh and by the way after this math activity, we're going to take a break You've been working. It's already almost an hour has gone by almost Yeah. Yeah, so we need a break anyways, um Use the back of that booklet if you need to ever work out a problem, okay, so you have that if you need um If you are counting in order, which of these numbers would you say first you can tap it with your finger if you want How many centimeters long is the pencil So what do I do here just tap on the same? Oh for this one you have to tell me i'm sorry. Oh 13 Nice If all the dots on the line had numbers what number would go where a is 30 If two of these ducks flew away, how many would be left? And if you're counting in order which of these numbers would you say first And these beads form a pattern on the pegs How many beads should be put on the empty peg? Um four. Thanks Neil had five marbles and was given three more. How many marbles does neil have now? So he had five marbles. He caught three three more perfect On what day of the week is the 14th? of like october Uh, just on that calendar there. What day of the week does it show? 14th tuesday. Mm-hmm Um This graph shows the number of books given to the city library by students from four different schools Going across the bottom of the graph. What are the schools? I think they are central and west Yep, the numbers on the sides for the number of people so central Um, sorry the number of books I said people I meant books Um given by each school. How many books did eastman school give? 40. Perfect. And how many nickels does it take to equal the value of one quarter? What number goes here where the empty circle is? seven And which is worth more six nickels four dimes or one quarter? Uh four dimes. Nice This graph shows the number of people who rode each fair ride The rides were the ferris wheel roller coaster merry-go-round waterslide pirate ship and train The numbers on the side show the number of people who rode each ride. How many people rode the ferris wheel? 15. Nice. Which number is in the tens place? Uh, 50. Nice. And how about the hundred thousands place? 900,000. Mm-hmm Robert has six toys together. Robert and max have 15 toys How many toys does max have? Nine. You're fast. Good job. What time is shown on this clock? The time it is 15. Wonderful If you flipped a coin 10 times, how many times would you expect the coin to land on heads? Okay, so Um because okay, so say i'm gonna flip a coin, right? You say it's heads. It's 51% chance I've heard people say this before. Yes You know what? Let's just say the coin has Yes, 50 50. Yeah, and then uh Five times on it. You're right, but very clever because I have Heard that before You're the second person to tell me that So very clever Um, all right. We have a cake question Miss Rivera served cake for dessert. She cut the cake into six equal pieces If carlos eats two pieces and jenna eats one piece What fraction of the cake would be left? uh Three six. Mm-hmm. That's right A room has four rows of chairs. Each row has the same number of chairs There's a total of 24 chairs. How many chairs are in each row? six And if today is the third of the month and anita's cousin will come to visit on the 17th How many weeks must anita wait until her cousin arrives? two If you cut a cake into six equal pieces, what fraction of the cake would each piece be? One Now which choice shows what this triangle will look like if the graph paper is rotated 90 degrees Yeah, you can tap this one if you'd like To the right a you chose Let me see I mean i'm really bad at doing it in my head. But yeah, it looks right. It looks right to me um Now for this one, I want you to put these fractions in order from smallest to largest trick question This is a trick question I'm feeling this you know what don't overthink this one. I promise it's not that bad Because um One two looks like one half it does It does. Okay. I see where you're going with that. Yeah. No, i'm totally under i'm really bad at fractions I know Grade five and six they do fractions a lot. So Don't ask me any fraction questions Okay for this one. I want you to find the perimeter in meters The perimeter in meters. Yes If you can those questions are easy. Oh That was easy for you Okay, what is the next number in this pattern where the question mark is And by the way, these are getting hard so just take your time if you need okay Okay, I figured out where this is going it's like the top number is like what you're timesing it by I don't see what you see, but i'm missing look Two times three equals six six times four equals 24 and then 24 times five equals Is that what you're working on right now in your head? Would it be helpful if you use this? Yeah. Yeah use the paper 120 You're Really good. That was good Okay I don't know if you've been taught these before lucas, but we'll try it. I have okay Sorry Assuming angle a is 90 degrees And angle b is 20 degrees What is the number of degrees in angle c? Let me skip this one, of course, don't worry you can skip anyone you need to skip Okay Eli went to sleep at 10 30 p.m and woke up at 7 a.m. The next morning How long did he like eight and a half hours job Okay. Okay. I don't think you've done these but if you have great Paul has scores of 95 80 85 and 80 on his first four math tests What is his average test score? Yeah, I can get this one. I'm pretty sure good for you. All right He has like an average of like 85 Well done Okay Which choice shows what this figure will look like if the graph paper is rotated? 180 degrees And which one did you pick a nice? Okay, which decimal is closest in value to five over six? Okay, mary had two hundred dollars Then she bought four tires each tire costs 35 dollars and 50 cents plus Three dollars each for balancing. How much money did she have left? If you can do this one, great Give it a try This could be okay. You know what and that's okay I understand. It's just math Take as long as you need Wait, so when like plus dollars for um balancing. Um, like When I like do I add it to like the total what do you think do you think Are you trying to figure out like how to add it or yeah, like how to add it? Like what do I do with like three dollars for balancing? What do you think you should do with it? I'm sorry. I wish I can help but i'm not allowed apparently so So she has 66 dollars and 50 cents How did you get that? Okay, I see you worked really hard for that one. Good job All right We're almost done with this and then we're going to take a break The charity drive reached one fourth of its goal in march one third of its goal in april And one sixth of its goal in may what part of the goal was reached during these three months? It's been really tricky. Do you want to skip this one? Yes, I know we're getting like oh and that happened to be the last question All right whoo Great job. It was the easiest. Hey out of all those hard ones. That one was The most fun. Okay, good. I'm glad it wasn't that bad. Now. Let's get a snack. Shall we? Yeah, you don't have any allergies you While you eat that i'm gonna have my snack It's just a banana Do you have to go back to school today? No amazing Oh, um for your break. Do you want I don't have a whole lot of games on the ipod. I also have I don't have the app because I don't have So i've been using chrome. So you go in youtube Why is it in black and white? Oh, okay. Okay. Never mind. Okay Okay Yeah, and then people are watching like minecraft videos Feel free to do whatever you'd like on this as long as it's not inappropriate to your phone The volume might be maxed out just fyi It's half oh, okay. Okay. yeah Yep, I do you get them I Have to hold my breath because then they won't stop. No, I stayed for three hours I would go cuckoo Okay, i'm gonna hold my breath Okay, i'm gonna go get the vr headset and then one more minute Okay Okay Yeah, if you don't mind and we could we'll Leave this more towards the last 20 minutes Oh, sorry. Here's the curtain We haven't done reading so we'll do a little bit of reading and then by the way, do you have to go back to school today? Yay Are you excited not to have to go back and get a little day off? My sister did this. Hey, oh, yeah. No, no Um, they actually forgot to send I just realized yeah, I checked on global and I don't see a Interesting. No, okay. I'm gonna Thank you, thank you. Yeah good catch, okay Um, what are we saying? Um, my sister did this and um Yeah, she's she missed school And then she after she got to go wherever she wanted Because of dad he was like, let's spoil you today What did she get to do? Like she went to like subway. She got a gift card and stuff Okay, jealous tin hockey packs came out Oh, that's right. Yeah. Yeah, did you um instead? Um, I was getting lunch after I got to mortars like this morning for breakfast Yeah And then um, I got five packs and then my mom has like 20 more Oh my gosh, did you see what you got yet? No Oh, i'm excited for you. Maybe you got something good. Are you looking for a particular player? No, you're just looking for completing the set got it. Um, like my cousin me my cousin like We collect together and then like whenever we get like doubles we just trade and stuff That makes sense. yeah, that's actually really handy to have someone who And I like started the set like really early the day it opened More in the morning. No way and got like a binder and stuff because binders are like hard to find really Yeah, they sell out so quick Like at like walmart or staples and only two mornings you can get them Oh the bot. Oh, I see what you're yeah, I know what you mean And then um the 21 22 set my cousin collects was collecting. I collected 23 24 24 25 and then this year 25 26 So like yeah, so then the first year I started collecting Um, like the year before two years before that my cousin got like 100 packs for christmas And he completed the set twice Oh my gosh, what is he gonna do? Did he sell it or maybe? No, he gave it to his younger brother. Hey that worked out Yeah, that's good Wow Two complete sets. That's pretty rare. Yeah It's hard to oh my gosh. Yeah, the set was like 300 cards. Holy Seriously that many Is that how many there are usually you know in a set? There's like 220 Wow in like um a really like big set. Yeah 1100 cards Yeah, I don't know how I would No, I would be so overwhelmed Personally myself I would All right, so you don't need any pen or paper. What we're gonna do is just read these words out loud Always start at the left corner and then go Into mine They bear other cow don't stone when stops guy And then just remember to go Across yeah. Yeah. Yeah. Don't worry. It's okay. We're gonna do this one now freeze fight between goat foot long seat clout frozen knife distance equipment manager's photograph Crump playful and rhythm Posted budget budget Ruin tough garnish ridiculous interject radiant Poised Well done. How's the last one? Yeah, I know right not too bad short and sweet there is another reading thing that we will do now and it has to do a lot with passages and All you need to do is read them to yourself or out loud if you prefer Um after each one, I'm just gonna ask you questions about what you read And you're allowed to look back at the stories so Tell me when you finish reading this Yeah, of course Oh good job What? It's asking for this question what word does the advertisement use just to describe the cartoon characters? Oh like premium And what type of 100 cotton is used to make shirts Yeah, what type of cotton is used I'm not too sure if it says i'm not too sure. No, it doesn't say Next question then. Let me see if this one. Okay. What information is given in the advertisement about cleaning the shirts? um You can use a washing machine And what are the shirt sizes that can be ordered? extra small small medium and large And why does the ollie owl shirt cost more than the other two shirts? Um because there's more detail And what other information would someone need to know in order to purchase one of these shirts, um Like what else? Yeah, like what else like, um the shirts made out of And tell me when you finish reading this passage And besides colorful which word best describes gobbledygook Yeah, besides colorful what word describes gobbledygook I don't even know what that is the did it not it says but like Like what is it? I see. Okay. I some of these questions are a little tricky. I don't know if it's in there or not Let's try this next one. What two ingredients must you have to make gobbledygook? cold starch and warm water Mm-hmm And how does step two change the gobbledygook? by adding four drops of food coloring And stir until it's mixed well And so what does it do in general like does it like? Sticky and fun to play with. Mm-hmm And if the gobbledygook is too thin and watering a watery, what can you do to make it thicker? Add more cornstarch and mix until it's just watery How long do you have to mix the cornstarch with the warm water? Two minutes And what do you predict would happen if you skipped step six? It would be liquid or hard. It would be liquid or or hard, right? Yeah Nice which Words in the passage say it's okay to touch it with your hands your bare hands Step five. What does it say there? It says mix everything together for three minutes Using your fingers to mix so you can feel the consistency is right. Good. And is there any other Spot in there? It's okay All right, almost done with the reading I believe this is the second last one or the last one. I'm not sure Name three dangers encountered by the siblings in the book Falling into the water Asking if they should abandon everything and save themselves Good. And according to Shyla's review, what lesson did the Silvas need to learn? Um how to like control the boat And which part of the review says that the three siblings didn't return home by the end of the book? They were like trekking through a mountain Oh, right. Yes that part. Okay Which part of the review suggests the Silvas The Silvas siblings are committed to their chosen work If it says anything in there, I'm not too sure Sorry These are kind of hard, aren't they? Yeah, I know. These are I think way more than grade five probably Okay provide two words from the review that suggests the story is unrealistic a very bad storm That would never happen Happens in once in a blue moon. A really really bad storm. That's true. And then like not being able to control your boat In a really really bad storm. No, you're right. That was the last passage, by the way Okay I promise this is the last reading one and it's just words just words. Are you ready? Yeah, because you have to read them fast So I want you to read some words as fast as you can without making mistakes and read them left to right If you want you can use your finger to point if you find that helpful So here are the words. Are you ready? Go says an earthquake island truth long theory we guard suit beauty on our ocean stomach later poor glidance chaos rhythm dough We long to breathe So very late steak Sit your quick cough sneeze more Nausea Gate and stop there one more and remember to read them quick and go Cheer of you heard sign guess meant which I am Tort Debit board unique routine muscle circus tongue double counter surgeon Uh debate Uh sword And your island Dork sweat Hurt Uh And stop it's hard No, don't don't worry. These are for all grades Yes, so it starts off. You notice very very easy. Yeah, and then it got really hard. That's yes because it's for everyone So you're not expected to know those hard ones. Yeah Okay, and now let's do some vr. Let's give it a shot Yeah, you can turn it off for sure thank you for asking Um While i'm getting it set up Maybe there's a game that you'd like to play on this We'll see If there's anything in particular because it's going to take me about two minutes to set it up. yeah It's just turning on now have you used anything like this? Yeah. Oh nice. Okay Okay. Yeah, I see like the virtual office that we're in. yeah, I see. All right, i'm gonna hold it there and then i'm gonna Tight tight tight. Tell me when to stop That's good. Okay, if it's too tight you just Yeah All right Um, i'm gonna give you a control You're left-handed, right? Yeah And here's the controller for your left hand, oh, sorry here oh here give me your yeah there like that. yeah Can you control everything Yeah While you play around with that i'm going to that by you, yeah, of course you can Okay ready when you are i'm ready. Okay. Are you done with this one? What is it exactly? It's like a shoe. Oh Sorry, i'm gonna come around you you're gonna hear me walk up i'm gonna press a button You should get back in the room. I can see you. Okay, good. I can see half of you. Okay, cool. Now you're cozy Is that yeah, okay um Do you see in your vision? Yeah, do you see a app where it has like nine dots or six dots? Where would it be? I think it's like yeah, it's like a menu. Yes. That's what i'm looking for That is going to bring us to like our library of apps Let me know if you can find that like six dot or nine dot thing. Is it called like hangout? No, it's not hangout. What if you were to turn your head and see over here? Is there anything? No, no Hmm. What do you see on the bottom menu bar? um Here. Yeah, I see like find the imposter play hangout find instagram followers find facebook friends That's what i'm looking for. Okay, let me see i'm gonna take the headset off and i'm gonna see if I can find that darn Oh, sorry It's so frustrating because it's really hard to find it sometimes. Oh, yeah, I see what you mean Yeah Oh, I see it. I see it. It's not an app. Yeah here. Can I borrow that person? Yeah, it wasn't an app That's probably where you can find it. All right so Oh the three dots. yeah, I think it was Nine dots, but I mean I still oh wait, where are you? Are you back in the game? Yeah What's the head Okay, I I clicked the button under the headset so Do you three dots, right? Do you see anything where it says aula a u l a A u l a Can you tighten this a little bit? Oh, i'm so sorry. Yes. Oh, is that too tight? No, it's good. Okay If you need it tighter P u l a do you see uh, it's like it should be an app that says Right now the menu like you're in front of the menu. Yes Do you see in the menu? What do you see right now? So I see like The imposter thing right here I see like the world here And then I see like games here Okay on the games area. Is there something with a green apple? And if not, that's okay I will Games over here. Uh, I don't see anything Okay, um One more time trying to steal that Sorry, let's see if we can get this. Okay, i'm gonna quit the game Do you want this? Oh, yes, please I'm gonna quit that And then our screen will be a way less busy Yeah, okay Put this on. Okay, you're gonna be in a game soon Yeah, do you see? Anything? Yeah, i'm gonna get that school. Perfect under a desk. That's oh you're under a desk. Oh my gosh. yeah you are How do you know? You see I I just saw that it was not positioned correctly like it gave me a little warning Okay I'm gonna exit out really quick Feels like you're gonna fall if I lean forward Okay. Okay. You're back here, right? I'm gonna do it again. Let's see if it improves still I see giants around me. Yes, basically I'll lean forward i'm gonna fall Um If you were to get up out of the chair, sorry And i'm going to see if maybe walking to the couch will do anything So here i'll help you. I got your hands and then chair I'm assuming you're still free and that's what I want you to do. So create. Yes. Yes, barely Barely, okay. I'm gonna come back Stand up Right, you're back in the office, right? Yep. Does it say create new boundary? Here you know what walk get up out of the chair And then I want you to walk see if it's going to ask you to create a new boundary sit back in the chair You know, i'm still everything's over here Okay, yeah, let's try sit back Yeah Should I click quit or resume? Um, can you click resume? Okay, i'm now i'm in the school room but i'm still on there oh my god, okay, you know what i'm gonna How about you exit? We're gonna exit and then we're gonna redo it Okay Can you click quit button? Yep, I clicked it. All right, i'm gonna restart it on my computer So it should allow you now to click the green apple app What is it called like? You got it Oh, yes, okay Is it working now? Yeah. Oh, thank goodness Now you're welcome to uh the classroom All right, I do have to switch the controller so i'm going to come to you in just 10 seconds I promise you won't you have a nice comfy couch there Is it working is it popping the balloon thing Too high. Okay. Okay. Phew keep looking. Did you get all them? Yeah
Clinical Notes
Psychotherapy Session Note
Date: SESSION_DATE
Patient: PATIENT_NAME
Provider: DOCTOR_NAME
Diagnosis: [Patient's Diagnosis, if applicable]
Presenting Problem:
PATIENT_NAME presented with concerns about work-related stress, difficulty sleeping, and feeling overwhelmed.
Mental Status:
PATIENT_NAME appeared alert and oriented. Mood was reported as stressed, but affect was congruent with mood. Speech was clear and coherent. Thought process was logical and goal-directed. No evidence of psychosis or suicidal ideation.
History of Present Illness:
PATIENT_NAME reported increased stress at work due to increased responsibilities and a demanding boss. They described feeling constantly on edge, experiencing difficulty sleeping, and struggling to concentrate. They acknowledged trying relaxation techniques from previous sessions but found it difficult to incorporate them into their daily routine. They also reported difficulty falling asleep and waking up frequently during the night, leading to daytime fatigue.
Past Psychiatric History: [Patient's Past Psychiatric History, if applicable]
Medical History: [Patient's Medical History, if applicable]
Social History: [Patient's Social History, if applicable]
Family History: [Patient's Family History, if applicable]
Medications: [Patient's Current Medications, if applicable]
Treatment Plan:
- Continue working on stress management techniques, including mindfulness exercises.
- Develop strategies to incorporate relaxation techniques into daily routine.
- Explore sleep hygiene strategies, including a sleep diary to track sleep patterns and identify potential triggers.
- Discuss setting boundaries at work to manage workload and reduce feelings of overwhelm.
Goals:
- Improve stress management skills.
- Improve sleep quality.
- Set healthy boundaries at work.
Prognosis: Prognosis is good with continued therapy and adherence to treatment plan.
Next Steps:
- Schedule follow-up appointment for next week to continue working on identified goals.
Notes:
- PATIENT_NAME demonstrated willingness to engage in therapy and actively participate in the treatment plan.
- They expressed a desire to improve their well-being and reported feeling hopeful about achieving their goals.