Chapter 5

tick tick tick, a sound so small her husband doesn't hear, he's too deep into sleep, but she can't sleep, she already slept during the day tick tick tick she rolls around the bed booking for rest of her mind, this silence except for that tick tick tick her head spirals once more, she closes her eyes. 

tick tick tick* 

BIO-PSYCHOSOCIAL ASSESSMENT

Patient's full name: Dereck Ortega 

Age: 42

The following information was received from: Dereck Ortega 

-Dereck describes symptoms, of fear and hallucinations of his dead mother, he describes how he feels he's locked in a room all the time. The patient describes how he feels he's being followed all the time. 

Current symptoms: Migraine, hallucination, depersonalization, paranoia, elevated mood, anxiety, high alert

The patient seems not responsive from time to time and thinks he is on another dimension, the patient shows a history of depressive episodes but no depressive symptoms at the moment

The patient looked confused during the session and kept repeating “he didn't need to be here”. The patient yelled to be led out, but security detained him from running away. 

Dereck denies any medication