Subjective

The patient, Ryan, presented with complaints of stress and anxiety related to remote learning and family dynamics. He reported difficulty sleeping, often going to bed late around midnight. He described feeling more at ease falling asleep since his phone was taken away, as it eliminated late-night distractions. He lives with his mother and three younger brothers, and currently has strained relationships with his mother. Ryan has a limited social network of two friends, which has been further impacted by his lack of access to a phone. He expressed a lack of interest in physical activity and spending time outdoors, which his mother has suggested.

Objective

Ryan's mood appeared anxious, and he had clear difficulties with stress management and sleep. He verbalized his struggles and was receptive to suggestions for improvement. He was communicative about his current home situation and its impact on his mental health.

Assessment

Ryan is suffering from stress and anxiety, likely exacerbated by the current remote learning environment and family tensions. Insomnia is present, possibly due to a variety of factors including his late-night routine and stress levels. There's a potential lack of social support due to limited friendships and current familial discord.

Plan

A two-pronged approach was discussed to address Ryan's insomnia. First, Ryan agreed to implement a regular bedtime routine, including taking a warm shower approximately an hour before his new bedtime. Second, a gradual adjustment of his bedtime was suggested, aiming to roll back his current bedtime by 30 minutes each week until a more suitable time is reached. Ryan agreed to this plan and is willing to return for a follow-up in a week or two to assess progress and make any necessary adjustments.

Subjective

Patient named Ryan presents with:

• Increased levels of stress and anxiety due to remote learning and family dynamics.
• Difficulty initiating sleep, often going to bed at midnight or later.
• Improved sleep initiation following the removal of his phone, attributing this to decreased late-night disturbances.

Family and social situation:

• Lives with his mother and three younger siblings, with tension in his relationship with his mother.
• Limited social support network (two friends), and communication has been made more difficult by the removal of his phone.
• Patient expresses disinterest in suggested activities like outdoor exercise.

Objective

Assessment

Plan

Subjective

Ryan is an adolescent who lives at home with his mother and three younger brothers. He presented with complaints of stress and anxiety, which he attributes to remote learning and difficulties at home. He reports difficulty sleeping, with a late bedtime of around 12-12:30 AM. He also mentions he falls asleep more easily now after his mother took his phone away. He has two friends but his interactions are limited due to his lack of phone. He is having difficulty with his mother and he expresses he feels forced into activities he doesn't want to participate in, such as leaving his room more frequently and exercising.

Objective

Ryan appears to be experiencing stress and anxiety, with symptoms affecting his daily life including his sleep schedule. He reports difficulty falling asleep and staying asleep, though he does note an improvement since his phone was taken away. His social support network is minimal and he expresses dissatisfaction with current familial relationships. Ryan does not seem engaged in physical activity or outdoor time, which might be affecting his overall mental health.

Assessment

Ryan is showing signs of stress and anxiety, possibly exacerbated by home circumstances, remote learning, and a lack of social interactions. He has sleep disturbances that appear to be connected to these stressors. His limited social network and strained relationship with his mother also seem to be contributing factors to his overall mental well-being.

Plan