Progress Note

Session conducted by: Dr. Melina Roach

Patient Name: Lady Macbeth
Patient Number: 100625
History: I have been informed that the patient constantly sleep-walks, has a
compulsive nature to act out the motion of washing her hands, talks in her sleep, and
has anxiety attacks. In the episodes of sleepwalking the patient is reported to use words
that one would associate with violence or something that would cause one to feel guilt;
the main one being blood. The patient did not start acting this way until about 1-2 weeks
ago.

Session Notes:

I noticed the patient was nervous first stepping in to the room.

I asked her some general questions like how she was feeling and how her day
had been and she acted very normal.
The beginning of the session was going great and then and I started to ask about
the sleep walking and the use of strange words in her sleep and the patient
seemed very uncomfortable.
I went on to ask the patient about the anxiety and then I noticed her compulsive
action; she did this washing of the hands right after hesitantly answering my
previous questions.
I pointed out the action and the patient lost it. She started crying and panicking.
The patient then went on with this story about her helping her betrothed to kill
King Duncan and how she did out of greed and the guilt was eating her alive.
I didnt know what to do at this point. The patient in front of me is like a ticking
time bomb and Im afraid for her safety and the safety of those around her.

Mental Status: Lady Macbeth is consumed with guilt, and is emotionally unstable.
Demeanor was charming at first and then was scared and desperate. At the start
paranoia was evident and she seemed to be hiding something. She denied having
recurring suicidal ideas. She did admit to considering it once or twice but denies wanting
to harm herself again. I personally do not believe her and I think she should be kept
under watch. Her vitals and cognitive functions are intact but you can clearly tell she has
been under heavy stress.

Diagnoses:
Mild OCD
Clinical Depression
General Anxiety Disorder

Panic Disorder
Paranoid Personality Disorder
Chronic Guilt Disorder
Borderline Schizophrenia

Instructions/ Recommendations/ Plan: Lady Macbeth should be admitted into

an institution so she can be monitored for episodes of anxiety panic, paranoia, and
suicidal behavior. She should be given antidepressants, a mood stabilizer, and zanex
when the patient completely losses control.

Signature of Specialist:

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