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PRAC 6645 WEEK 4 Assignment 1 : Clinical Hour and Patient Logs

PRAC 6645 WEEK 4 Assignment 1 : Clinical Hour and Patient Logs

Walden University PRAC 6645 WEEK 4 Assignment 1 : Clinical Hour and Patient Logs-Step-By-Step Guide

 

This guide will demonstrate how to complete the Walden University PRAC 6645 WEEK 4 Assignment 1 : Clinical Hour and Patient Logs assignment based on general principles of academic writing. Here, we will show you the A, B, Cs of completing an academic paper, irrespective of the instructions. After guiding you through what to do, the guide will leave one or two sample essays at the end to highlight the various sections discussed below.

 

How to Research and Prepare for PRAC 6645 WEEK 4 Assignment 1 : Clinical Hour and Patient Logs

 

Whether one passes or fails an academic assignment such as the Walden University PRAC 6645 WEEK 4 Assignment 1 : Clinical Hour and Patient Logs depends on the preparation done beforehand. The first thing to do once you receive an assignment is to quickly skim through the requirements. Once that is done, start going through the instructions one by one to clearly understand what the instructor wants. The most important thing here is to understand the required format—whether it is APA, MLA, Chicago, etc.

 

After understanding the requirements of the paper, the next phase is to gather relevant materials. The first place to start the research process is the weekly resources. Go through the resources provided in the instructions to determine which ones fit the assignment. After reviewing the provided resources, use the university library to search for additional resources. After gathering sufficient and necessary resources, you are now ready to start drafting your paper.

 

How to Write the Introduction for PRAC 6645 WEEK 4 Assignment 1 : Clinical Hour and Patient Logs

The introduction for the Walden University PRAC 6645 WEEK 4 Assignment 1 : Clinical Hour and Patient Logs is where you tell the instructor what your paper will encompass. In three to four statements, highlight the important points that will form the basis of your paper. Here, you can include statistics to show the importance of the topic you will be discussing. At the end of the introduction, write a clear purpose statement outlining what exactly will be contained in the paper. This statement will start with “The purpose of this paper…” and then proceed to outline the various sections of the instructions.

 

How to Write the Body for PRAC 6645 WEEK 4 Assignment 1 : Clinical Hour and Patient Logs

 

After the introduction, move into the main part of the PRAC 6645 WEEK 4 Assignment 1 : Clinical Hour and Patient Logs assignment, which is the body. Given that the paper you will be writing is not experimental, the way you organize the headings and subheadings of your paper is critically important. In some cases, you might have to use more subheadings to properly organize the assignment. The organization will depend on the rubric provided. Carefully examine the rubric, as it will contain all the detailed requirements of the assignment. Sometimes, the rubric will have information that the normal instructions lack.

 

Another important factor to consider at this point is how to do citations. In-text citations are fundamental as they support the arguments and points you make in the paper. At this point, the resources gathered at the beginning will come in handy. Integrating the ideas of the authors with your own will ensure that you produce a comprehensive paper. Also, follow the given citation format. In most cases, APA 7 is the preferred format for nursing assignments.

 

How to Write the Conclusion for PRAC 6645 WEEK 4 Assignment 1 : Clinical Hour and Patient Logs

 

After completing the main sections, write the conclusion of your paper. The conclusion is a summary of the main points you made in your paper. However, you need to rewrite the points and not simply copy and paste them. By restating the points from each subheading, you will provide a nuanced overview of the assignment to the reader.

 

How to Format the References List for PRAC 6645 WEEK 4 Assignment 1 : Clinical Hour and Patient Logs

 

The very last part of your paper involves listing the sources used in your paper. These sources should be listed in alphabetical order and double-spaced. Additionally, use a hanging indent for each source that appears in this list. Lastly, only the sources cited within the body of the paper should appear here.

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Sample Answer for PRAC 6645 WEEK 4 Assignment 1 : Clinical Hour and Patient Logs

Clinical Logs

Insomnia

Name: A.L

Age: 33 years

Diagnosis: Insomnia

S: A.L is a 33-year-old client that came to the unit today for his regular follow-up. He was diagnosed with insomnia five months ago and has been on individual psychotherapy. The client recalled that his diagnosis with insomnia was made due to a number of problems that he had been experiencing. They included persistent lack of quality and quantity sleep. The client reported that he found it hard to fall asleep and maintain it. He had used sleep enhancing medications but without any success. The client also reported that he often fell asleep during the day at his workplace due to lack of sleep the previous nights. The lack of quality and quantity sleep was affecting his performance in workplace, as he always felt that he did not have enough energy to undertake his assigned duties. The client denied any history of medical conditions, drug, or s

substance abuse that could have contributed to the symptoms. As a result, he was diagnosed with insomnia and initiated on individual psychotherapy sessions.

O: The client appeared dressed appropriately for the occasion. His orientation to self, others, time, and events were normal. His judgment was intact. He did not appear tired during the assessment. He maintained normal eye contact. His speech was of normal rate and volume. He denied illusions, hallucinations, and delusions. He also denied suicidal thoughts, attempts and plans.

A: The desired outcomes of treatment have been achieved. The client reports that he no longer experiences insomnia and his functioning has improved tremendously.

P: The individual psychotherapy sessions were terminated with consent from the client. The termination was reached because the treatment goals had been achieved.

Major Depression

Name: D.K

Age: 40 years

Diagnosis: Major Depression

S: D.K is a 40-year-old client that came to the unit as a referral by his physician. He was referred for further psychiatric review for what the physician felt that the health problem was not medical. The client reported that he felt hopeless in life and wanted to take his life. His hopelessness was due to his perception that he had failed his family in providing the best they needed. The client was further probed, which revealed that the feelings of hopelessness persisted in most days throughout the day. He also experienced depressed mood in most days. He also reported that he has trouble in falling asleep. His appetite had declined significantly leading to his lack of energy in most of the days. He also reported having suicidal thoughts without plans. He noted that his ability to make decisions and concentrate had worsened significantly over the past month. The symptoms were not attributable to any medical condition, medication or substance abuse. As a result, he was diagnosed with major depression and initiated on treatment.

O:The patient appeared poorly groomed for the occasion. His speech was reduced in terms of rate with normal volume. His self-reported mood was depressed. The client denied illusions, delusions, and hallucinations. He maintained normal eye contact during the assessment. His thought content was future oriented. He reported suicidal thoughts without a plan or attempt.

A: The client is experiencing symptoms of major depression.

P: The client was initiated on antidepressants and group psychotherapy to help improve mood and coping skills of the client with depressive symptoms. He was scheduled for a follow-up visit after four weeks.

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Alcohol Use Disorder

Name: K.P

Age: 38 years

Diagnosis: Alcohol use disorder

S: K.P is a 38-year-old male who came to the clinic today for his regular follow-up visit. K.P was diagnosed with alcohol use disorder five months ago and has been on pharmacological and psychotherapy treatments. The client recalled that he was diagnosed with the disorder after he presented with several complaints that related to alcohol abuse. The client had complained of three years binge consumption of alcohol. The binge consumption of alcohol was beyond his control. This was despite his efforts such as abstaining from it, which were fruitless. He was worried that the binge consumption of alcohol was becoming difficult for him to control. K.P reported that the withdrawal symptoms made it difficult for him to abstain from alcohol. He also reported that alcohol abuse had affected his social and occupational functioning adversely. The socioeconomic wellbeing of his family has also been affected adversely. As a result, he was willing to participate in any treatment that could have helped him to overcome his addition problem. Therefore, he was diagnosed with alcohol use disorder and initiated on treatment.

O: The patient was dressed appropriately for the occasion. His orientation to self, others and events were intact. He did not demonstrate any abnormal behaviors such as tics. His thought content was intact. He denied any recent history of illusions, delusions, and hallucinations. He also denied suicidal thoughts, attempts, plans, and intent. His speech was normal in terms of tone, rate, content and volume.

A: There is continuous improvement in the symptoms of alcohol use disorder.

P: The client was advised to continue with the treatment. He was scheduled for a follow-up visit after four weeks.

 

 

Insomnia

Name: J.T

Age: 25 years

Diagnosis: Insomnia

S: J.T is a 25-year-old female who came to the unit with complaints of severe lack of quality sleep. She reported that she has been experiencing the symptoms for the last six months. She has been finding it extremely difficult for her to fall and maintain sleep. J.T also reported that the difficult in sleeping was accompanied by other symptoms such as awakenings at night and finding it hard to fall asleep again. The disturbances in sleep were reported to have significant distress as well as impairment in social, educational, occupational and behavioral areas of functioning of the client. The lack of quality sleep was not attributed to any causes such as substance abuse, medication use or medical condition. As a result, she was diagnosed with insomnia and initiated on psychotherapy.

O: The client appeared appropriately dressed for the clinical visit. She was oriented to self, place, time and events. She appeared tired during the assessment. She attributed it to lack of sleep the previous night. Her judgment was intact with the absence illusions, delusions, and hallucinations. She denied history of suicidal thoughts, attempts and plans.

A: The client is experiencing the symptoms of insomnia as stated in DSMV. The insomnia is affecting negatively her quality of life.

P: The client was initiated on group psychotherapy sessions. She was also educated on use of effective interventions to enhance sleep such as avoiding caffeine close to bedtime and eliminating any distractors. She was scheduled for a follow-up visit after four weeks.

 

 

Major Depression

Name: X.Y

Age: 44 years

Diagnosis: Major Depression

S: X.Y is a 44-year-old female who came to the unit for his regular follow-up visits. The client was diagnosed with major depression eight months ago and has been on antidepressants and group psychotherapy sessions. The client recalled that he had come to the unit with complaints of persistent feeling of having depressed mood in most of the days. He also reported that his interest in pleasurable things had declined significantly. He was also socially withdrawn, as he liked spending his time indoors. X.Y also reported an increase in his appetite. In some cases, she experienced feelings of being worthless and failure in life. He however denied any history of suicidal thoughts, attempts, and plans. Based on the above symptoms, the client was diagnosed with major depression and initiated on treatment.

O: X.Y appeared dressed appropriately for the occasion. His self-reported mood was ‘I no longer experience incidences of depressed mood for the last three months.’ His judgment was intact. He had normal speech in terms of rate and volume. The client denied illusions, delusions and hallucinations. He also denied any history of suicidal thoughts, attempts or plans.

A: There has been optimal improvement in the symptoms of major depression.

P: The use of group psychotherapy sessions was terminated with consent from the client. He was advised to continue with the antidepressants. He was scheduled for a follow-up visit after two months to determine his response to the use of antidepressants alone.

 

 

Schizophrenia

Name: J.L

Age: 30 years

Diagnosis: Schizophrenia

S: J.L is a 30-year-old female that has been undergoing treatment in the unit due to schizophrenia. She was diagnosed with the disorder five months ago and has been on pharmacological and psychotherapy treatments. Today she came to the unit for her regular follow-up visits. J.L recalled that she was diagnosed with schizophrenia after she started experiencing symptoms that included seeing imaginary things, hearing voices, and having a disorganized speech. The client also reported that the symptoms had affected severely her level of functioning in areas that included interpersonal relations, work, and self-care. The symptoms had persisted for more than five months. The spouse of the client could not attribute the symptoms to causes such as medication use, substance abuse, and medical conditions. As a result, she was diagnosed with schizophrenia and initiated on treatment.

O: The client appeared well groomed for the occasion. She was oriented to space, time, events, and self. She denied any recent experience of illusions, delusions, and hallucinations. She also denied any abnormality in speech content, volume and rate. She denied suicidal thoughts, attempts, and plans. Her thought content was future oriented. She did not demonstrate any abnormal behaviors such as avoidance of eye contact and tics.

A: The assessment findings show that the improvement in the symptoms the client is experience has stabilized. The client also tolerates the pharmacological and psychotherapeutic interventions used in the management of her health problem.

P: The psychotherapy session were discontinued with the consent of the client. The discontinuation was because the treatment goals had been achieved. She was advised to continue with the pharmacological treatments. She was scheduled for the next follow-up visit after four weeks.

 

 

Post-Traumatic Stress Disorder

Name: N.N

Age: 57 years

Diagnosis: Post-traumatic stress disorder

S: N.N is a 57-year-old female client who came to the with complaints of abnormal health and wellbeing since the death of her spouse. The client reported that she always experiences flashbacks of the events that led to the death of her husband. She also experienced nightmares and avoidance of any stimuli or events that led to his death. The symptoms often led to her emotional distress, which impaired her normal functioning as a teacher. The family members of the client also reported that N.N was demonstrating abnormal behaviors. They included the presence of exaggerated negative thoughts about the world, negative affect, decline in interest in activities, and self-isolation. The family members had noted that the client was becoming easily irritated, experiencing difficulties in sleeping and concentration. Based on the above symptoms raised by the client and her family members, N.N was diagnosed with post-traumatic stress disorder and initiated on treatment.

O: The client was well groomed for the occasion. Her orientation to self, others, environment, and events were intact. Her self-expressed mood was depressed. Her level of judgment was intact. She denied suicidal thoughts, plans or attempts, illusions, delusions, and hallucinations.

A: The client is experiencing moderate symptoms of post-traumatic stress disorder. She needs treatment that aims at normalizing her moods and coping with the depressive symptoms.

P: The client was initiated on antidepressants and group psychotherapy. Antidepressants were prescribed to help the client improve her mood. Group psychotherapy aimed at helping the client cope with the distressing symptoms of post-traumatic stress disorder. She was scheduled for the next follow-up visit after four weeks.

 

 

Generalized Anxiety Disorder

Name: A.X

Age: 22 years

Diagnosis: Generalized Anxiety Disorder

S: A.X is a 22-year-old female who came to the department with complaints of excessive fear and worry of the unknown. According to her, she had been experiencing intensive anxiety and fear of things over the past few months. She feared that she might die of unknown cause and that her life was in danger. The excessive fear had made it difficult for her to concentrate in her academics. The additional complaints that she raised were that she getting fatigued easily and lacked control over her excessive worry and fears. The excessive fear and anxiety could not be attributed to any cause such as medical condition, medication, or substance use and abuse. The client also reported that she occasionally experienced chest pains and palpitations during her episodes of anxiety attacks.

O: The patient appeared well kempt. She was oriented to place, time, and self. The speech rate and volume were normal. The mood of the patient was normal with some anxiety. The client denied any history of hallucinations, delusions, and illusions. The memory of the client was intact.

A: The client appears to have moderate anxiety.

P: The client was started on group psychotherapy sessions with the aim of equipping her with effective skills that she could use to manage her excessive worry and anxiety. She was scheduled for the next follow-up visit after one month.

 

 

Bipolar Disorder

Name: T.E

Age: 28 years

Diagnosis: Bipolar disorder

S: T.E is a 28-year-old client that came to the unit for his fifth follow-up visit. He has been on antidepressant and psychotherapy treatments for bipolar disorder. He was diagnosed with bipolar disorder after he presented to the unit with complaints that included periods of elevated mood. The mood elevation was characterized by behaviors that that included over activity, engaging in goal-directed initiatives, excitement, euphoria and delusions. There was also the alternation of the above symptoms with periods where the client would feel to be significantly depressed. The depressive symptoms included lack of energy, too much sleeping, difficulties in concentrating and making decisions. The depressed mood could happen almost every day for a specific period such as two weeks, followed by elated mood. Further examination of the client had revealed that the symptoms were not severe to cause any impairment in the normal functioning of the client. The symptoms were also not associated with drug use, medical problem or substance and alcohol abuse. As a result, he was diagnosed with bipolar disorder and initiated on treatment.

O: The client appeared appropriately dressed for the occasion. He was oriented to self, place, time and events. His judgment was intact. He denied any recent experience of delusions, hallucinations, illusions, suicidal thoughts, plans, and attempts.

A: The adopted treatments have been effective in improving the manic and depressive symptoms of bipolar disorder. There is gradual improvement in symptoms, which demonstrate treatment effectiveness.

P:  The client was advised to continue with the current treatments. The decision was made because of the improvement in symptoms and tolerability of the treatments. He was scheduled for a follow-up visit after one month.

 

 

Binge Eating Disorder

Name: M.O

Age: 32 years

Diagnosis: Binge eating disorder

S: M.O is a 32-year-old female who came to the unit for her fifth follow-up visit. The visit was due to her diagnosis with binge eating disorder. She has been undergoing psychotherapy treatment in the unit. The client recalled  she was diagnosed with the disorder after she presented with symptoms included recurrent episodes of binge eating. The symptoms associated with binge eating included eating within a discrete period of time food that was perceived more than what most people would eat during that time. She also reported the lack of control over her eating habits. The binge eating was associated with eating more than normal, eating alone or avoiding others during meals, and being distressed by her eating behaviors. There was also the absence of use of compensatory behaviors such as fasting and purging. The above symptoms led to the diagnosis of binge eating disorder. The client has been undergoing psychotherapy sessions in the unit.

O: The client appeared dressed appropriately for the occasion. She was oriented to self, time, others and events. Her judgment was intact. Her self-reported mood was normal. She denied any instances of altered judgment. Her speech was of normal rate and volume. She denied suicidal thoughts, plans, and attempts, illusions, delusions and hallucinations.

A: The client has demonstrated progressive improvement in the symptoms of binge eating disorder. She is confident that she can use the knowledge and skills gained from the psychotherapy sessions to manage her problem.

Sample Answer for PRAC 6645 WEEK 4 Assignment 1 : Clinical Hour and Patient Logs

 

PRAC 6645 WEEK 2:  Clinical Hour and Patient Logs

 

Student’s Name

 

Department Affiliation, University Affiliation

 

Course Number: Course Name

 

Instructor’s Name

Date

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Alcohol Use Disorder

Name: B.D

Age: 36 years

Gender: Male

Diagnosis: Alcohol Use Disorder

S: B.D. is a 36-year-old male patient who came to the facility to seek help. He reports a history of chronic alcohol consumption. The patient reports negative impacts such as deteriorating health, work difficulties, and relationship issues. He has continually become alcohol dependence and quit drinking.

O: The patient is unkempt and disheveled with signs of poor self-care. He is alert and oriented. His speech is slurred, and he exhibits impaired coordination. His memory is intact with a coherent though process. However, thought content is preoccupied with drinking thoughts. He denies suicidal thoughts or ideations.

A: According to the DSM-V criteria, the patient’s symptoms indicate alcohol use disorder.

P: The patient needs to start CBT individual therapy sessions to help address the underlying issues leading to the problem.

Binge Eating Disorder

Name: L.S

Age: 16 years

Gender: Female

Diagnosis: Binge Eating Disorder

S: L.S. is a 16-year-old female patient who visited the facility, indicating that she has been advised by friends to seek help. She reports engaging in in periods of binge eating where he eats large quantities of food and even has an urge to eat more even if she is full. She experiences guilt and shame, which makes her uncomfortable.

O: The patient is well-dressed and appropriately groomed. She is also alert and oriented. She appears overweight. The patient’s mood is depressed and anxious. She has a normal speech. Her thought process is coherent but focused on concerns regarding her body size and shape. She has an intact memory. She denies any thoughts of self-harm.

A: The patient’s symptoms are indicative of binge eating disorder

P: The patient should start weekly CBT sessions to help with maladaptive thoughts.

Intermittent explosive disorder (IED)

Name: M.M

Age: 37 years old

Gender: Female

Diagnosis: Intermittent explosive disorder (IED)

S: M.M is a 37-year-old female patient who came to the facility with history frequent loss of temper. She claims to be moody most of the time, especially the time of the year every year. She exhibits other symptoms such as weight gain and trouble with sleep. In addition, she complains of boredom and low concentration levels. She also finds it hard to keep friends.

O: she is well-dressed and groomed. She is also oriented and alert. The patient is irritable and angry. She has an intact memory. She has a pressured speech.  She has a coherent thought process. She is delusional and exhibits a threat of harm to herself and others.

A: Regarding the DSM-V criteria, the patient has intermittent explosive disorder.

P: The patient should start individual CBT sessions to help with the symptoms.

Major Depressive Disorder

Name: R.N

Age: 16 years old

Gender: Female

Diagnosis: MDD

S: R.N. is a 16-year-old female patient who came to the facility for an evaluation. She indicates that she had been diagnosed with depression and she used antidepressants to manage them. However, she stopped using the medication for fear of being judged. She exhibits other symptoms such as sleeping difficulties, reduced appetite, crying spells, reduced concentration levels, and reduced interest in activities.

O: The patient is well-dressed and groomed. She is alert and oriented. She speaks fluently, in a normal tone and volume. Her insight is congruent. Her thought process is age-appropriate, with unremarkable judgment.  Her memory is intact. She, however, displays a sad mood and seems to be distracted most of the time. She reports a feeling of worthlessness but denies suicidal ideation.

A: Based on the DSM-V criteria the patient has MDD

P: The patient should start group therapy sessions to help with the symptoms.

 

Obsessive Compulsive Disorder

Name: M.T

Age: 37-years

Gender: Male

Diagnosis: Obsessive compulsive disorder

M.T is a 37-year-old male patient who came to the facility for a psychiatric visit. He indicates that he has been having distressing and intrusive thoughts related to contamination. He dreads germs and contamination making him frequently wash his hands. He reports that such action reduces his anxiety and fear of germs. Such symptoms and behavior have negatively impacted his daily life.

O: The patient is well-dressed and appropriately groomed. He is alert and oriented. He looks restless. He has a normal speech. He also has a coherent thought process and memory. However, his thoughts are preoccupied with contamination and germs. He is easily distracted. He denies delusions or hallucinations.

A: Based on the DSM-V criteria, the patient’s symptoms show obsessive compulsive disorder.

P: The patient needs to start weekly CBT sessions for better coping skills.

 

Enuresis Disorder

Name: S.N

Age: 9 years old

Gender: Male

Diagnosis: Enuresis Disorder

S: S.N. is a 9-year-old boy who was brought in by her mother to seek help. She indicates that her son has development a habit of bedwetting. She indicates that when the patient went camping, they shared a bed with a friend who noticed that the patient wet the bed at night. Ever since they have been making him and calling him names, he has lost interest in routine activities and doesn’t even want to go to school.

O: The patient is generally healthy, with no signs of any delays in the developmental stages. He is also alert and oriented. He looks anxious and sad. He has a coherent thought process and intact memory. He denies suicidal action

A: The patient wets the bed at night; hence, he has enuresis disorder.

P: The patient should start family therapy sessions to help with the maladaptive thought patterns.

Acute Stress Disorder

Name: D.D

Age: 31-years

Gender: female

Diagnosis: Acute Stress Disorder

D.D is a 31-year old female patient who came to the clinic for a visit. He reports experiencing work pressure and a recent incident of witnessing an accident scene. She reports intense fear, nightmares, flashbacks, and intrusive memories related to the accident. She also reports feeling on the edge for some time now.

O: The patient is well-dressed and groomed. She is also alert and oriented. She finds it difficult to concentrate and she is easily distracted. She exhibits and anxious mood. Her thought process is preoccupied with memories and thoughts of the accident. She denies suicidal thoughts or ideations.

A: The patient’s symptoms are indicative of acute stress disorder.

P: The patient should start trauma-focused CBT to help address the symptoms.

Bipolar Disorder

Name: W.C

Age: 15 years old

Gender: Female

Diagnosis: Bipolar Disorder

S: W.C. is a 15-year-old female patient who came to the facility accompanied by her father. The father indicates that their daughter has been having mood fluctuations. However she has been missing her doses due to forgetfulness. She also reports that in most cases, she doesn’t feel like taking the medication since they do little to make her better.  Her mood fluctuations have intensified in the past week

O: The patient walked in well-groomed in age-appropriate clothes. The patient maintained eye contact during the interview with appropriate facial expressions. Her thought process is coherent and logical. She denies delusion, hallucinations, and suicidal ideation. She confirms being forgetful, but her long-term memory is intact.

A: The patient’s symptoms are indicative of bipolar disorder

P: The patient should start group therapy sessions to help with the symptoms.

General Anxiety Disorder (GAD)

Name: O.M

Age: 52 years old

Gender: Female

Diagnosis: General Anxiety Disorder (GAD)

S: O.M. is a 52-year-old female patient who visited the clinic for a psychiatric assessment. She presents with signs of anxiety, accompanied by headache, decreased appetite, and diarrhea 2 to 3 times every week. She reports anxiety about her retirement, which she feels she is not prepared for, and about her husband, who wants a divorce.

O: She is well-dressed and appropriately groomed. She is alert and well-oriented in person, place, and time. She actively participate in the interview. She looks anxious and sad. She displays a constricted effect with good insight and judgment. Her memory is intact, with an unremarkable thought process. Mild impairment was observed in her functional status.

A: Based on the DSM-V diagnostic criteria, the patient has generalized anxiety disorder

P: The patient should start weekly individual CBT sessions to help deal with the symptoms.

Intellectual Development Disorder

Name: C.V

Age: 10-years

Gender: female

Diagnosis: Intellectual development disorder

S: C.V. is a 10-year-old female patient who was brought to the facility by her parents. They indicate that their daughter has exhibited developmental delays and adaptive functioning challenges. She has exhibited various delays in motor skills and language. She also finds it hard to carry out self-care activities.

O: The patient is well-dressed and groomed. She is also alert and oriented. She has a positive and stable mood. She has a concrete speech lacking complexity. She also exhibits limited insight. She exhibits limited ability to express thoughts and ideas verbally. She denies delusions or hallucinations

A: The patient’s symptoms are indicative of intellectual development disorder.

P: The patient needs to start family therapy sessions to help address behavioral challenges.

Delusional disorder

Name: F.A

Age: 36 years

Gender: Female

Diagnosis: Delusional disorder

F.A. is a 36-year-old female patient who came to the facility accompanied by her younger brother. He indicates that the patient has been showing disturbing symptoms. She has been reporting seeing non-existent people, places, and events. She recently claimed that some people have been spying on them and want to harm them. Her brother denies seeing such people.

O: She is well dressed. She is also alert and oriented. She looks anxious and demonstrates signs of hypervigilance. She is anxious and fearful. Her memory is intact. She also has a clear speech. Her thought content is preoccupied with delusional beliefs people who want to harm her. She denies suicidal thoughts.

A: According to DSM-V criteria, the patient has delusional disorder.

P: The patient should commence weekly CBT sessions to help with the symptoms.

 

Separation Anxiety Disorder (SAD)

Name: T.B

Age: 9 years old

Gender: Male

Diagnosis: separation anxiety disorder

S: T.B. is 9-year-old boy who was brought to the facility by his parents for a checkup. They report that he has expressed worry and anxiety all the time about silly things, such as what will happen if the parents fail to pick him up from school. He tends to be stubborn most of the time, throwing objects around the house and easily getting irritated. He finds it difficult to sleep at night due to frequent nightmares. When at school, he consistently asks for permission to go home, complaining of stomach aches or headaches.

O: He is well-groomed and oriented. He is also oriented in person, place, and time. He looks sad and displays clingy behavior. He has a clear speech. Well-organized thought process. He exhibits intact memory with an appropriate thought process. Denies potential harm to self or others.

A: Based on the DSM-V criteria, the patient has a separation anxiety disorder

P:  The patient should commence weekly sessions of family therapy to help deal with the symptoms.