PRAC 6645 WEEK 6 Assignment 1 : Clinical Hour and Patient Logs
Walden University PRAC 6645 WEEK 6 Assignment 1 : Clinical Hour and Patient Logs-Step-By-Step Guide
This guide will demonstrate how to complete the Walden University PRAC 6645 WEEK 6 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 6 Assignment 1 : Clinical Hour and Patient Logs
Whether one passes or fails an academic assignment such as the Walden University PRAC 6645 WEEK 6 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 6 Assignment 1 : Clinical Hour and Patient Logs
The introduction for the Walden University PRAC 6645 WEEK 6 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 6 Assignment 1 : Clinical Hour and Patient Logs
After the introduction, move into the main part of the PRAC 6645 WEEK 6 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 6 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 6 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 6 Assignment 1 : Clinical Hour and Patient Logs
Clinical Logs
Major Depression
Name: Y.Y
Age: 28 years
Diagnosis: Major depression
S: Y.Y is a client who came to the psychiatric department today for her follow-up visit after being diagnosed with major depression eight months ago. The patient has been on antidepressants and group psychotherapy. She was diagnosed with major depression due to the symptoms that included persistent feelings of guilt and worthlessness. The client reported feeling sad in most days almost throughout the day. She felt that her mood was depressed in most of the times almost every day. She also complained of lack of energy to engage in her activities of the daily living and professional work. There was also the complaint of decline in her appetite. She also noted that her energy levels were cons
istently low, as she felt fatigued in engaging in an activity. She had however denied suicidal thoughts, plans, or attempts. Y.Y was diagnosed with major depression and has been undergoing treatment in the unit.
O: The client was dressed appropriately for the occasion. Her orientation to self, others, time and events were intact. Her self-reported was normal. Her speech was normal in terms of rate and volume. She denied illusions, delusions, and hallucinations. She also denied suicidal thoughts, attempts, and plans.
A: The client is responding well to the treatment. The client is tolerating treatment. The symptoms of major depression have improved as expected in the treatment plan.
P: Psychotherapy sessions were terminated with consent from the client. The client was advised to continue using antidepressants. She was scheduled for a follow-up visit after four weeks.
Major Depression
Name:
Age: 43 years
Diagnosis: Major depression
S: A.A is a 43-year-old client that came to the unit as a self-referral, as perceived abnormal mental health and wellbeing. The client reported that he felt hopeless in life and wanted to take his life. The feelings of hopelessness
persisted in most days throughout the day. He also experienced depressed mood in most days. He 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 had slowed speech. His self-reported mood was depressed. The client denied illusions, delusions, and hallucinations. 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.
Major Depression
Name: Z.Y
Age: 33 years
Diagnosis: Major depression
S: Z.Y is a 33-year-old female that came today to the unit for her regular checkup after being diagnosed with major depression three months ago and has been on antidepressants and psychotherapy treatments. One of the symptoms that led to her diagnosis with major depression was the persistent feeling of worthlessness, which made her contemplate committing suicide. The client also reported that she preferred spending her time indoors and alone. The client also reported a decrease in her appetite, which led to weight loss and lack of energy in most of the days. There was also the complaint of lack of concentration and difficulty in making decisions. The client also complained that she experienced insomnia for the last one week prior to the hospital visit. The above symptoms were noted to have affected adversely the ability of the client to perform optimally in her social and occupational roles. As a result, she was diagnosed with major depression and initiated on treatment.
O: The client was appropriately dressed for the occasion. Her self-reported mood was ‘better.’ The orientation to self, place, time, and events were intact. She denied any illusions, delusions, ad hallucinations. The client also denied any recent experience of suicidal thoughts, plans, and attempts.
A: The treatment appears to be effective in managing depressive symptoms. The client also reports positive experience with psychotherapy sessions.
P: The client was advised to continue with the current treatments and schedule for a follow-up visit after one month.
Insomnia
Name: C.H
Age: 40 years
Diagnosis: Insomnia
S: C.H is a 40-year-old male who has been undergoing treatment in the facility due to insomnia. C.H was diagnosed with insomnia seven months ago after he presented to the clinic with a number of complaints. They included the lack of quality and quantity sleep for the last four months prior to the hospital visit. He also complained that he found it difficult to maintain sleep once he fell asleep. There were also the complaints that the sleep disturbance had affected significantly his ability to concentrate in his occupational activities. He was worried that his productivity and performance would have worsened if the condition was not managed. Further assessment of the client had revealed that the symptoms were not attributed to any factors such as medication use, medical condition or substance abuse. He was therefore diagnosed with insomnia and initiated on treatment.
O: The patient appeared well groomed for the occasion. His orientation to self, others, time and events were intact. His judgment was also intact, as he denied illusions, delusions and hallucinations. The client also denied suicidal thoughts, attempts and plans. The speech was of normal rate and volume.
A: The client reported consistent improvement in the quality and quantity of sleep for the last three months. The treatment has been effective in improving his symptoms of insomnia.
P: The treatment was terminated with consent from the client. The treatment outcomes had been achieved. The client was scheduled for a follow up visit after two months.
Insomnia
Name: K.R
Age: 32 years
Diagnosis: Insomnia
S: K.R is a 32-year-old client that came to the unit today for his first clinical visit. The client came with complaints of lack of quality sleep. He reported the persistent lack of quality and quantity sleep. The client reported that he found it hard to fall asleep and maintain it despite using sleep enhancing medications. 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 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 appeared 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 client is experiencing the symptoms of insomnia. The symptoms are affecting his ability to engage in the activities of the daily living.
P: The client was initiated on individual psychotherapy. He was educated about the importance of minimizing caffeine intake towards bedtime. He was also educated about the importance of avoiding distractors during bedtime. He was educated about the need for routines such as physical activity in the evening to boost the quality of sleep. He was scheduled for a follow-up visit after one month.
Post-Traumatic Stress Disorder
Name: K.T
Age: 25 years
Diagnosis: Post-traumatic stress disorder
S: K.T is a 25-year-old male client who came to the unit today for his regular follow-up visits for post-traumatic stress disorder. He was diagnosed three months ago with the disorder and has been undergoing treatment. The client reported that his problems started after he was involved in a road accident. He experienced symptoms that included flashbacks and nightmares about the accident. He also reported avoidance of any stimuli that related to the accident. K.T further reported persistent experience of emotional distress following the accident. The family members of the client had also noted that he was becoming easily irritated, experiencing difficulties in sleeping and concentration. Therefore, they brought him to the unit where he was diagnosed with post-traumatic stress disorder and initiated on treatment.
O: The client was well groomed for the occasion. His orientation to self, others, environment, and events were intact. He reported improved mood since the last visit. His level of judgment was intact. He denied suicidal thoughts, plans or attempts, illusions, delusions, and hallucinations.
A: The client is responding positively to the treatment. He is also tolerating the medications, as evidenced by the minimal side effects of the antidepressants.
P: The client was advised to continue with the treatments and scheduled for a follow-up visit after one month
Post-Traumatic Stress Disorder
Name: A.N
Age: 38 years
Diagnosis: Post-traumatic stress disorder
S: .A.N is a 38-year-old client that came to the unit for her regular follow-up visits after she was diagnosed with post-traumatic stress disorder seven months ago. She has been using antidepressants to manage her mood and psychotherapy to cope with the depressive symptoms. A.N was diagnosed with post-traumatic stress disorder after she was sexually abused two years ago. The client reported a number of symptoms that led to her being diagnosed with post-traumatic stress disorder. They included the persistent recurrence of the distressing memories about the traumatic event. She also reported experiencing distressing dreams that related to the ordeal. There was also the report of flashbacks and intense distress following the exposure of the patient to the stimuli that related to the event. The client also demonstrated avoidance behaviors of the stimuli that related to the traumatic event. The symptoms had a negative effect on the ability of the client engage in her occupational and family roles. As a result, she was diagnosed with post-traumatic stress disorder and has been on treatment in the unit.
O: The client was dressed appropriately for the occasion. She was oriented to self, others, time and events. Her judgment was intact. She denied illusions, delusions, and hallucinations. She also denied suicidal thoughts, attempts, and plans.
A: The client continues to tolerate the prescribed treatment. She has developed the desired coping skill with depressive symptoms.
P: The client’s participation in psychotherapy sessions was terminated because the treatment objectives had been achieved. She was advised to continue with the antidepressants. She was scheduled for a follow-up visit after two months.
Generalized Anxiety Disorder
Name: B.K
Age: 24 years
Diagnosis: Generalized anxiety disorder
S: .B.K is a 24-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 three months. She feared that she might contract an infection as well as failing in her college examinations. 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. As a result, she was diagnosed with generalized anxiety disorder and initiated on treatment.
O: The client appeared appropriately dressed for the occasion. She was oriented to place, time, and self. The speech rate and volume were normal. The self-reported mood of the client was ‘I am so anxious, and fear something bad might happen to me.’ The client denied any history of hallucinations, delusions, and illusions. The memory of the client was intact.
A: The client is experiencing severe symptoms of generalized anxiety disorder. The symptoms have affected her social and academic functioning.
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: P.A
Age: 34 years
Diagnosis: Bipolar Disorder
S: P.A is a 34-year-old female who has been undergoing treatment in the facility due to bipolar disorder. She was diagnosed with bipolar disorder six months ago and has been on psychotherapy and antidepressants treatments. P.A reported that she was diagnosed with bipolar disorder after she experienced a number of health problems. They included an expansive mood that was characterized by the patient feeling that he was in control of everything. P.A also reported that he was easy irritable and agitated. She also found it difficult to concentrate in tasks. The patient reported additional symptoms included lack of sleep, increased talkativeness, and being easily distracted. The patient also engaged significantly in goal directed activities and impulsive behaviors. The client was worried that the episodes of the above symptoms had a negative effect on his social and occupational functioning. As a result, she was diagnosed with bipolar disorder and has been on treatment with the aim of stabilizing his mood.
O: P.A was dressed appropriately for the occasion. She was oriented to self, time, space and others. Her judgment was intact. The speech was of normal rate and volume. She denied illusions, delusions, and hallucinations. She also denied suicidal thoughts, attempts and plans.
A: The desired treatment objectives have been achieved. The response of the client to the treatment has been positive.
P: Psychotherapy sessions were terminated, as the treatment objectives had been achieved. The client was advised to continue with pharmacological treatment. She was scheduled for follow-up visit after four weeks.
Alcohol Use Disorder
Name: M.A
Age: 32 years
Diagnosis: Alcohol use disorder
S: M.A is a 32-year-old male who came to the clinic today for his regular follow-up visit. He was diagnosed with alcohol use disorder three months ago and has been undergoing treatment. The diagnosis was reached after he presented with a number of complaints. One of them was binge consumption of alcohol that was beyond his control. The binge consumption of alcohol was despite his efforts such as abstaining from it, which were unsuccessful. The client also reported that alcohol abuse had affected his social and occupational functioning adversely. It has also affected the stability of his family, as it was at a verge of collapsing. The socioeconomic wellbeing of his family has also been affected adversely. 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 tremors. 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: The client is responding positively to the treatment.
P: The client was advised to continue with the treatment and scheduled for a follow-up visit after four weeks.
Sample Answer 2 for PRAC 6645 WEEK 6 Assignment 1 : Clinical Hour and Patient Logs
Name: D.S
Age: 9 years old
Gender: male
Diagnosis: Enuresis Disorder
D.S is a nine-year-old white male patient who visited the facility accompanied by his mother. The mother reports that her son has been wetting his bed at night, which is a source of worry since he feels embarrassed every time he does it. She indicated that the patient only wets his bed at night but is able to keep it dry during the day. The patient has been forced to use pull-ups at night to protect the bedding from urine, but he indicates that he doesn’t enjoy using them. The boy has since become more withdrawn and turns down any chance of sleepovers at friends’ houses for fear of embarrassment. He continually prefers staying and playing alone. He is also lonely and sad.
O: The patient is well dressed by the mother and groomed. The patient is alert and oriented. His mood can be described as sad and worried. The patient’s speech is coherent with appropriate volume and tone. The boy denies any suicidal thoughts or ideation. His memory is intact. He denies hallucinations or delusions. He confirmed that he would like the problem sorted.
A: The patient has consistently been wetting the bed at night; however, he is managing to stay dry during the day. Therefore, the boy has been diagnosed with Enuresis disorder.
P: The patient needs psychotherapy sessions. Therefore, weekly DBT sessions should be used to help the patient have adjustments to the behavior patterns to help him stop bedwetting at night.
Intermittent Explosive Disorder
Name: S.A
Age: 35 years old
Gender: male
Diagnosis: Intermittent explosive Disorder
S.A is a thirty-five-year-old male patient who visited the facility seeking help with his temper. He has been consistently having temper outbursts and finds it hard to control his temper. He indicated that he had observed a pattern with his temper problem since they came seasonally. He has observed for the last few years, and he suspects that there could be an underlying problem that needs to be solved. The period is accompanied by other undesirable symptoms such as the inability to keep friends, getting bored easily, and finding it hard to concentrate. His concentration becomes so low that he even misses meeting some deadlines which have been set. He also experiences problems with sleep and finds it difficult to sleep. Another aspect that makes him worried is that he also gains weight, and he fears that he may become unhealthy.
O: The patient was appropriately dressed and well-groomed. He was able to maintain eye contact. The patient’s speech is fluent but appears rushed and pressured. The patient’s mood is sad. He is also irritable; the patient denies suicidal thoughts, ideation, or action; he also denies the intention of harming others or self-harm. The patient is, however, delusional. He has problems with concentrating and rarely concentrates during the assessment
A: The patient has been unable to control his aggression and anger, which has been exhibited in constant anger outbursts. The patient also looks depressed and frustrated. Therefore, based on the DSM-V diagnostic criteria, the patient has been experiencing the intermittent explosive disorder
P: The patient needs to start psychotherapy sessions. Cognitive behavioral therapy can be vital in helping the patient deal with the symptoms.
Postpartum Depression
Initials: G.T
Age: 23 years
Gender: Female
Diagnosis: Postpartum Depression
G.T is a twenty-three-year-old female patient who visited the facility accompanied by her partner of five years. The patient was brought in by the partner after the partner traveled from another city where he works and found the patient depressed and unhappy a few weeks after giving birth to their first-born baby. The patient indicates that the baby developed a tendency to cry a lot just two days after being born. The baby cries a lot, especially at night which makes her struggle with sleep. She is, therefore, tired and fatigued during the day. The patient also reports that the baby is so demanding, making her unable to rest, which has made her sad. She has also lost interest in activities such as reading novels which she has loved for years. The partner has been away since the birth of their child; hence the patient has no one to help her. Therefore, they decided to visit the facility for potential help.
O: The patient is appropriately dressed and groomed. She is alert and oriented. She, however,r, looks tired and exhausted. The patient manages to satisfactorily maintain eye contact. Her speech is clear and fluent. She also has a coherent thought process with intact short-term and long-term memory. She denies delusions, hallucinations, obsessions, or suicidal thoughts. The patient has no intention of self-harm or thoughts of harming her baby.
A: The patient finds it difficult to cope with the stress of having a first baby and transitioning to motherhood. She, therefore, experiences insomnia and postpartum depression.
P: The patient needs support, and therefore, psychotherapy sessions can be used to help her.
Post-Traumatic Stress Disorder
Initials: V.S
Age: 35 years
Gender: Male
Diagnosis: Post-traumatic stress disorder
V.S is a thirty-five-year-old white male patient who came to the facility accompanied by his brother. The brother reports that the patient has never been the same since the time he was caught up in a hurricane but survived the disaster. He explained that the patient sometimes takes off, claiming that he can hear the sounds of the hurricane coming and that it would harm him. The brother confirms that he has never heard such sounds. The patient recently experienced depressive symptoms after talking about some of his friends who he saw die during the hurricane. He has also been experiencing repeated nightmares regarding the occurrences of hurricanes. He also claims that the sounds of hurricanes disturb his night sleeps, making it hard for him to sleep at night. Consequently, he suffers a lot during the day due to fatigue.
O: The patient is smartly dressed and well-groomed. He is oriented and alert. The patient looks sad and appears disturbed. The patient has a rushed and pressured speech. He denies suicidal thoughts, ideations, or actions. The patient has persistent nightmares related to a hurricane that he experienced sometime back. He is positive for hallucinations. The patient avoids discussions or events which remind him of the hurricane
A: The patient’s symptoms point to Post-traumatic stress disorder, especially due to the fact that he had a first-hand experience with hurricane
P: The patient needs to start weekly cognitive behavioral therapy sessions to help him with the symptoms. He also needs to visit the facility after four weeks for review.
Bipolar Disorder
Name: B.S
Age: 45 years
Gender: Male
Diagnosis: Bipolar Disorder
B.S is a forty-five-year-old white male patient who came to the facility accompanied by his first bone son. The son indicates that for the last few weeks, his father has been exhibiting strange behavior and talking about imaginary people who intend to harm him. Therefore, the patient fears staying alone at home. He no longer goes to work after the symptoms worsen, so he was advised to take a break from work. However, the patient finds it easy to stay at a neighbor’s house who has also been his friend for some time now. The patient experiences notable mood, behavior, and energy shifts. He also experiences mood swings, feelings of sadness and depression, and shifts to extreme happiness. The patient denies using any drugs or alcohol. Other symptoms exhibited by the patient include headache, dizziness, and weakness.
O: The patient has not dressed appropriately and looks shaggy. The patient is alert and oriented. He appears sad and restless. Mood swings have been noted as the patient showed grief and sadness and a quick shift to excitement and display of energy. The patient’s speech is incoherent and difficult to follow. The patient is positive for both visual and auditory hallucinations. He denies any suicidal thoughts. The patient gets easily distracted.
A: the patient has expressed notable manic symptoms and therefore, has been diagnosed with bipolar disorder.
P: The patient needs to start cognitive behavioral therapy to help with the manic symptoms.
Alcohol use disorder
Name: A.L
Age: 40 years
Gender: Male
Diagnosis: Alcohol use disorder
A.L is a forty-year-old African American man who visited the facility with a history of alcoholism and failed rehabilitation attempts. The patient has been using alcohol since when he was in his mid-twenties; however, the habit never got out of hand until he was in his mid-thirties. In the last few months, the patient has turned to heavy consumption of alcohol after he lost his job. The patient consumes more than five glasses of alcohol every day which has negatively impacted his social functionality and family life. He is no longer able to fulfill his responsibilities making him have frequent quarrels with his wife and children. The patient believes that he has reached a point where he seriously needs help to turn his life around.
O: The patient is appropriately dressed and groomed. He is also alert and oriented. The patient maintains eye contact. He has a clear speech, though he talks at a louder-than-usual volume. He has a coherent thought process and intact short and long-term memory.
A: The patient longs for a turnaround of his life following heavy consumption of alcohol for months which has negatively impacted his life. The patient should be treated for alcohol use disorder.
P: The patient should start psychotherapy sessions to help him cope with the depressive symptoms and behavior patterns. Weekly DTB is therefore recommended.
Attention Deficit Hyperactive Disorder
Name: H.R
Age: 6 years
Gender: Female
Diagnosis: Attention Deficit Hyperactive Disorder
H.R. is a six-year-old white female patient who was brought to the facility for assessment. The mother indicates that the patient has been showing undesirable symptoms, which she hoped would go away, but unfortunately have persisted. The girl has been expressing explosive mood and irritability. She also doesn’t concentrate when adults are talking to her. She usually fails to complete tasks assigned to her due to loss of concentration and easy loss of focus. These symptoms have also been reported in school since the lack of concentration has made her lag behind in class and school. The patient has also expressed impulsive behavior, which makes it difficult to control her at home, calling for more supervision. The mother believes that they can get help if the boy is assessed for attention deficit.
O: The patient was well-dressed, alert, and groomed. She is alert and oriented. She finds it difficult to maintain eye contact and keeps on moving in the examination room. Her speech is clear, though loud. She has a coherent thought process and intact memory. The patient denies delusions, obsessions, and hallucinations. she has a limited attention span, and she is easily distracted. The patient’s short-term memory is distorted; however, the long-term memory is still intact.
A: The assessment reveals that the patient is hyperactive and impulsive. She is also easily distracted and has deficits in her thinking and memory
P: The patient needs to start psychotherapy sessions. Therefore, weekly DBT should be started.
Major Depressive Disorder
Name: N.C
Age: 37 years
Gender: Female
Diagnosis: Major Depressive Disorder
N.C is a thirty-seven-year-old white female patient who came to the facility with a major complaint of persistent sadness and feelings of hopelessness and emptiness. However much she tries to be positive, the symptoms keep on appearing. She has also lost interest in most of the things she loves doing, and she struggles to complete her work on time. She also reports having worrying thoughts at night, which makes it difficult for her to fall asleep, and she is easily distracted from sleep. She is, therefore, fatigued during the day and forces herself to complete her jobs. She also finds it difficult to concentrate on her tasks. The patient has also gained some weight after having a period of increased appetite.
O: The patient is appropriately dressed and well-groomed. She is alert and oriented. Her mood is sad. She has coherent and clear speech. The patient’s thought process is also coherent. The patient’s short-term and long-term memory is intact. She denies hallucinations, delusions, suicidal thoughts, ideation, or actions.
A: The patient’s symptoms point to a major depressive disorder that needs to be managed.
P: The patient should start psychotherapy sessions. She needs to start weekly cognitive behavioral sessions for four weeks before coming for a review.
Insomnia
Name: B.S
Age: 45 years
Gender: Female
Diagnosis: Insomnia
B.S is a forty-five-year-old female patient who visited the clinic indicating that she had been experiencing sleeping problems. She finds it difficult to sleep and easily wakes up. She easily gets distracted from her sleep and has complications with falling asleep again. She has tried some over-the-counter medication sleep tablets to improve her sleeping habits, but little has changed. Therefore, she doesn’t have a regular sleep pattern. She gets fatigued and tired during the day due to a lack of enough sleep at night. She also indicated that her daily chores had been interrupted due to fatigue and tiredness.
O: The patient is well-dressed and groomed. She is alert and oriented and willing to actively take part in the discussion. The patient is vibrant and alert at the start of the interview but appears exhausted and tired as the assessment goes on. Her thought process is coherent and intact in short-term and long-term memory. She denies illusion, hallucination, or delusions. She also denies any suicidal thoughts or mind.
A: The patient has insomnia, as displayed by the symptoms. She needs an intervention since the symptoms have been persistent.
P: The patient needs to be educated on how to eliminate potential detractors and also commence DBT sessions.
General Anxiety Disorder
Name: H.B
Age: 43 years old
Gender: Female
Diagnosis: General Anxiety Disorder
H.B is a forty-three-year-old female patient of Asian origin who came to the facility indicating that she needs a psychiatric evaluation. The patient indicates that she has been having various symptoms, such as anxiety, headache, loss of appetite, and diarrhea. She has tried managing the headache with medication. She recently changed jobs and is anxious about how she will perform in her new role. The patient has also been experiencing cases of oversleeping and sometimes sleeps even for more than eight hours.
O: The patient is appropriately dressed and well-groomed. She is also alert and oriented. The patient’s speech is clear and coherent. The patient’s judgment and insight are intact. She maintains satisfactory eye contact. Her short-term and long-term memory are both intact. The patient has impaired functionality which is mild. She denies suicidal thoughts, actions, or ideations. She also denies hallucinations and delusions.
A: The symptoms presented by the patient point to the presence of generalized anxiety disorder; hence a management approach should be used.
P: The patient needs to start a psychotherapy session to help with the symptoms. Weekly sessions of cognitive behavioral therapy are indicated.
Binge Eating Disorder
Name: M.M
Age: 19 years old
Gender: Female
Diagnosis: Binge Eating Disorder
M.M is a nineteen-year-old female patient who visited the clinic with a history of a binge eating disorder. Attempts to treat the condition have not borne the expected fruits. She is not happy with her elder siblings and parents, who she accuses of not being ready to help her overcome the problem. She has been getting hurting statements from them such as “ you eat too much”, ” your love for food is unmatchable,” and “you will be obese because of your love for food”. She finds these statements annoying and hurting, which makes her sad and depressed. She also reports feelings of embarrassment and helplessness. She fears she will soon gain unwanted weight, which will make her obese.
O: The patient is appropriately dressed and well-groomed. She is also alert and oriented. Her mood is sad, and she also looks worried and bothered. She reports depression, feelings of unworthiness, and helplessness; she also has low self-esteem. The patient denies delusions, hallucinations, and suicidal thoughts or mind. Her thought process is coherent. She also has intact short-term and long-term memory.
A: The patient’s symptoms indicate that she has a binge eating disorder which also makes her sad
P: The patient needs to start psychotherapy sessions to help with the symptoms.
Schizophrenia
Name: T.J
Age: 55 years old
Gender: Female
Diagnosis: Schizophrenia
T.J is a fifty-five-year-old female patient who visited accompanied by her daughter. The patient lives with the daughter after she fell ill and started to attend clinics for diabetes and hypertension. The patient has been exhibiting some strange behavior, according to her daughter. The daughter reports that her mother has been seeing non-existing individuals and also hearing unique sounds. She claims to be seeing some individuals who are jealous of her children’s progress and therefore planning to harm them, especially her eldest daughter, who has a stable family and a good job. The patient also indicates that some people often watch them through the walls and want to harm them. She, therefore, prefers staying indoors as she doesn’t want to go and meet them. The patient has reportedly lost interest in activities and has been showing incidences of anger.
O: The patient is appropriately dressed and groomed. She is also alert. She has rapid and inconsistent speech. Her mood is stressed. She denies suicidal thoughts or mind. The patient is positive for auditory and visual hallucinations. The patient denies self-injurious behavior and nightmares.
A: The patient’s symptoms point to the presence of schizophrenia.
P: The patient should start weekly cognitive behavioral therapy to help with the symptoms and improve her overall life functionality.