PRAC 6645 WEEK 8 Assignment 1 : Clinical Hour and Patient Logs
Walden University PRAC 6645 WEEK 8 Assignment 1 : Clinical Hour and Patient Logs-Step-By-Step Guide
This guide will demonstrate how to complete the Walden University PRAC 6645 WEEK 8 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 8 Assignment 1 : Clinical Hour and Patient Logs
Whether one passes or fails an academic assignment such as the Walden University PRAC 6645 WEEK 8 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 8 Assignment 1 : Clinical Hour and Patient Logs
The introduction for the Walden University PRAC 6645 WEEK 8 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 8 Assignment 1 : Clinical Hour and Patient Logs
After the introduction, move into the main part of the PRAC 6645 WEEK 8 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 8 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 8 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 8 Assignment 1 : Clinical Hour and Patient Logs
Clinical Logs
Insomnia
Age: 24 years
Diagnosis: Insomnia
S: X.X is a 24-year-old male who came to the clinic for his fifth follow-up visit after being diagnosed with insomnia six months ago. He was diagnosed with insomnia after he presented to the unit with complaints of difficulties in falling asleep and maintaining sleep. He also reported frequent episodes of waking up while asleep and finding it hard to get sleep afterwards. The energy levels of the client during the day were significantly reduced. As a result, he was worried that his productivity was not to the expected level in his organization. The difficulties in sleep could not be attributed to any medical condition, medication, or substance
abuse. Due to the above complaints, the patient was diagnosed with insomnia, and has been undergoing group psychotherapy sessions in the unit.
O: The client appeared appropriately dressed for the occasion. His orientation to self, place, time and events were intact. The self-reported mood of the client was normal. The judgment of the client was intact. He denied any history of delusions, hallucinations, and illusions. He also denied any history of suicidal thoughts, attempts, and plans.
A: The use of group psychotherapy treatment has been effective in improving the symptoms of insomnia being experienced by the client
P: The participation of the client in the group psychotherapy sessions was terminated, as the treatment objectives had been achieved. He was informed to visit the clinic should the symptoms relapse.
Schizophrenia
Name: B.T
Age: 38 years
Diagnosis: Schizophrenia
S: B.T is a 38-year-old female that came to the unit for her sixth follow-up visit after being diagnosed with schizophrenia seven months ago. She recalled that she had come to the unit with complaints 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 symptoms could not be attributed 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 denied suicidal thoughts, attempts, and plans. Her thought content was future oriented. She did not demonstrate any abnormal behaviors such as tremors and flight of ideas.
A: The treatment objectives have been achieved with the adopted treatment interventions. The client also demonstrates no side effects to the adopted treatments.
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.
Attention-Deficit Hyperactive Disorder (ADHD)
Name: K.P
Age: 9 years
Diagnosis: ADHD
S: K.P is a 9-year-old boy who came to the unit for his regular assessment in the company of his parents. He was diagnosed with ADHD at the age of 7 years and has been on treatment. The parents recalled that K.P was diagnosed with the disorder due to symptoms that included the lack of attention alongside impulsivity and hyperactivity for more than six months after being enrolled in school. The symptoms of impulsivity were reported to affect negatively the social and academic performance of the client. The client also demonstrated the above symptoms both in school and at home. The teacher had reported that the client day dreamed and seemed distant while in class. He also fidgeted and failed to complete her assignments on time.. A further assessment of the client showed that the symptoms were not attributable to any cause, hence, the diagnosis with ADHD.
O: The client appeared appropriately dressed. His orientation to self, others, time and space was intact. His attention span was moderate. The client demonstrated flight of ideas. The teacher reported that his daydreaming had stopped with the interests of the client on learning activities improved significantly.
A: The symptoms of ADHD have improved with the currently adopted treatment.
P: The parents of the client were advised to continue with the medications and attend the monthly follow-up visits.
Post-Traumatic Stress Disorder
Name: D.D
Age: 40 years
Diagnosis: Post-traumatic stress disorder
S: D.D is a 28-year-old client that came to the unit for her regular follow-up visits after being diagnosed post-traumatic stress disorder eight months ago. She was diagnosed with the disorder following her experience with a violent relationship. The client raised a number of symptoms that included the persistent recurrence of the distressing memories about the traumatic events she underwent in the relationship. There was also the report of flashbacks and intense distress following the exposure of the patient to the stimuli that related to the traumatic events. The client also demonstrated avoidance behaviors of the stimuli that related to the traumatic events. 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. She was initiated on antidepressants and group psychotherapy sessions.
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. She also denied avoidance behaviors and distressing emotional experiences associated with the accident.
A: There has been continued improvement in the symptoms of post-traumatic stress disorder being experienced by the client. The client also reports no side or adverse effects to the treatment.
P: Group psychotherapy sessions were terminated with consent from the client. She was advised to continue with antidepressant treatment. She was scheduled for a follow-up visit after one month.
Major Depression
Name: K.B
Age: 30 years
Diagnosis: Major Depression
S: K.B is a 30-year old client that was brought today to the unit by his family with history of suicidal attempt. The client had attempted to commit suicide by drinking an organophosphate. K.B reported that he wanted to take his life because he always feels depressed and hopeless. He also reported that he not want to interact with people and often locked himself indoors. The family noted with concern that K.B lacks interest in things and pleasure in most of the days. He also gets easily irritated with things. The client also reported that his energy levels were low in most of the days. When asked about changes in his appetite, the client reported that his appetite had increased significantly over the past few days. He denied current suicidal plan. Due to the above complaints, the client was diagnosed with major depression and initiated on treatment.
O: The client appears poorly groomed for the occasion. He maintains minimal eye contact during the assessment. His orientation to self, others, place, time and events were intact. K.B denied hallucinations, illusions, and delusions. His speech was normal in rate and volume. He reported recurrent suicidal thoughts with one attempt. He does not have any suicidal plan now. The judgment is intact with thoughts that are future oriented.
A: The assessment findings show that the client is experiencing severe symptoms of depression and is at risk of self-harm.
P: The client was admitted for inpatient monitoring. He was prescribed antidepressants, antibiotics, and wound cleaning. He would be initiated on psychotherapy once stabilized
Major Depression
Name: C.Y
Age: 43 years
Diagnosis: Major Depression
S: C.Y is a 40-year-old client that came to the unit as a referral by his family physician for psychiatric assessment. C.Y came with complaints of feeling hopeless in life and wanted to take his life. Further assessment showed that 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 speech was normal 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
Major Depression
Name: R.E
Age: 40 years
Diagnosis: Major Depression
S: R.E is a 29-year-old male client who was brought today to the unit for psychiatric assessment after being reported to act abnormally for the last two months. The spouse reported that R.E had lost interest and pleasure alongside depressed mood most of the days. R.E reported that he dislikes interaction with people and prefers spending his time indoors. He acknowledged his depressed mood and added that he feels worthless. R.E also reported poor sleeping habits, as he has been experiencing insomnia in most of the days. R.E was also concerned about his health, as he found himself easily irritated and experienced difficulties in making informed decisions. History taking about suicidal thoughts plans, and attempts showed that R.E was contemplating committing suicide. However, he did not disclose any plans. Based on the above data, the client was diagnosed with major depression and initiated on treatment.
O: The client appeared poorly groomed for the clinical visit. His mood was depressed. His insight was altered with flat affect. His speech was reduced in terms of rate and volume. His orientation to self, others, time, and events were intact. The client reported suicidal thoughts without plans or attempts.
A: The client is experiencing symptoms of major depression.
P: The client was initiated on antidepressants and group psychotherapy sessions. He was scheduled for a follow-up visit after four weeks to determine his response to treatment.
Conduct Disorder
Name: L.N
Age: 15 years
Diagnosis: Conduct Disorder
S: L.N is a 15-year-old client that came to the unit as a referral by his physician for psychiatric assessment. The mother to the client reported that her son has been showing abnormal behaviors for the last one year. According to her, she hoped that the symptoms would resolve, as they were part of his development. The symptoms included showing significant aggression towards others. L.N was always found to have violated the rights of others by ways such as causing harm and destroying properties. The mother also reported that the son had been reported to be a bully in school and the community church. The additional complaints that were raised concerning L.N’s behavior included initiating fights with others, threatening to harm, stealing, and engaging in deceitful acts to gain favors. The client denied any recent substance use or abuse. The above symptoms could not be attributed to other causes such as medications, medical condition, or substance abuse. Therefore, he was diagnosed with conduct disorder and initiated on treatment.
O: The client appeared appropriately dressed for the occasion. He maintained normal eye contact during the assessment. His speech was of normal rate and volume. His orientation to self, others, place and time were intact. He denied illusions, delusions and hallucinations. He also denied suicidal thoughts, attempts and plans.
A: The client appears to experience intrusive symptoms of conduct disorder.
P: The client was initiated on individual psychotherapy to assist him develop effective skills for overcoming the abusive symptoms and behaviors. He was scheduled for a follow-up visit after four weeks.
Generalized Anxiety Disorder
Name: M.C
Age: 24 years
Diagnosis: Generalized Anxiety Disorder
S: M.C is a 24-year old client that came to the unit for follow-up visit after being diagnosed with generalized anxiety disorder five months ago. The client had come to the unit initially with complains of excessive worry and anxiety about anticipated negative experiences in her life. She raised persistent fear of unknown impending doom, which was beyond her control. Her experiences had made her avoid any situations that could precipitate the excessive fear and anxiety. A further inquiry showed that she experienced other symptoms that included chest tightness and chest pains during periods of anxiety attack. The client had denied any history of medication use, substance abuse and medical condition. The client also was significantly worried that the symptoms would affect her performance in her academics. As a result, she was diagnosed with generalized anxiety disorder and initiated on group psychotherapy treatment.
O: The client appeared well groomed for the occasion. She was oriented to self, others, time and events. She was alert during the assessment and maintained normal eye contact. She denied illusions, delusions, and hallucinations. She also denied suicidal thoughts, attempts and plans.
A: The client has continued to demonstrate improvement in symptoms over the last five months. She is confident about her abilities to manage the triggers of anxiety attacks.
P: The client’s participation in the group psychotherapy sessions was terminated with her consent. The developed treatment objectives had been achieved. She was informed to come to the unit should the symptoms relapse in the future.
Bipolar Disorder
Name: R.D
Age: 28 years
Diagnosis: Bipolar Disorder
S: R.D is a 28-year-old client that came to the unit for her follow-up after she was diagnosed with bipolar disorder eight months ago. She had been diagnosed with the disorder after she came to the unit with complaints of cycles of elevated and depressed mood. The elevation in mood was associated with symptoms such as engaging in goal-directed initiatives, excitement and delusions. She further reported that the symptoms alternated with those of depression such as the lack of energy and difficulties in concentrating and feelings of worthlessness. The depressed mood could happen almost every day for a specific period such as one month, followed by elated mood. The above symptoms had affected significantly the ability of the client to engage in her daily routines. The symptoms were also not associated with drug use, medical problem or substance and alcohol abuse. As a result, she was diagnosed with bipolar disorder and initiated on treatment.
O: The client appeared appropriately dressed for the occasion. She was oriented to self, place, time and events. Her judgment was intact. She denied any recent experience of delusions, hallucinations, illusions, suicidal thoughts, plans, and attempts.
A: The treatment objectives have been achieved. The client tolerates the treatment well.
P: The psychotherapy sessions were terminated due to the realization of the desired treatment objectives. She was advised to continue with the prescribed medications. The client was scheduled for a follow-up visit after four weeks.
Sample Answer 2 for PRAC 6645 WEEK 8 Assignment 1 : Clinical Hour and Patient Logs
Nightmares and Night Terrors
Name: D.J
Age: 32 years
Gender: Male
Diagnosis: Post- Nightmares and Night Terrors
S: D.J. is a 32-year-old male patient. He claims to experience disturbing dreams, which fill him with a lot of panic and fear, hence leading him to abrupt awakenings and difficulty going back to sleep. He explains that those dreams have been frequent and intense, and so they leave him exhausted and full of anxiety.
O: The patient looks neat, well-groomed, and appropriately dressed for her gender and age. He also looks tired and sleepy. He is congruent with mood, full of apprehension and anxiety when discussing his experience with nightmares and night terrors. The patient’s speech is normal, but hesitant to talk about nocturnal experiences.
A: Based on DSM-V criteria, the patient’s symptoms are indicative of nightmares and night terror disorder.
P: The patient needs Cognitive Behavior Therapy for Insomnia (CBT-I). CBT-I techniques, such as sleeping hygiene education, stimulus control, relaxing training, and cognitive restructuring, will help the patient manage nightmares and night terrors.
Intellectual Developmental Disorder.
Name: T.J
Age: 7 years
Gender: Male
Diagnosis: Intellectual Developmental Disorder.
S: T.J., a 7-year-old male child, was accompanied by his mother to the health care facility. The mother complains of his son’s difficulty in academic achievement, social interactions, and adaptive functioning. His mother notes that her son has been given special educational services and support at school with no improvement.
O: The patient is well and neatly dressed, which is appropriate for his age. His behavior shows delays in speech and language, motor coordination, and social skills. The patient is able to engage in age-appropriate play activities but with support and supervision. He is cooperative, content, and calm during the assessment, though he demonstrates intellectual functioning impairment, including problem-solving difficulties, reasoning deficit, and lack of self-care and self-awareness skills.
A: From the observed symptoms, the patient has an Intellectual Developmental Disorder.
- The patient should begin an Applied Behavioral Analysis to identify his weak areas, such as self-help skills and socialization, to help provide the appropriate interventions. The patient also needs to continue with his education support program and also start weekly speech and language therapy.
Encopresis Disorder
Name: J.S
Age: 9 years old
Gender: Female
Diagnosis: Encopresis Disorder
S: J.S. is a nine-year-old female patient who visited the facility accompanied by her parents. The patient has been experiencing frequent bowel movement accidents, which leave her extremely embarrassed and shy. Recently, she had a bowel movement accident in class, and since then, her classmates have continually teased her, making her lean towards avoiding school. The patient has a history of constipation.
O: The patient is well-dressed and groomed. She is alert and oriented. However, she looks anxious. Physical exams revealed no specific cause of the problem. She has steady speech, a coherent thought process, and an intact memory. She denies suicidal thoughts or ideation.
A: Based on DSM-V criteria, her symptoms point to encopresis disorder
P: The patient should start CBT sessions to help identify and challenge irrational thoughts and teach her coping strategies.
Schizophrenia Spectrum and Other Psychotic Disorders
Name: G.R
Age: 69 years
Gender: Male
Diagnosis: Schizophrenia Spectrum and Other Psychotic Disorders
S: G.R. is a 69-year-old male patient who came to the clinic accompanied by his son. The patient complained about seeing people come to her house with the motive of harming her. He also stays awake at night because he hears loud noises around her house. He also complains that there are people who watch her through the television screens with the intention of snatching her food. The son confesses that he has never seen such people nor heard strange voices.
O: The patient is appropriately dressed. He is also alert and oriented. He exhibits a delusive character and claims to see some cat in his room. She finds it hard to maintain eye contact and continually gazes in the room. He is positive for hallucinations and delusions. He has a disorganized thought process. She denies suicidal thoughts or behaviors
A: based on the DSM-5 criteria, the patient’s symptoms indicate schizophrenia spectrum and other psychotic disorders.
P: The patient should begin a weekly CBT session to help her identify and challenge the distorted beliefs and thought patterns.
Internet Gaming Disorder
Name: D.P
Age: 39 years
Gender: Male
Diagnosis: Internet Gaming Disorder
S: D.P. is a 39-year-old male patient who presents to the facility for a psychiatric visit. He explains that he is happy about his internet gaming habits. He has developed a habit of playing online games for hours every day. This habit disrupted his daily activities, hence making him neglect his family roles and responsibilities. He says that the habit also makes him stressed and anxious. He also indicates that he feels guilty and frustrated since he has so far failed to control the behavior.
O: The patient is neatly dressed and groomed. He is also alert and oriented. He appears disheveled and tired. He frequently checks his phone for gaming notifications during the session. He also has a coherent speech, and his thought process is coherent. The patient Denies any suicidal thoughts or actions.
A: The patient’s presented symptoms are indicative of internet gaming disorder.
P: The patient should start weekly CBT sessions to help him overcome the addiction.
Schizoaffective Disorder
Name: P.A
Age: 65 years
Gender: Female
Diagnosis: Schizoaffective disorder
P.A. is a 65-year-old female patient who was brought to the facility by her daughter due to mental health concerns. The patient has been showing symptoms such as paranoid thoughts and auditory hallucinations. She also faces periods of difficulty in concentration, disrupted sleep, and low moods. She also expresses feelings of hopelessness, worthlessness, and racing thoughts.
O: The patient is well-dressed and groomed. She appears disheveled and shows psychomotor agitation. She participates in a conversation with signs of emotional distress and auditory hallucinations. She has clear speech but, in most cases, stops to respond to internal stimuli. She denies suicidal ideations or thoughts.
A: Following the DSM-V criteria, symptoms point to schizoaffective disorder.
P: The patient should start weekly sessions of individual therapy
Social Anxiety Disorder
Name: J.L
Age: 15 years
Gender: Female
Diagnosis: Social Anxiety Disorder
S: J.Lis is a 15-year-old female patient who came to the health facility accompanied by her mother. The patient confesses to being distressed when in social environments, such as when having to participate in school games. She dreads negative evaluation; hence, she avoids social interactions. She also experiences other physical symptoms, such as nausea and trembling in the face of social stimuli. She longs to have better social interactions.
O: The patient is well-dressed and groomed. She is also alert and oriented. She fidgets a lot and gives brief and hesitant responses. She has a clear speech. She has a coherent thought process and intact memory. She also expresses anxiety and fear when topics such as social events are discussed. She denies suicidal thoughts or ideation.
A: Based on DSM-V criteria, the symptoms point to social anxiety disorder.
P: The patient should start weekly CBT sessions to help him address negative thought patterns.
Antisocial Personality Disorder
Name: D.N
Age: 29 years
Gender: Female
Diagnosis: Antisocial personality disorder
S: D.N. is a 29-year-old female patient who was brought to the facility by her sister for psychiatric assistance. The patient finds it difficult to retain employment and has problems with interpersonal relationships. She has also been arrested several times in the past due to theft and fraud. However, she has never been remorseful for her actions and behavior. Her sister reports that D.N. is deceitful and manipulative. The sister indicates that the patient has been displaying impulsivity and a lack of consideration for others’ well-being.
O: The patient is appropriately dressed and has a self-assured demeanor. She is alert and oriented. She has a clear and persuasive speech. She also has a coherent thought process and intact memory. She denies suicidal actions or thoughts. However, she exhibits minimal empathy for others.
A: From the DSM-V criteria, the patient’s symptoms show antisocial personality disorder.
P: The patient needs to commence DBT sessions to help with thinking patterns and maladaptive behavior.
Persistent Depressive Disorder
Name: P.M
Age: 43 years
Gender: Male
Diagnosis: Persistent Depressive Disorder
P.M. is a 43-year-old male patient who visited the clinic for a psychiatric check. The patient indicates experiences of persistent feelings of hopelessness and low mood, which have been there for around two years. He also exhibits other symptoms, such as thoughts of worthlessness, low energy, disrupted sleep patterns, and difficulty finding pleasure in activities he loves.
O: The patient is well-dressed and groomed. He is alert and oriented, but he looks fatigued and struggles to maintain eye contact. He displays a sad mood. He also has a slow speech and finds it difficult to concentrate. He denies a history of hypomania or mania. He also denies suicidal thoughts or ideation.
A: The patient’s symptoms show persistent depressive disorder.
P: The patients should start sessions of CBT to help address the negative thought patterns and develop coping strategies.
Borderline Personality Disorder
Name: S.M
Age: 41 years
Gender: Male
Diagnosis: Borderline personality disorder
- S.M. is a 41-year-old male patient who visited the facility to seek help. He indicates that he has been experiencing symptoms such as mood swings, unstable relationships, and self-harming behaviors. He also reports experiences of frequent sense of emptiness, being overwhelmed by shifting and intense emotions, and struggles with unstable self-image. He claims to experience interpersonal conflict, which leaves her feeling alone
O: The patient is appropriately dressed and neat. He is alert and oriented but displays rapid mood shifts. He has coherent speech. He also shows hopelessness and frustration about her relationships. He has an intact memory and a coherent thought process. He denies suicidal thoughts or ideation.
A: According to the DSM-V criteria, the patient’s symptoms show borderline personality disorder.
P: The patient should start weekly DBT sessions to improve her emotional regulation.
Attention-Deficit/Hyperactivity Disorder
Name: C.M
Age: 9 years
Gender: Female
Diagnosis: Attention-Deficit Hyperactivity Disorder.
S: C.M. is a 9-year-old female patient who was brought to the facility by her mother. She complains that her daughter has difficulty in paying attention. Other symptoms include impulsivity and hyperactivity. As such, she finds it difficult to maintain focus in her activities, complete homework, and, in general, perform poorly in school. The symptoms have been persistent for some time.
O: The patient is well-dressed and groomed. She is also alert and oriented. She fidgets, finds it difficult to stay seated, and is restless. She has clear speech but tends to shift topics rapidly and interrupts. She also finds it hard to follow instructions. She has a coherent thought process and intact memory. She denies suicidal thoughts or ideation.
A: Based on DSM-V criteria, the symptoms point to ADHD.
P: The patient should start weekly sessions of CBT to help improve emotional regulation and develop coping strategies.
Post-Traumatic Stress Disorder
Name: Z.P
Age: 15 years
Gender: Male
Diagnosis: Post-traumatic stress disorder (PTSD)
P.T. is a 15-year-old male patient who visited the facility for a psychiatric assessment accompanied by his parents. He complains of frequent and unpleasant nightmares after experiencing a serious accident. The symptoms reported include irritability, agitation, emotional detachment, social isolation, hostility, anxiety, and sleep difficulties.
O: The patient is well-dressed and groomed. He is also alert and oriented but shows symptoms of distraction. He fidgets during the exams. The patient had an intact thought process and short and long-term memory. He is positive for suicidal thoughts and nightmares. He denies hallucinations.
A: The patient’s symptoms point to PTSD.
P: The patient should start weekly CBT sessions.