PRAC 6645 WEEK 10 Assignment 1 : Clinical Hour and Patient Log
Walden University PRAC 6645 WEEK 10 Assignment 1 : Clinical Hour and Patient Log-Step-By-Step Guide
This guide will demonstrate how to complete the Walden University PRAC 6645 WEEK 10 Assignment 1 : Clinical Hour and Patient Log 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 10 Assignment 1 : Clinical Hour and Patient Log
Whether one passes or fails an academic assignment such as the Walden University PRAC 6645 WEEK 10 Assignment 1 : Clinical Hour and Patient Log 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 10 Assignment 1 : Clinical Hour and Patient Log
The introduction for the Walden University PRAC 6645 WEEK 10 Assignment 1 : Clinical Hour and Patient Log 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 10 Assignment 1 : Clinical Hour and Patient Log
After the introduction, move into the main part of the PRAC 6645 WEEK 10 Assignment 1 : Clinical Hour and Patient Log 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 10 Assignment 1 : Clinical Hour and Patient Log
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 10 Assignment 1 : Clinical Hour and Patient Log
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 10 Assignment 1 : Clinical Hour and Patient Log
Clinical Logs
Major Depression
Age: 45 years
Diagnosis: Depression
S: S.K is a 45-year-old client that has been undergoing treatment in the unit due to major depression. She was diagnosed with depression six months ago and has been undergoing group psychotherapy sessions and using antidepressants. She was diagnosed with depression after she presented with complaints of feeling sad most of the days almost all the days, feeling worthless and guilty most of the times. She also reported decline in her appetite, as well as becoming socially withdrawn. Her interest in pleasure also declined significantly. The symptoms had affected significantly her ability to perform optimally in her academic and social roles. The symptoms could not be attributed to other causes such as medication use, medical conditions or substance abuse. She was therefore diagnosed with major depression and has been undergoing treatment in the facility.
O: The patient appeared dressed appropriately for the occasion. She was oriented to s
elf, place, time and events. Her judgment was intact. She denied any suicidal thoughts, attempts or plans as well as illusions, delusions and hallucinations. Her mood was normal.
A: The client has responded well to the treatments. Her mood has improved
P: Psychotherapy sessions were terminated with consent obtained from the client. She was advised to continue with antidepressant therapy. She was scheduled for follow-up visit after two months.
Major Depression
Name: T.M
Age: 28 years
Diagnosis: Depression
S: T.M is a 28-year-old client that was brought to the unit by his relatives for psychiatric review. The client was brought with history of suicide attempt by hanging. The client reported that he wanted to kill himself, as he felt that
his life was useless. The client also noted that his mood has been depressed for almost every day. The depressed mood had made it difficult for him to engage in his activities of the daily living. The family also reported that his interest in things had diminished significantly. The client reported suicidal thoughts and attempt. He denied any suicidal plan during the clinical visit. Based on the above complaints the client was diagnosed with depression and initiated on treatment.
O: The client appeared poorly dressed for the occasion. He reported that his mood was depressed. The client was oriented to self, others, time, and events. He denied illusions, delusions, and hallucinations. He reported suicidal thoughts and attempts. He denied current suicidal plans. The client does not have a current suicidal plan. His speech was reduced in terms or rate and volume.
A: The client is experiencing severe symptoms of depression. The client requires treatment to improve his mood and functioning.
P: The client was admitted for further observation. He was prescribed antidepressants to manage the depressive symptoms he was experiencing.
Major Depression
Name: K.U
Age: 36 years
Diagnosis: Depression
S: K.U is a 30-year old client that was brought today to the unit by his family with history of suicidal attempt. The client attempted suicide by getting himself in the highway to be hit by fast moving cars. K.U reported that he wanted to take his life because he always feels depressed and hopeless. He also reported that he lacks interest and pleasure. The family reported that K.U gets easily irritated with things. There was also history of increase in appetite and insomnia. 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.U 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: M.R
Age: 38 years
Diagnosis: Depression
S: M.R is a 38-year old client that came to the unit for his first follow-up visit for depression. He was diagnosed with depression after being brought in the first visit for admission due to history of self-harm. The client wanted to kill himself, as he felt useless about his life. He had reported that he had suicidal thoughts in almost all the days, as well as depressed mood. He did not want to interact with people and lacked interest in things and pleasure. His level of irritation had also risen, which made it difficult for him to concentrate. The symptoms could not be attributed to any cause such as drug abuse, medication use, or medical conditions. Due to the above complaints, the client was diagnosed with major depression and initiated on treatment.
O: The client appears appropriately groomed for the occasion. He maintains normal eye contact during the assessment. His orientation to self, others, place, time and events are intact. He denies hallucinations, illusions, and delusions. His speech is normal in rate and volume. He denied recent experience of suicidal thought, attempt or plans.
A: The adopted treatments have been effective in reducing the severity of depressive symptoms being experienced by the client.
P: The client was advised to continue with the current treatments. He was scheduled for a follow-up visit after four weeks.
Post-Traumatic Stress Disorder
Name: B.N
Age: 34 years
Diagnosis: Post-traumatic stress disorder
S: BN is a 34-year-old client that came to the unit for her regular follow-up visits after she was diagnosed with post-traumatic stress disorder three months ago. She was diagnosed with the disorder following her experience with a road accident. The client raised complaints during her first visit to the unit that included the persistent recurrence of the distressing memories about the accident. She also reported flashbacks and intense distress following her exposure to stimuli that related to the event. She also avoided any 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 adopted treatment interventions have been effective in managing the depressive symptoms of post-traumatic stress disorder. The client reports improved tolerability to the treatment.
P: The client was advised to continue with the current treatments. She was scheduled for a follow up visit after four weeks.
Attention Deficit Hyperactive Disorder
Name: K.T
Age: 8 years
Diagnosis: Attention Deficit Hyperactive Disorder
S: K.T is an 8-year-old boy who was brought to the unit for his regular assessment for ADHD. He was diagnosed with ADHD at the age of 6 years and has been on treatment. The diagnosis was reached after he started experiencing symptoms that included the lack of attention alongside impulsivity and hyperactivity for more than five months after being enrolled in school. The symptoms of impulsivity were reported to affect negatively the social and academic performance of the client. The teacher had reported that the client daydreamed 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 social and cognitive functions had 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.
Dementia
Name: T.R
Age: 67 years
Diagnosis: Dementia
S: T.R is a 68-year-old male client who has been on treatment in the unit for dementia after being diagnosed with it three years ago. He was diagnosed with dementia after he started experiencing a significant decline in his memory. The client had started experiencing gradual loss of memory, as he could not remember the names of his family members and his familiar places. The client also reported getting lost in his familiar environments, placing him at risk of harm. There was also the complaints by the family members that the client was easily agitated and irritated by others and events. The symptoms were reported to be worsening on a daily basis, leading to the client being brought to the setting for further assessment. He was diagnosed with dementia and has been on treatment.
O: The patient appeared well groomed for the occasion. His orientation to self, time, others, and events were intact. He reported that his mood was normal for few months. The client denied any suicidal thoughts, illusions, hallucinations, and delusions.
A: The client is responding well to the treatment.
P: The decision to continue with the current treatment modalities was adopted. The client was scheduled for a follow-up visit after four months.
Bipolar Disorder
Name: C.H
Age: 28 years
Diagnosis: Bipolar Disorder
S: C.H is a 28-year-old client that came to the unit for her follow-up after being diagnosed with bipolar disorder five months ago. She was diagnosed with the disorder after she complained of uncontrolled cycles of mood depression and elevation. C.H noted that the elevation in mood was associated with symptoms such as engaging in goal-directed initiatives and over excitement. The mood elevation cycle alternated with depressive episodes where she felt she lacked energy to engage in her daily activities. She also complained about insomnia and lack of interest in things and activities. The depressive symptoms lasted for less than a month, when the patient reported optimal health and wellbeing. 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.
Alcohol Use Disorder
Name: H.V
Age: 43 years
Diagnosis: Alcohol Use Disorder
S: H.V is a 43-year-old male who came to the clinic today for his regular follow-up visit after being diagnosed with alcohol abuse disorder and has been on treatment. The client was diagnosed with the disorder after he came to the unit with complaints of 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. He was distressed that the excessive consumption of alcohol was negatively affecting his life and that of the family members. He was however willing to adopt any intervention that could have facilitated the effective management of the 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. His thought content was intact. He denied any 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.
Schizophrenia
Name: Y.R
Age: 33 years
Diagnosis: Schizophrenia
S: Y.R is a 33-year-old male client that came to the unit for his follow-up visit after being diagnosed with schizophrenia four months ago. He was diagnosed with schizophrenia after he came to the unit with complaints of seeing imaginary things and hearing voices. He also reported that the symptoms had affected severely his 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, he was diagnosed with schizophrenia and initiated on treatment.
O: The client appeared well groomed for the occasion. He was oriented to space, time, events, and self. He denied any recent experience of illusions, delusions, and hallucinations. He also denied suicidal thoughts, attempts, and plans. His thought content was future oriented.
A: The adopted treatments are effective in managing the symptoms of schizophrenia.
P: The patient was advised to continue with the current treatments. He was scheduled for the next follow-up visit after four weeks.
- Schizoaffective disorder
Name: B.E
Age: 37 years old
Gender: Male
Diagnosis: Schizoaffective disorder
S: B.E is a 37-year-old African-American male patient who arrived with his wife at the psychiatric facility. The patient’s wife reports that her husband has a history of depression, panic disorder, PTSD, and schizoaffective disorder. He confirms that he is being treated for these problems with trazodone, benztropine, and Seroquel. His current mood has been bleak, with hints of depression as a result of his failure to take his medication on occasion. He also gets dreams about his father dying in a car accident when he is by his side. The patient confirms visual and auditory hallucinations that could put others at risk. Denies depression, flashbacks, and suicidal/homicidal ideas.
O: Although the patient appears to be in good health, he is intrusive and preoccupied. His speech is hasty, illegible, loud, and rapid. His state of mind is exuberant, with a strong sense of grandeur. His affect reflects his emotions. The patients thought the process was slightly impeded. He has auditory and visual hallucinations. His short-term memory is perfect, but his long-term memory is severely impaired. His attention span is adequate, and his cognitive performance is average. His instincts and judgment are significantly impaired. Denies having ever had suicidal thoughts or attempted suicide.
A: The patient has been depressed and gloomy for the preceding three months. According to the DSM-V diagnostic criteria, he also has auditory and visual hallucinations, which support this diagnosis.
P: Involve the patient in realistic activities such as card games, writing, sketching, rudimentary arts and crafts, or listening to music. It is advised that CBT sessions focus on real-life plans, concerns, relationships, and coping abilities.
- Alcohol Use Disorder
Name: C.K
Age: 25 years
Gender: Male
Diagnosis: Alcohol use disorder
S: C.K., a 25-year-old man, came in today for a normal check-up. The patient was diagnosed with alcohol use disorder five months ago and has been getting pharmaceutical and psychotherapy treatments. The client described being diagnosed with the disease as a result of several symptoms related to alcohol abuse. The client had complained about excessive drinking for three years. He was unable to control his binge drinking despite his best efforts, such as abstaining from alcohol. He was worried that his binge drinking was becoming difficult to control. The withdrawal symptoms, according to the patient, made it impossible for him to stop consuming alcohol. He also mentioned that alcohol negatively impacts his social and professional effectiveness. His family’s financial situation has also suffered.
As a result, he was willing to attempt any treatment that might help him overcome his addiction. As a result, he was diagnosed with alcoholism and began treatment.
O: The patient is appropriately attired for the occasion. His sense of self, people, and events was unaffected. He possessed no abnormal habits, such as tics. His mental content was comprehensive. He denied having recently experienced any illusions, delusions, or hallucinations. He also denied any suicidal ideas, plans, or intentions. His speech was typical in terms of tone, tempo, content, and loudness.
A: Alcohol consumption disorder symptoms are gradually improving. He fits the prerequisites for this diagnosis, according to the DSM-V diagnostic criteria.
P: Suggest to the patient that he or she try group cognitive behavioral treatment. Substance abuse support group sessions can also be beneficial to the patient. When the patient is ready, consider rehabilitation.
- Major Depression
Name: T.M
Age: 49 years
Gender: Male
Diagnosis: Major Depression
S: T.M., a 49-year-old patient, was referred to the facility by his family doctor. The doctor thought his situation was not medical and referred him for further psychiatric assessment. The client admitted that he felt like life was meaningless and that he wanted to commit suicide. His sense of failure to give his family the finest life possible led to his melancholy. Further inquiry revealed that the person’s feelings of hopelessness persisted throughout the day on the majority of days. On the vast majority of days, he was also depressed. He added that he had trouble going to sleep. He no longer has a large appetite, which leaves him generally low on energy. He added that he had trouble going to sleep. Also, he acknowledged having suicidal ideas without making any plans. He claimed that in the previous month, his capacity for judgment and concentration had drastically declined. The symptoms weren’t brought on by disease, medication, or drug addiction. He was given a major depression diagnosis as a result, and therapy was started.
O: The patient had an unkempt appearance for the situation. His voice was softer and his speech was slower. He said he was in a bad mood. The client disputed any delusions, distortions, or hallucinations. He maintained eye contact the entire assessment. His intellectual outlook was futuristic. But, he made no indication of a plan or attempt.
A: Major depressive disorder is the patient’s diagnosis supported by the DSM-V diagnostic criteria.
P: Encouraging clients to express their feelings and think of alternative ways to deal with their frustration and rage. Interpersonal therapy and CBT are two suitable psychotherapeutic modalities for this patient.
- Attention Deficit Hypersensitivity Disorder (ADHD)
Name: G.T
Age: 10 years old
Gender: Male
Diagnosis: ADHD
S: G.T. is a 10-year-old white boy patient who was admitted to the psychiatry unit for a mental checkup and treatment monitoring. Her father joined the patient and shared that his ADHD was getting worse. At home, he commits careless errors and frequently overlooks doing his schoolwork. Because of his extreme forgetfulness, his father occasionally needs to send him a letter to remind him to complete his assignments. Her instructor says that the patient has been daydreaming a lot and is constantly alone, unable to communicate with other kids, which has affected his academic performance. He hasn’t played since kicking his friend during a soccer match. He has never attempted suicide or engaged in self-harm. He consumes a diet that is balanced and gets enough sleep at night.
O: During the mental examination, the psychiatrist found that the patient suffers from depression and has been bullied since the first day of school. He has impulsive, hyperactive, and inattentive characteristics that started soon after he started preschool. Positive signs include forgetfulness, a short attention span, repeated careless errors, an inability to follow instructions, excessive fidgeting, and interruption of discussions.
A: The patient’s primary care physician gave the patient’s instructor instructions to fill out an ADHD questionnaire based on the patient’s symptoms. A similar questionnaire was completed by the patient’s father, who received favorable results for ADHD. The diagnostic criteria from the DSM-V were also applied in cases when the patient met the requirements for an ADHD diagnosis.
P: Consider psychotherapy as an alternative to drugs. The child can become less impulsive, hyperactive, and inattentive with behavioral treatment.
- Separation Anxiety Disorder (SAD)
Name: H.W.
Age: 9 years old
Gender: Male
Diagnosis: separation anxiety disorder
S: Nine-year-old H.W. and his mother visited the psychiatric facility for a mental health evaluation. According to the patient’s mother, he has always been anxious and worried about little things, such as if she would pass away or pick him up from school. The patient’s heightened anxiety has no clear source. The patient’s mother continues by saying that he typically prefers his younger brother to him. He tends to be stubborn and tosses things around the house, which puts him in danger at school. Because of his frequent nightmares, he struggles to fall asleep at night. He routinely asks for permission to leave school because he has headaches or stomachaches. His mother also notes that the patient has lost three pounds in the last three days and won’t eat. The patient also occasionally wets the bed, even though his doctor gave him DDVAP, which seems to be of no effect.
O: The patient seemed to be doing well. Person, place, and time orientations are all present. When maintaining eye contact, the patient cooperates and answers questions genuinely. The patient is standing and appears to be active. Responds to fluent speech and talk clearly. When he stares at his mother, he becomes depressed and distracted all of the time. His short and long-term memory are both intact. Denies the possibility of causing harm to oneself or others. Suicidal ideation, hallucinations, or delirium are denied.
A: The patient was separated from his father when he was only six years old. In addition, the patient has frequent nightmares, a chronic aversion to sleeping alone or in the dark, frequent emotional suffering away from home, and physiological symptoms such as headache, stomach pain, or headache when separated from a critical family member. He satisfies the diagnostic criteria for SAD.
P: Suggest cognitive behavioral therapy (CBT) to help the child address and manage separation and uncertainty issues.
- Binge Eating Disorder
Name: P.L
Age: 16 years old
Gender: Female
Diagnosis: Binge Eating Disorder
S: P.L., a 16-year-old Asian female who visited the clinic, has a history of binge eating issues. She talked about her failed attempts to treat this disease. The patient affirms past therapy techniques while still in junior high school after a serious sexual assault episode. She recalled telling the doctor about her eating disorder, but he disregarded it and instead focused on her unpleasant experience. She has put on weight since the binge diagnosis was made, and she feels humiliated by her issue. She currently takes statins and follows a strict diet to manage her hyperlipidemia and obesity. She denies having a history of any psychological disorders or drug sensitivity.
O: The patient’s vital signs were normal besides an elevated blood pressure of 149/90 mmHg and a BMI of 30, though. The results of a physical examination are negative. A psychiatric evaluation reveals that the patient feels unworthy, is depressed, and has low self-esteem.
A: The patient has a binge eating disorder and is receiving ineffective treatment, according to both her subjective and objective evidence. She is obese as well.
P: To help patients replace negative habits with positive ones and stop bingeing episodes, practitioners may employ dialectical behavior therapy, interpersonal psychotherapy, or cognitive behavioral therapy (CBT).
- Insomnia
Name: D.K
Age: 33 years old
Gender: Female
Diagnosis: Insomnia
S: D.K., a 33-year-old female, has been concerned about a lack of enough sleep for the past year. She reports that falling and staying asleep is tough for her. She further mentioned that the sleeping difficulties were followed by other symptoms such as nightly awakenings and trouble settling asleep again. Sleep issues were found to cause significant distress as well as impairments in the client’s social, educational, vocational, and behavioral functioning. There were no explanations provided for the lack of quality sleep, such as substance abuse, prescription drug use, or a medical condition. As a result, she was diagnosed with insomnia and began counseling.
O: The client is appropriately clothed for the clinical visit. She was conscious of herself, her surroundings, time, and events. She appeared tired during the evaluation. She put it down to a lack of sleep the night before. Illusions, delusions, and hallucinations did not affect her judgment. She denied ever having suicidal thoughts, attempts, or schemes.
A: According to DSMV, the client is experiencing sleepiness. Her quality of life is suffering as a result of her inability to sleep. Unfortunately, her tiredness is worsening, demanding immediate treatment to avoid long-term repercussions.
P: Suggest CBT teaches sleep hygiene and relaxation techniques to improve the patient’s sleeping quality and length.
- Enuresis Disorder
Name: H.S.
Age: 11 years old
Gender: Male
Diagnosis: Enuresis Disorder
S: H.S. is an 11-year-old boy whose mother brought him in for nighttime bedwetting. According to her mother, the patient’s doctor suggested Desmopressin (DDAVP), which appears to be ineffective. She claims that one night while camping, the patient shared a bed with a friend, who noticed the patient peeing on the bed. They’ve been making him and calling him names even then. He is uninterested in routine work and refuses to attend school. The patient begins to have problems sleeping at night. The patient’s vaccinations are current, and he or she is growing normally. There was no mention of medical problems. There has been no previous history of nocturnal enuresis. Except for the DDAVP, the patient is not taking any other drugs. There are no drugs or food sensitivities that have been identified.
O: The patient appears to be in good health, with no indications of developmental issues. The bladder and kidneys can be palpated and show no signs of abnormality or enlargement. There are no abnormalities found in a neurological examination of the lumbosacral spine. According to a psychiatric checkup, bedwetting generates sadness and embarrassment.
A: The subjective findings indicate nocturnal enuresis. Even though there is no evident cause for the patient’s symptoms, objective data confirm the diagnosis. Also, the patient has unpleasant mental symptoms that must be addressed.
P: Encourage the child while reassuring the parents. Promote bladder retention training like drinking more in the morning and early afternoon, reducing the number of times you urinate during the day, trying to hold for at least eight hours, and interrupting urination and behavior modification.
- Posttraumatic Stress Disorder (PTSD)
Name: R.B
Age: 16 years old
Gender: Male
Diagnosis: PTSD
S: R.B., a 16-year-old male patient, arrived for a psychiatric evaluation for PTSD. He stated he took off because he heard fireworks. He served in the military for eight years and has vivid memories of battle. He claims that he can’t sleep because of nightmares. He also expresses anxiety, abdominal tightness, and nausea. He denies ever informing anyone about his ordeal or seeking medical attention.
O: The patient appears to be neat. He’s agitated and scared. He stammers and speaks shakily. His demeanor is downcast, which is unnerving. There is no evidence of hostility. In his mental process, there is no evidence of delusions or hallucinations. He is also opposed to suicidal beliefs. His outlook is optimistic. He is conscious of the current date, location, and individual. Both remote and present memory is excellent. A sufficient amount of data. The patient is aware of his mental illness and wishes to improve his condition.
A: The patient has been out of the military for about a year and exhibits the majority of the symptoms associated with PTSD, like nightmares, anxiety, flashbacks, and wrath, among others.
P: To help manage the patient’s PTSD symptoms, cognitive-behavioral treatment (CBT), eye movement desensitization and reprocessing (EMDR), and prolonged exposure therapy is indicated.
- Bipolar Disorder
Name: B.E
Age: 19 years old
Gender: Female
Diagnosis: Bipolar Disorder
S: B.E. is a 19-year-old female patient who came to the psychiatric clinic with both of her parents, complaining about mood swings. She states that she missed her doses due to carelessness. She also alleges that the drugs haven’t helped her difficulties. She denies any suicidal or self-harming conduct in the past.
O: The patient was dressed neatly and adequately for his age. The patient maintains eye contact and appropriate facial expressions throughout the session. Communicates clearly, with a consistent tone and rate of speaking. Her thought process is reasonable and logical. She denies having hallucinations, delusions, or suicidal ideas. She admits to becoming forgetful, but her long-term memory remains intact. Her comprehension is poor. The patient’s ability to recognize the consequences of her actions is limited. Denies having suicidal thoughts or attempting suicide in the past.
A: To be diagnosed with this disorder, the patient must demonstrate at least three of the following symptoms: racing thoughts, talkativeness, sleep loss, inflated self-esteem, easily distracted, and psychomotor agitation, among others. The patient displayed the majority of these symptoms, which satisfied the criteria for a bipolar disorder diagnosis.
P: Suggest talk therapy or CBT. Discuss with the patient how to resolve her troublesome feelings, attitudes, and habits during therapy sessions.
Sample Answer 2 for PRAC 6645 WEEK 10 Assignment 1 : Clinical Hour and Patient Log
- Obsessive Compulsive Disorder
Name: H.F.
Age: 21 years old
Gender: Female
Diagnosis: OCD
Notes: H.F. came to the clinic today for a follow-up appointment regarding psychotherapy for OCD. About two years ago, she received a diagnosis of OCD due to her preoccupation with germs. She refutes any occurrence of suicidal thoughts, nightmares, or hallucinations. During today’s visit, H.F. displays positive health and clearly understands their surroundings, including time, place, and identity. The patient shows a consistent pattern of restlessness, which impedes her capacity to maintain a seated position. Her speech is characterized by a sense of urgency, often leading to the use of incomplete sentences. There are indications of tension in her behavior. The individual’s cognitive functioning tends to provide excessive and irrelevant details. There is a slight impairment in her cognitive abilities. H.F. denies any thoughts of self-harm or harm towards others, any hallucinations, or any mental impairments. A suggestion was made to start CBT, which would involve incorporating exposure and response prevention. The patient’s next psychotherapeutic session is scheduled for two weeks from now.
- Autism Spectrum Disorder
Name: X.G.
Age: 17 years old
Gender: Male
Diagnosis: Autism Spectrum Disorder
Notes: X.G. attended the clinic today for a follow-up on treatment for OCD with his mother. X.G. came promptly for today’s appointment, looking tidy and well-groomed. He reiterated his worries. Nevertheless, his eye contact was lacking as he tapped his foot. He seemed agitated and impatient, showing signs of excessive thinking. He anticipated a negative outcome since his buddy declined to relocate her chair. X.G. continues to struggle to grasp social signals, and his speech remains repetitious, mirroring the prior session. The patient was advised to continue with psychotherapy. During cognitive behavioral therapy, the therapist collaborates with the patient to establish objectives and modify the individual’s thought process to alter their reactions to situations. The patient’s next psychotherapy appointment is planned for two weeks.
- Substance Use Disorder
Name: C.G.
Age: 35 years
Gender: Male
Diagnosis: Substance Use Disorder
Notes: C.G. attended the clinic today for a follow-up session about psychotherapy for drug use disorder. The patient was diagnosed with the condition two years ago after experiencing various ailments associated with alcohol usage. The patient reported a three-year history of excessive alcohol intake. He was unable to manage his excessive alcohol use, even if his attempts to refrain from it were ineffective. He was concerned that his excessive alcohol usage was becoming unmanageable. The patient said that the withdrawal symptoms hindered their ability to refrain from alcohol use. The patient was dressed adequately during today’s appointment. His self-awareness, interpersonal relationships, and perception of situations were all functioning well. He did not exhibit any aberrant behaviors, such as tics. His cognitive content was undamaged. He denied having had any recent illusions, delusions, or hallucinations. He refuted any suicide ideation, efforts, strategies, and purpose. The speech had typical characteristics in terms of tone, pace, substance, and loudness. The patient was invited to participate in an anonymous alcohol group to support sobriety and also continue cognitive-behavioral therapy. He had an appointment for a follow-up visit in one week.
- Rumination Syndrome
Name: F.B.
Age: 24 years old
Gender: Male
Diagnosis: Rumination Syndrome
Notes: F.B. came to the clinic today for a follow-up appointment regarding psychotherapy for Rumination Syndrome. The patient reported experiencing frequent episodes of food regurgitation. Furthermore, the patient also experiences sleeping difficulties, dizziness, bloating, nausea, discomfort, and regurgitation. The patient denies any symptoms of diarrhea, swallowing difficulties, or heartburn. According to his account, the symptoms began when he was separated from his mother, who was unfortunately imprisoned for drug possession. During today’s visit, the patient demonstrated good health and a clear understanding of their surroundings. The patient noted a modest improvement in his mood since initiating therapy. The patient was advised to undergo habit reversal behavior therapy to enhance motivation and acquire new skills to address both anxiety and eating disorders. The patient was scheduled for the next psychotherapeutic session in 2 weeks.
- Insomnia
Name: V.K.
Age: 31 years
Gender: Female
Diagnosis: Insomnia
Notes: V.K. arrived at the clinic today for a scheduled follow-up appointment regarding their psychotherapy treatment for insomnia. The patient was referred for further psychiatric evaluation as the physician expressed concern about the worsening of her insomnia despite the initial diagnosis of major depressive disorder. She has consistently been experiencing a low mood. In addition, she mentioned challenges with falling asleep. The patient’s attire was suitable for the clinic during today’s visit. Her speaking pace was reduced while still maintaining a moderate volume. She expressed experiencing symptoms of depression. The patient reported no instances of illusions, delusions, or hallucinations. Throughout the assessment, she maintained consistent eye contact. Her thinking focused on the future. The person mentioned having thoughts of suicide but did not provide any details about a specific plan or previous attempt. The patient was advised to maintain their use of antidepressants, specifically sertraline, to manage their previously diagnosed depressive disorder effectively. She received a recommendation to consider group psychotherapy to enhance her mood and explore traditional yoga and meditation techniques to address her insomnia. The patient’s next psychotherapeutic session is scheduled for two weeks.
- Substance-Induced Psychotic Disorder
Name: B.B.
Age: 23 years old
Gender: Female
Diagnosis: Substance-Induced Psychotic Disorder
Notes: B.B. came to the clinic today for a follow-up appointment regarding psychotherapy for Substance-Induced Psychotic Disorder. The patient has been using both cocaine and marijuana simultaneously with their partner while living together on a university campus. Approximately three years ago, she managed to flee from her place of residence while being pursued by law enforcement authorities. She is currently experiencing nightmares, as well as visual and auditory hallucinations. Her coordination skills are lacking, and she displays significant anxiety in interpersonal communication. She has concerns that her romantic partner may have alerted the authorities. However, she firmly rejects any consideration of self-harm. After conducting a comprehensive psychiatric assessment, the patient was observed to be fully alert and oriented to their surroundings and time. Her self-esteem diminishes, and she lacks appreciation for her existence. The person expresses feelings marked by a dearth of optimism and a sense of helplessness. Her thought process could benefit from improved coherence as she transitions between different subjects. The patient describes experiencing hallucinations and engaging in self-harming behaviors. It was recommended that she participate in group therapy to address her addiction, as well as family therapy to address her atypical behaviors. The patient’s next psychotherapeutic session is scheduled for two weeks.
- Posttraumatic Stress Disorder
Name: S.X.
Age: 14 years old
Gender: Male
Diagnosis: PTSD
Notes: S.X. came to the clinic today for a follow-up session on psychotherapy for PTSD with his mother by his side. The patient received a diagnosis of Post-Traumatic Stress Disorder approximately two years ago and has intermittently engaged in therapy. During today’s visit, the patient appears well-groomed. He is currently experiencing feelings of agitation and fear. The patient exhibits speech difficulties characterized by stammering and a shaky delivery. His somber expression is disconcerting. There is no evidence of any hostility. His cognitive functioning does not show any signs of delusions or hallucinations. He also objects to ideologies that endorse suicide. He possesses an optimistic perspective. He knows the current date, geographical location, and specific individual. Both remote and current memory are considered reliable sources of data. The patient demonstrates a clear comprehension of his mental illness and expresses a strong motivation to improve his overall well-being. To manage their symptoms effectively, the patient was advised to consider cognitive-behavioral therapy, eye movement desensitization, reprocessing therapy, and extended exposure therapy. The patient’s next psychotherapeutic session is scheduled for two weeks.
- Bipolar Disorder
Name: B.N.
Age: 15 years old
Gender: Female
Diagnosis: Bipolar Disorder
Notes: B.N. arrived at the clinic today for a follow-up session on psychotherapy for bipolar disorder, accompanied by her father. The patient received a bipolar diagnosis approximately eight months ago and has been engaging in intermittent psychotherapy since then. During today’s session, the patient’s clothing was suitable and age-appropriate. The patient maintains consistent eye contact throughout the session and displays appropriate facial expressions. Exhibits clear and coherent communication with a consistent tone and pace. A rational and logical approach characterizes her thought process. The person denies any occurrences of hallucinations, delusions, or thoughts of self-harm. While she acknowledges occasional forgetfulness, her long-term memory remains intact. Her comprehension is limited. The patient demonstrates a restricted ability to comprehend the implications of her actions. The person denies any past thoughts of suicide or previous suicide efforts. It was suggested that the patient engage in talk therapy to address and find solutions for her emotional, attitudinal, and behavioral challenges. The patient’s next psychotherapeutic session is scheduled for two weeks.
- Schizoaffective disorder
Name: S.F.
Age: 29 years old
Gender: Male
Diagnosis: Schizoaffective disorder
Notes: S.F. attended the clinic today for a follow-up session on psychotherapy for Schizoaffective disorder. The patient describes having visual and auditory hallucinations that might endanger others. The person refutes any signs of sadness, flashbacks, or thoughts of self-harm or violence towards others. During today’s psychotherapy session, the patient exhibited intrusive and obsessive behavior while seeming physically healthy. The patient speech delivery is marked by fast, unclear, and too-loud articulation. He displays a lively and grandiose frame of mind. His emotions are mirrored in his impact. The patients noticed a little obstacle in the procedure. He encounters both auditory and visual hallucinations. His short-term memory is preserved, but his long-term memory is significantly compromised. The person has an adequate attention span, and their cognitive abilities are within the typical range. His instincts and judgment are affected considerably. The person has not had any suicidal thoughts or attempted suicide in the past. The patient was recommended to participate in practical activities like playing card games, writing, drawing, necessary arts and crafts, or listening to music. CBT often addresses practical elements of people’s lives, such as their goals, worries, relationships, and coping abilities. The patient’s next psychotherapy appointment is set for two weeks from now.
- Attention Deficit Hypersensitivity Disorder
Name: Q.C.
Age: 9 years old
Gender: Male
Diagnosis: ADHD
Notes: Q.C. attended the clinic today for a follow-up session on psychotherapy for ADHD with his father. The patient’s father revealed that his symptoms of ADHD were worsening. His lack of attention to detail and neglect of academic responsibilities at home are evident. As a result of his father’s occasional reminder letters, he can stay on track and complete his assignments. Per the instructor’s observations, the patient often daydreams and consistently chooses to be alone, which hinders their ability to interact with peers and consequently affects their academic performance. He has not participated in football since the incident of kicking his friend during a match. There is no record of any previous suicide attempts or self-harming behaviors in his medical history. He ensures a well-rounded diet and gets adequate sleep at night. During today’s session, the patient displayed impulsive, hyperactive, and inattentive traits that emerged shortly after enrolling in preschool. Positive indicators include forgetfulness, a limited attention span, recurrent negligent mistakes, an inability to follow instructions, excessive restlessness, and disruption of conversations. The patient was advised to continue attending cognitive-behavioral therapy sessions and actively participate in their treatment. The patient’s next psychotherapeutic session is scheduled for two weeks.