PRAC 6665 WEEK 5 Assignment 1: Clinical Hour and Patient Logs
Walden University PRAC 6665 WEEK 5 Assignment 1: Clinical Hour and Patient Logs-Step-By-Step Guide
This guide will demonstrate how to complete the Walden University PRAC 6665 WEEK 5 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 6665 WEEK 5 Assignment 1: Clinical Hour and Patient Logs
Whether one passes or fails an academic assignment such as the Walden University PRAC 6665 WEEK 5 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 6665 WEEK 5 Assignment 1: Clinical Hour and Patient Logs
The introduction for the Walden University PRAC 6665 WEEK 5 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 6665 WEEK 5 Assignment 1: Clinical Hour and Patient Logs
After the introduction, move into the main part of the PRAC 6665 WEEK 5 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 6665 WEEK 5 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 6665 WEEK 5 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 6665 WEEK 5 Assignment 1: Clinical Hour and Patient Logs
Clinical Logs
Major Depression
Name: E.T
Age: 44 years
Diagnosis: Major Depression
S: E.T is a 44-year-old client that came to the unit for his follow-up visit after being diagnosed with depression two months ago. The diagnosis was reached after he presented initially with complaints of a suicide attempt. E.T. wanted to kill himself, as he felt useless. He also reported excessive feelings of guilt. E.T also reported a history of depressed mood for most of the days which made it hard for him to engage in his activities of daily living. The client’s interest in pleasure had also declined significantly. He appeared fatigued most of the days and found it hard in making decisions. There was also the complaint of the lack of appetite. The client reported suicidal thoughts and attempts. He denied any current suicidal plans. Consequently, he was diagnosed with depression and initiated on treatment.
O: The client appeared well dressed for the occasion. He reported that his mood was improved. The client was oriented to self, others, time, and events. He denied illusions, delusions, and hallucinations. He denied suicidal thoughts, attempts, and current suicidal plans. His speech was normal in terms of rate and volume.
A: The client is responding well to treatment. He does not report any adverse effects.
P: The client was advised to continue with the current treatment. He was scheduled for his follow-up visit after four weeks.
Major Depression
Name: X.V
Age: 38 years
Diagnosis: Major depression
S: X.V is a 38-year-old client that came to the unit for his fourth follow-up visit for major depression. He has been
on antidepressants and psychotherapy treatments. The diagnosis of major depression was reached after the client presented with symptoms that included persistent feelings of guilt and worthlessness. He reported feeling sad on most days almost throughout the day. He noted that his mood was depressed most of the time. There was also the complaint of a decline in his appetite and consistently low energy levels. He denied suicidal thoughts, plans, or attempts. The above complaints led to him being diagnosed with major depression and have been undergoing treatment in the unit.
O: The client was dressed appropriately for the occasion. His orientation to self, others, time, and events were intact. His self-reported mood was normal. His speech was normal in terms of rate and volume. He denied illusions, delusions, and hallucinations. He also denied suicidal thoughts, attempts, and plans.
A: The client is responding well to the treatment, as the symptoms of major depression have improved as expected in the treatment plan.
P: The client was advised to continue with the current treatments. He was scheduled for a follow-up visit after four weeks.
Major Depression
Name: A.A
Age: 27 years
Diagnosis: Major Depression
S: A.A. is a 27-year old client brought today to the unit with a history of a suicidal attempt. The client had attempted to commit suicide by drinking an organophosphate. The client reported that he wanted to kill himself because he always felt hopeless. The family reported that the client was socially withdrawn. He did not have an interest in pleasure. He also gets easily irritated with things. The client reported that his energy levels were low on most of the days. He denied his current suicidal plan. He however has a suicidal attempt. Due to the above complaints, the client was diagnosed with major depression and initiated 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 was intact. He 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 current suicidal plans. His judgment is intact.
A: 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. He would be initiated on psychotherapy once stabilized.
Post-Traumatic Stress Disorder
Name: G.L
Age: 34 years
Diagnosis: Post-traumatic stress disorder
S: G.L is a 34-year-old female client who came to the unit today for her regular follow-up visits for post-traumatic stress disorder. She was diagnosed with the disorder five months ago and has been undergoing treatment. She reported that her mental health problems began after being involved in a road accident. She came initially to the unit with complaints of flashbacks and nightmares about the accident. She also avoided any stimuli that related to the accident. G.L. further reported being easily irritated, experiencing difficulties in sleeping and concentration. Therefore, her family brought her to the unit where she was diagnosed with post-traumatic stress disorder and initiated on treatment.
O: The client was well-groomed for the occasion. Her orientation to self, others, environment, and events were intact. Her self-reported mood was normal. Her level of judgment was intact. She denied suicidal thoughts, plans or attempts, illusions, delusions, and hallucinations.
A: The client is responding positively to the treatment. She 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: X.G
Age: 40 years
Diagnosis: Post-traumatic stress disorder
S: X.G. is a 40-year-old male that came to the unit today for his third follow-up visit after being diagnosed with post-traumatic stress disorder four months ago. The diagnosis was reached after he started experiencing abnormal symptoms following his involvement in a road accident. He reported distressing memories that related to the accident. He also reported flashbacks and nightmares about the accident. The above symptoms had made him engage in activities to divert his attention from any stimuli related to the incident. The symptoms associated with the accident significantly affected his ability to perform optimally in his social and occupational roles. As a result, he was diagnosed with post-traumatic stress disorder and initiated on antidepressants and group psychotherapy sessions.
O: X.G. appeared dressed appropriately for the occasion. His orientation to self, others, time, and events were intact. His thought process was future-oriented. His mood was normal. He denied any recent suicidal thoughts, plans, or attempts. He also denied illusions, delusions, and hallucinations.
A: The adopted treatments are effective in symptom management.
P: X.G. was advised to continue with the currently prescribed medications and psychotherapy sessions. He was scheduled for a follow-up visit after four weeks
Generalized Anxiety Disorder
Name: R.E
Age: 23 years
Diagnosis: Generalized anxiety disorder
S: R.E is a 23-year old female client that came to the unit for her third follow-up visit after being diagnosed with generalized anxiety disorder four months ago. The diagnosis was reached after she came with complaints of excessive worry and anxiety about unknown outcomes in her life. The feelings were beyond her control. The accompanying symptoms that the client reported included chest pain, shortness of breath, and sweating. The symptoms could not be attributed to other causes such as medication use, substance abuse, and medical conditions. As a result, she was diagnosed with generalized anxiety disorder and initiated on individual psychotherapy.
O: The client appeared well-groomed for the occasion. She was oriented to self, others, time, and events. She denied illusions, delusions, and hallucinations. She also denied suicidal thoughts, attempts, and plans.
A: The individual psychotherapy treatment has been effective, as evidenced by improvement in symptoms.
P: The client was advised to continue with the current treatment. She was scheduled for a follow-up visit after four weeks.
Obsessive-Compulsive Disorder
Name: R.V
Age: 25 years
Diagnosis: Obsessive-compulsive disorder
S: R.V. is a 25-year-old male who came to the clinic for his third follow-up visit after being diagnosed with obsessive-compulsive disorder. He was diagnosed with the disorder after presenting with complaints that included frequent experiences of persistent and recurrent intrusive and unwanted urges. The symptoms were associated with considerable anxiety and distress, as he found it hard suppressing them. The compulsive behaviors included checking, which is time-consuming. The symptoms could not be attributed to other causes such as medication, medication, substance abuse, or medical condition. Therefore, he was diagnosed with obsessive-compulsive disorder and initiated on psychotherapy.
O: The client appeared well-groomed for the occasion. His orientation of the client to self, others, events, and time were intact. The mood was normal. Thought content and process were intact. He denied illusions, delusions, and hallucinations. He also denied suicidal thoughts, plans, and attempts.
A: There has been improvement in the symptoms of obsessive-compulsive disorder.
P: The client was advised to continue with psychotherapy sessions. He was scheduled for a follow-up after one month.
Insomnia
Name: H.O
Age: 30 years
Diagnosis: Insomnia
S: H.O is a 30-year-old male who came to the clinic for his fifth follow-up visit after being diagnosed with insomnia. He has been on group psychotherapy sessions to help him manage his problem. He was diagnosed with insomnia after he presented to the unit with complaints of difficulties in falling asleep and maintaining sleep. He also reported sleeping during the day due to the lack of enough sleep at night. His energy levels during the day were significantly reduced. As a result, he was worried that his productivity was not at the expected level. The client could not attribute the symptoms to any cause such as medical condition, medications, or substance abuse. Due to the above complaints, he 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, or illusions. He also denied any history of suicidal thoughts, attempts, and plans.
A: The use of group psychotherapy treatment has been effective in managing the symptoms of insomnia.
P: The decision to terminate the client’s participation in psychotherapy sessions was made. The treatment outcomes had been achieved.
Bipolar Disorder
Name: J.P
Age: 44 years
Diagnosis: Bipolar Disorder
S: J.P is a 44-year-old client that came to the unit for his follow-up visit after being diagnosed with bipolar disorder five months ago. The diagnosis was reached after she came with complaints that included an expansive mood that was characterized by the patient feeling that he was in control of everything. She was also easily irritable and agitated. She also found it difficult to concentrate on tasks. She also engaged in goal-directed activities and impulsive behaviors. The above symptoms affected her social and occupational functioning. As a result, she was diagnosed with bipolar disorder and has been on treatment in the unit.
O: The client 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.
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 a follow-up visit after four weeks.
Schizophrenia
Name: R.T.
Age: 26 years
Diagnosis: Schizophrenia
S: R.T is a 26-year-old client that came to the unit for her follow-up visit after being diagnosed with schizophrenia three months ago. The diagnosis was reached after she came with complaints of hearing voices. The client reported that the symptoms had affected severely her level of functioning in areas that included interpersonal relations and work life. The symptoms had persisted for more than five months. The symptoms could not be attributed to other causes such as medication use, medical condition, and substance abuse. 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.
A: The client continues to respond positively to the treatment.
P: The client was advised to continue with antipsychotics. She was scheduled for the next follow-up visit in one month.
Sample Answer 2 for PRAC 6665 WEEK 5 Assignment 1: Clinical Hour and Patient Logs
- Sleepwalking Disorder (Somnambulism)
Name: J.T
Age: 10 years
Gender: Male
Diagnosis: Sleepwalking Disorder
S: J.T. is a 10-year-old boy brought in by his parents due to concerns about sleepwalking episodes. The parents report that over the past three months, the patient has been getting out of bed and walking around the house while still asleep. These episodes occur approximately two to three times per week, typically within the first few hours of falling asleep. The patient appears disoriented and unresponsive during these episodes and has no memory of them upon waking. The parents have observed him performing routine tasks, such as opening doors and moving objects, but he has not engaged in any dangerous activities. They note no significant changes in his daily routine or stressors but mention that he has been more tired than usual. The patient denies experiencing any anxiety, nightmares, or other sleep disturbances.
O: The patient appears well-rested and cooperative during the examination. The patient’s physical examination is unremarkable, with normal vital signs and no signs of injury or illness. His mental status examination reveals a well-groomed boy who is alert, oriented, and developmentally appropriate for his age. He exhibits normal speech, thought processes, and affect, with no signs of distress or anxiety. A review of his sleep habits indicates a consistent bedtime routine, although his parents mention he occasionally stays up later on weekends.
A: The observed symptoms are consistent with Somnambulism.
P: Educated the parents about sleepwalking, including common triggers and the typical course of the disorder. Advised the parents to gently guide the patient back to bed during episodes without waking him, as awakening can cause confusion and distress. Recommended the patient to maintain a consistent sleep routine with adequate sleep duration to reduce the likelihood of episodes. Advised his parents to implement safety measures at home to prevent injury during sleepwalking episodes. Scheduled a follow-up appointment in three months.
- Panic Disorder
Name: H.L
Age: 19 years
Gender: Male
Diagnosis: Panic Disorder
S: H.L. is a 19-year-old girl presenting with recurrent episodes of intense fear and physical symptoms that began approximately six months ago. She reports experiencing sudden episodes of heart palpitations, sweating, trembling, shortness of breath, chest pain, dizziness, and an overwhelming fear of losing control or dying. These panic attacks occur unpredictably, often without an identifiable trigger, and typically last for about 10 to 20 minutes. The patient describes a persistent worry about having more attacks and avoids situations where she fears an attack might occur, such as crowded places or being alone. This avoidance behavior has begun interfering with her daily activities, including attending school and socializing with friends.
O: The patient appears anxious and is visibly distressed when discussing her symptoms. Physical examination is unremarkable, with normal vital signs and no evidence of cardiovascular or respiratory issues. The patient’s mental status examination reveals a well-groomed young woman who is alert and oriented, with normal speech and thought processes. She exhibits signs of anxiety, such as restlessness and difficulty maintaining eye contact. No evidence of mood disorders or psychosis is observed.
S: Based on DSM-V criteria, the patient has Panic Disorder.
P: Initiated CBT to address the underlying thoughts and behaviors contributing to panic attacks. Provided psychoeducation about Panic Disorder. Started sertraline (Zoloft) at an initial dose of 25 mg daily for one week. Prescribed lorazepam (Ativan) 0.5 mg once a day. Booked the patient for a follow-up appointment after two weeks.
- Frontotemporal Dementia
Name: J.K
Age: 59 years
Gender: Male
Diagnosis: Frontotemporal Dementia
S: J.K. is a 59-year-old man brought in by his wife due to concerns about significant changes in his behavior and personality over the past year. The wife reports that the patient has become increasingly disinhibited, making inappropriate comments and displaying socially unacceptable behaviors. He has also shown a marked decline in empathy and emotional responsiveness, often appearing indifferent to the feelings of others. The patient has exhibited repetitive, compulsive behaviors and a noticeable decline in executive functioning, including difficulties with planning, decision-making, and focusing on tasks. His memory remains intact, but language skills, particularly word-finding, have deteriorated. The wife denies any significant medical history, substance abuse, or recent head trauma. There is a family history of dementia in the patient’s father.
O: The patient appears well-groomed but demonstrates noticeable disinhibition and engages in inappropriate joking during the examination. The patient’s physical examination is unremarkable, with normal vital signs. Neurological examination reveals no motor or sensory deficits. Mental status examination shows a cooperative but easily distracted man with impaired judgment, poor insight, and limited ability to perform complex tasks. His speech is fluent but occasionally tangential, and he struggles with word-finding. He displays limited concern for his behavior and its impact on others.
A: The presented symptoms are in line with Frontotemporal Dementia.
P: Started sertraline (Zoloft) 25 mg daily and memantine (Namenda) 10 mg twice daily. Provide psychoeducation to the patient and his family about Frontotemporal Dementia, its progression, and management strategies. Coordinated care with a multidisciplinary team, including neurologists, neuropsychologists, and social workers, to provide comprehensive care and support. Booked the patient for review after two weeks.
- Borderline Personality Disorder
Name: D.Z
Age: 30 years
Gender: Female
Diagnosis: Borderline Personality Disorder
S: D.Z is a 30-year-old woman presenting with longstanding patterns of unstable relationships, intense emotions, and impulsive behaviors. She reports experiencing frequent mood swings, feelings of emptiness, and intense fears of abandonment. The patient describes her relationships as tumultuous, with episodes of idealizing partners followed by rapid devaluation and conflict. She has a history of impulsive behaviors, including binge eating, reckless driving, and self-harming (cutting), particularly during periods of intense emotional distress. The patient acknowledges experiencing episodes of intense anger and difficulty controlling it, often resulting in verbal outbursts. She has a history of multiple suicide attempts and frequent suicidal ideation, particularly when feeling rejected or abandoned. The patient reports a traumatic childhood with a history of emotional and physical abuse. She denies current substance abuse but admits to past usage to cope with emotional pain.
O: The patient appears anxious and distressed during the examination, frequently shifting between tearfulness and irritability. Physical examination is unremarkable, with normal vital signs and no immediate medical concerns. Scars from self-harming behaviors are visible on her forearms. She is cooperative during the examination but emotionally labile, with rapid shifts in mood and affect. Her thought processes are coherent but marked by pervasive fears of abandonment and a pattern of splitting (seeing people as all good or all bad). She expresses chronic feelings of emptiness and intense, inappropriate anger.
A: The patient has Borderline Personality Disorder.
P: Started CBT sessions. Referred the patient to a therapist specializing in Dialectical Behavior Therapy (DBT). Started sertraline (Zoloft) 25 mg daily for seven days. Scheduled regular follow-up appointments every three months.
- Developmental Coordination Disorder (DCD)
Name: W.R
Age: 8 years
Gender: Male
Diagnosis: Developmental Coordination Disorder (DCD)
S: W.R. is an 8-year-old boy brought in by his parents due to concerns about his motor skills. The parents report that the child has difficulty with tasks requiring fine motor coordination, such as writing, buttoning clothes, and using utensils. They also mention that he appears clumsy and frequently trips or drops things. These difficulties have been present since he started preschool but have become more noticeable with increased academic and social demands. The parents are concerned about his performance at school, and teachers have noted his struggles with handwriting and participation in physical activities. No recent injuries or illnesses are reported.
O: The patient appears well-nourished and cooperative during the examination. The patient’s physical examination is unremarkable, with normal vital signs. Neurological examination reveals normal muscle tone and strength but poor fine motor coordination. The patient struggles with tasks such as drawing shapes, writing his name, and buttoning his shirt. His gait appears awkward, and he occasionally stumbles. Gross motor skills like running and jumping are also below age expectations. No signs of neurological deficits or abnormalities in sensory function are observed.
A: Based on the observed symptoms, the patient has Developmental Coordination Disorder (DCD).
P: Provided psychoeducation to the parents about Developmental Coordination Disorder, its symptoms, and management strategies. Referred the patient to an occupational therapist. Collaborated with the patient’s school to implement appropriate accommodations. Planned for follow-up appointments every four weeks.
- Narcissistic Personality Disorder
Name: L.K
Age: 43 years
Gender: Female
Diagnosis: Narcissistic Personality Disorder
S: L.K. is a 43-year-old woman returning for a follow-up visit. She was previously diagnosed with Narcissistic Personality Disorder (NPD) and has been receiving therapy for six months. The patient reports some improvement in her interpersonal relationships and acknowledges a greater awareness of her behaviors and their impact on others. However, she continues to struggle with feelings of entitlement, a need for admiration, and difficulties in accepting criticism. She notes occasional conflicts at work and home but feels more equipped to handle them. She expresses frustration with the slow progress and sometimes doubts the benefits of therapy. The patient denies any new stressors or significant changes in her life since the last visit.
O: The patient appears well-groomed and confident during the examination. Her speech is articulate, and she maintains strong eye contact. She continues exhibiting signs of grandiosity and tends to dominate the conversation. Despite this, she shows moments of insight and reflection about her condition. There is no evidence of mood disturbances or anxiety. Physical examination is unremarkable, and vital signs are within normal limits.
A: The patient has Narcissistic Personality Disorder, improved.
P: Continued cognitive Behavioral Therapy (CBT) and Dialectical Behavior Therapy (DBT). Continued fluoxetine (Prozac) 20 mg daily. Started quetiapine (Seroquel) 25 mg at bedtime.
- Separation Anxiety Disorder
Name: G.O
Age: 27years
Gender: Female
Diagnosis: Separation Anxiety Disorder
S: G.O. is a 27-year-old woman presenting with symptoms of significant anxiety related to separation from her fiancé and family members. She reports excessive worry and fears about potential harm coming to her loved ones when they are not with her. These feelings have intensified over the past year, particularly after her recent relocation to a new city for work. The patient describes experiencing physical symptoms such as nausea, headaches, and difficulty sleeping when she is separated from her fiancé. She avoids social events and opportunities that require her to be away from her loved ones. The patient notes that these symptoms affect her job performance and personal relationships. She denies any history of similar symptoms in childhood and reports no significant medical history or substance use.
O: The patient appears anxious and tense during the examination. Physical examination is unremarkable, with normal vital signs. Mental status examination reveals a cooperative, alert, oriented woman with coherent thought processes. She exhibits signs of anxiety, such as fidgeting and difficulty concentrating. Her mood is anxious, and her affect is congruent with her mood. No evidence of depression, psychosis, or other psychiatric disorders is observed.
A: The patient’s symptoms are indicative of separation anxiety disorder.
P: Provided psychoeducation about Separation Anxiety Disorder. Started CBT sessions. Introduced exposure therapy to gradually increase the patient’s tolerance to being away from her loved ones. Started sertraline (Zoloft) at 25 mg daily for the first week, then increased to 50 mg daily and hydroxyzine (Vistaril) at 25 mg daily. Schedule regular follow-up appointments every four weeks.
- Enuresis (bedwetting)
Name: V. T
Age: 12years
Gender: Female
Diagnosis: Enuresis
S: V.T. is a 12-year-old boy returning for a follow-up visit for persistent Enuresis (bedwetting) despite previous interventions. The patient and his parents report that he continues to experience bedwetting episodes approximately 3-4 times per week. They note that there have been no significant changes in stressors or routines at home or school since the last visit. The patient feels embarrassed and frustrated by the continued bedwetting, which is affecting his self-esteem and social activities. He denies any pain or discomfort associated with urination and reports normal daytime voiding habits.
O: During the examination, the patient appears well-nourished and developmentally appropriate for his age. Physical examination is unremarkable, with no signs of abnormality in the genitalia or abdomen. Neurological examination is within normal limits. There are no signs of urinary tract infection or other medical conditions.
A: The presented symptoms still point to Enuresis.
P: Increased desmopressin acetate (DDAVP) from 0.2 to 0.6 mg orally at bedtime. Reinforce and modify behavioral strategies, such as limiting fluid intake in the evening, using the bathroom before bedtime, and rewarding dry nights with positive reinforcement. Scheduled for follow-up appointment in six weeks.
- Pica
Name: N.N
Age: 8 years
Gender: Male
Diagnosis: Pica
S: N.N. is an 8-year-old boy presenting for a follow-up visit for pica. His parents report that he continues to eat non-nutritive substances, such as dirt, chalk, and paper, despite previous interventions. They note that these behaviors have been ongoing for the past year and have caused concern for his health and safety. The parents have tried to monitor and redirect his behavior with limited success. They express worry about potential health risks and social implications of his behavior. The patient does not appear to be aware of the abnormality of his eating habits and shows little concern about them.
O: The patient appears well-nourished and in no acute distress. Vital signs are within normal limits. During the interview, he is cooperative but somewhat inattentive. There are no signs of physical harm or malnutrition. The patient’s oral mucosa and teeth are normal, with no visible damage from ingesting non-food items. A physical examination reveals no abnormalities. Mental status examination reveals age-appropriate cognitive functioning but limited insight into his pica behaviors.
A: The patient continues to exhibit symptoms consistent with pica.
- Encouraged consistent routines and close supervision to prevent the ingestion of harmful substances. Continued with behavioral therapy focusing on positive reinforcement for appropriate eating behaviors and redirection techniques to discourage pica behaviors. Booked for follow-up after four weeks.
- Schizoid Personality Disorder
Name: B.K
Age: 47years
Gender: Male
Diagnosis: Schizoid Personality Disorder
S: B.K. is a 47-year-old man presenting for an initial evaluation of concerns related to social isolation and emotional detachment, which are suggestive of schizoid personality disorder. He reports a long-standing pattern of preferring solitude and having little interest in forming close relationships, including with family members. He states that he rarely experiences strong emotions and does not find pleasure in most activities. The patient lives alone and works in a job that requires minimal social interaction. He denies any recent changes in mood, hallucinations, or delusions. His primary concern is maintaining his current lifestyle without pressure to change.
O: The patient appears appropriately groomed and in no acute distress. Vital signs are within normal limits. During the interview, he maintained limited eye contact and exhibited a flat affect. His speech is coherent and goal-directed, but he provides brief responses and shows minimal emotional expression. There are no signs of psychomotor agitation or retardation. Mental status examination reveals a constricted affect and a preference for solitary activities. Cognitive function appears intact, with no evidence of hallucinations or delusions.
A: The patient’s presentation is consistent with schizoid personality disorder.
P: Commenced cognitive-behavioral therapy (CBT) to address any specific issues related to social skills and coping strategies for managing solitary life effectively. Encouraged the patient to engage in activities that he finds enjoyable, even if solitary, to maintain a sense of fulfillment. Scheduled a follow-up appointment in 4 weeks.