PRAC 6635 WEEK 10 Assignment 1 : Clinical Hour and Patient Logs
Walden University PRAC 6635 WEEK 10 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
- 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.
Depression
Name: B.T
Age: 33 years
Diagnosis: Depression
S: B.T is a 33-year-old male who came to the clinic today for his follow-up visit. He was diagnosed with depression three months ago and has been on antidepressants and group psychotherapy treatments. The patient was diagnosed with depression after he presented with a number of complaints. The complaints included the feelings of sadness almost every day. The client also felt intense guilt that made him socially isolated. There was also the change in the sleeping habits of the patient. Accordingly, he noted the increasing difficulties he was experiencing to fall asleep and maintain sleep. The client also reported lack of energy, and suicidal ideations and attempts. There was also the complaints of lack of interest in the social and occupational roles that the patient used to engage in before the diagnosis. Based on the above symptoms, the client was diagnosed with depression and initiated on antidepressants and group psychotherapy.
O: The patient appeared appropriately dressed for the occasion. He was oriented to self, place, time and events. The rate and volume of speech of the patient was normal. The self-reported mood of the client was normal. The client denied illusions, delusions and hallucinations. He also denied recent history of suicidal thoughts, attempts, and plans.
A: The client appears to have responded positively to the treatment. There have been moderate improvements in the symptoms of depression. The client expressed satisfaction with the treatment and was willing to adopt additional therapies that will improve the care outcomes.
P: The decision that the patient continues with the current treatment was made. This was based on the improvement in the symptoms of depression.
Bipolar disorder
Name: C.X
Age: 40 years
Diagnosis: Bipolar Disorder
S: C.X is a 40-year-old client who came to the clinic for the second follow-up care for bipolar disorder. The patient was diagnosed with bipolar disorder a month ago due to a number of complaints. She complained of inflated self-
esteem. She felt that she could achieve more outcomes within a short period than expected. The client also complained of insomnia. The client reported the recent experiences of hardship in getting and falling asleep. The client also reported that she was having trouble in concentrating and making decisions. The difficulties in contrating was reported to affect her ability to make sound decisions. The client also felt that she was easily distracted than before. This made it difficult for her to engage in her social and occupational roles. Based on the above complaints, the client was diagnosed with bipolar disorder and initiated on treatment.
O: The client appeared appropriately dressed for the occasion. She was oriented to self, others, time, and events. The self-reported mood of the client was ‘I can now concentrate, as am not feeling hyper active.’ The client had normal rate and volume of speech. She also had intact judgment, as she denied illusions, hallucinations and delusions. The client also denied any recent thoughts, plans or intent of committing suicide.
A: The client responded moderately to the selected treatment interventions. The ability of the client to engage in social and occupational roles has improved significantly.
P: The decision to continue with the current treatment was made. The decision was based on the moderate improvements in the symptoms of bipolar disorder. The client was scheduled for a follow-up care after four weeks.
Schizophrenia
Name: T.T
Age: 37 years
Diagnosis: Bipolar Disorder
S: T.T is a 37-year-old male that came to the psychiatry department as a referral by his physician for further assessment. The client reported a number of complaints that led to his diagnosis with schizophrenia. One of the complaints that the client raised was hallucinations. The client reported that he was seeing Jesus. Jesus was instructing him about the near end of the world. The client also had disorganized speech. The disorganized speech could be seen from flight of ideas. There were also the evidence of abnormal tics and inappropriate behaviors such as laughing even in the lack of a stimulus. The additional symptoms that accompanied the above included insomnia, increased anxiety, derealization, and increased irritability. The client and his family were worried about the effect of his health status on social and occupational functioning. As a result, they came to the hospital for further assessment and treatment.
O: The client appeared appropriately dressed for the occasion. He was oriented to place and time. His orientation to others and events was altered. The client experienced flight of ideas. The thought content was altered, as evidenced by the presence of hallucinations. There were mild tics during the assessment. The client denied illusions and delusions. He also denied recent history of suicidal thoughts, plans, and attempts.
A: The client is experiencing moderate symptoms of schizophrenia. The cognitive functioning of the client is impaired. He needs treatment to restore functioning in both social, academic, and occupational roles.
P: The patient was initiated on treatment that included the use of pharmacological agents and psychotherapy. He was scheduled for a follow-up visit after one month.
Dementia
Name: X.A
Age: 63 years
Diagnosis: Dementia
S: X.A is a 63-year-old female who came today to the clinic accompanied by her daughter for her regular checkups. The client was diagnosed with dementia six months ago and has been on treatment in the unit. The client was diagnosed with the disorder following a number of complaints. The complaints included loss of memory for a period of six months. The loss of memory could be seen from her forgetfulness of names of family members and getting lost in her familiar environments. The client also experienced aphasia as well as difficulties in making decisions. She also demonstrated hardships in making decisions that involved arithmetic or critical and creative thinking. The client also reported an increase in her level of irritation and anger. The above symptoms were reported to have affected negatively the ability of the client to engage independently in social activities. The above symptoms were not attributed to any cause. As a result, she was diagnosed with dementia and initiated on treatment.
O: The client is well groomed for the occasion. The orientation to self, others, place, and events were intact. The mood of the client was normal. The judgment of the client was intact as evidenced by absence of illusions, delusions, and hallucinations. The client denied any suicidal thoughts, plans, and attempts.
A: The client is demonstrating a positive response to the selected treatments.
P: The decision to continue with the current treatments was adopted due to continued improvement in symptoms. The client was scheduled for a follow-up visit in two months’ time.
Attention Deficit Hyperactive Disorder
Name: Z.A
Age: 11 years
Diagnosis: Attention Deficit Hyperactive Disorder
S: Z.A is a 11-year-old male who has been undergoing treatment in the unit due to ADHD. The patient was diagnosed with the disorder one year ago and has been on treatment and regular follow-up. The client came was diagnosed with ADHD after his parents brought him to the clinic with a number of complaints. The complaints included inattention, hyperactivity and impulsivity. There were also the accompanying symptoms that included failing to pay attention to details, challenges in completing tasks, and organizing activities. The client was also reported to be easily distracted and fidgets with feet, easily irritable, and symptom interference with the social and school life of the client. The symptoms were reported to have persisted for more than two years. The client has therefore been on treatment with the aim of improving the social and academic functioning.
O: The client was dressed appropriately for the occasion. The orientation to self, others, events, and time were intact. The parents reported significant improvement in social functioning of the client. The report by Z.A’s teacher indicated that his attention span and ability to engage in complex activities such as mathematics had improved significantly.
A: The client appears to be responding positively to the treatment. The client’s ability to engage in social and academic activities has improved considerably.
P: The decision that the client should continue with the current treatment was made. The fact that there has been considerable improvement in symptoms informed the decision. The client was to be assessed after one month to determine his response to treatment. The family was also given assessment tool for the teacher to determine the client’s response to treatment.
Post-Traumatic Stress Disorder
Name: K.A
Age: 26 years
Diagnosis: Post-traumatic stress disorder
S: K.A is a 26-year-old female that was brought to the unit as a referral by her physician for further assessment. The client developed abnormal symptoms after she was sexually abused. The client reported a number of symptoms that led to her being diagnosed with post-traumatic stress disorder. One of the symptoms that the client reported was the persistent recurrence of the distressing memories about the traumatic event. The client also reported that she was experiencing distressing dreams that related to the ordeal. There was also the report of flashbacks and intense distress following the exposure of the patient to the stimuli that related to the event. The client also demonstrated avoidance behaviors of the stimuli that related to the traumatic events. The symptoms had a negative effect on the ability of the client engage in her academic, social, and family roles.
O: The client appeared poorly dressed for the occasion. Her mood was depressed. Her orientation to self, others, time and space were intact. The speech volume and rate were normal. The client denied suicidal thoughts, attempts and plans. She also denied illusions, delusions and hallucinations.
A: The client is experiencing the moderate symptoms of major depression. Focus of treatment should be on improving the mood of the client.
P: The client was initiated on antidepressants and individual psychotherapy. The client was to be followed-up to determine the effectiveness of the treatment after one month.
Generalized Anxiety Disorder
Name: Q.T
Age: 20 years
Diagnosis: Generalized anxiety disorder
S: Q.T is a 20-year-old female who came to the unit for a follow-up visit after she was diagnosed with generalized anxiety disorder two months ago. The patient came to the unit with a number of complaints that led to her diagnosis with generalized anxiety. One of the symptoms was excessive worry. The client reported experiencing excessive worry about unknown things. The worry was beyond her control. The client also reported that the excessive worry was associated with a number of symptoms. They included easy fatigability, irritability, restlessness, and muscle tension. The client also reported the excessive worry which has affected her academic performance, social and occupational functioning. Further assessment showed that the symptoms were not attributed to any other cause such as medication use, substance abuse and medical condition. The client was initiated on group psychotherapy.
O: The client appeared appropriately dressed for the occasion. The orientation to self, others, events and time were intact. The volume and rate of speech of the client was normal. The client reported normal mood. The client denied any suicidal thoughts, attempts, and plans. She also denied illusions, delusions and hallucinations.
A: The client appears to be responding well to the treatment. Her ability to cope with excessive worry has improved.
P: The client was advised to continue with the prescribed treatment. The decision was attributed to the moderate improvement in symptoms. The client was scheduled for a follow-up visit after a month.
Panic Disorder
Name: C.T
Age: 21 years
Diagnosis: Panic disorder
S: C.T is a 21-year-old male who came to the clinic for a follow-up visit for treatment due to panic disorder. The client was diagnosed with panic disorder three months ago and has been individual psychotherapy treatment. The client was diagnosed with the disorder following a number of symptoms. The symptoms included feelings of excessive fear of failing in his academics. The client reported that a number of symptoms accompanied the excessive fear. The symptoms included palpitations, sweating, trembling, and feeling chocked. Severe fear was associated with symptoms that included chest pain, feelings of chocking, dizziness, and feelings of unreality. The above symptoms were reported to have affected the academic, social and occupational functioning of the client. He was diagnosed with panic disorder and initiated on group psychotherapy.
O: The client appeared appropriately dressed for the occasion. He was oriented to self, space and time. The thought content of the client was normal. He denied illusions, hallucinations, and delusions. The client also denied suicidal thoughts, plans, and attempts.
A: The client has achieved the desired outcomes in the treatment. There have been more than moderate improvements in the symptoms of panic disorder.
P: The decision to terminate the contract with the client was reached after mutual assessment of the treatment progress. The client was educated on further interventions that
Obsessive Compulsive Disorder
Name: B.B
Age: 23 years
Diagnosis: Obsessive-compulsive disorder
S: B.B is a 23-year-old female who came to the clinic for further assistance due to her problem. According to the information given by her, she often experiences persistent and recurrent urges that are intrusive and unwanted. The client reported them to be associated with considerable anxiety and distress. The client also reported having trouble in attempting to suppressive the unwanted thoughts and urges. The client uses diversion behaviors to neutralize the urges and thoughts. The client also reported compulsive behaviors that included frequent hand washing that are time consuming in nature. The increased demands from the compulsive behaviors were reported to cause considerable distress as well as impairment in social and occupation functioning. Further assessment of the client showed that the above symptoms could not be attributed to any other mental disorder such as depression and mania. It was also not attributed to medication, substance abuse, or medical condition. It was identified during the assessment that the client recognized that the obsessive-compulsive beliefs were untrue and needed to be addressed for his improved social and occupational functioning. The above symptoms led to the development of a diagnosis of obsessive compulsive disorder.
O: The client appeared well groomed for the occasion. The orientation of the client to self, others, events, and time were intact. The mood of the client was normal. Thought content and process were intact. He denied illusions, delusions and hallucinations. He also denied suicidal thoughts, plans and attempts. His speech was of normal rate and volume.
A: The client is distressed with the symptoms of obsessive-compulsive disorder that he is experiencing. He should be assisted to develop effective coping skills.
P: The client was initiated on group psychotherapy sessions. The client was to be followed up for response of treatment after one month.
Depression
Name: R.A
Age: 49 years
Diagnosis: Depression
S: R.A is a 49-year-old client that came to the unit today for assessment as a referral from his physician. The physician felt that the client had symptoms of a psychiatric disorder that needed attention from the psychiatric team. The patient came with his spouse, who was the informant during the assessment. The spouse reported a number of symptoms that the patient experienced. One of the symptoms was feeling sad daily for most part of the day. The patient also expressed hopelessness and guilt in failing to achieve his dreams. The spouse also reported that the patient lacked energy to engage in his activities of the daily living. The lack of energy was attributed to reduced appetite that the patient experienced. The spouse further reported that R.A had informed her that he felt that he needed to commit suicide to end his problems. The spouse felt that the symptoms were worsening, hence, seeking medical attention.
O: The patient appeared poorly groomed. His orientation to self and time was intact. His orientation to events was altered. The speech of the patient was reduced in terms of volume and rate. The patient’s mood was flat. His judgment was also altered. He denied history of illusions, delusions, and hallucinations. He however reported recent history of suicidal plan.
A: The patient appears to have symptoms of severe depression. The cognitive functioning of the patient is altered.
P: The patient was initiated on Zoloft 25 mg orally per day. He was also initiated on group psychotherapy. The patient was to be reviewed after one month to determine his response to treatment.
Sample Answer 2 for PRAC 6645 WEEK 8 Assignment 1 : Clinical Hour and Patient Logs
- Autism Spectrum Disorder
Name: S.G.
Age: 15 years old
Gender: Male
Diagnosis: Autism Spectrum Disorder
S: An Asian 15-year-old boy patient with a medical history of autism, anxiety, and depression was brought to the clinic by his mother. He was hospitalized in the mental ward. The patient has been undergoing cognitive therapy for these concerns since elementary school. The patient’s parents describe wrath, antagonism, and social isolation. There was no documented history of mental illnesses in the family. During the consultation, the patient exhibited signs of social phobia, excessive concern, and behaviors similar to obsessive-compulsive disorder.
O: The patient presents in excellent health and wears acceptable clothing for his age. He is aware of geographical, social, and temporal aspects. He has perfect understanding. The patient speaks and behaves in a way that is consistent with expectations. Considering his age, he exhibits a noteworthy degree of maturity. He keeps his manner the same all the time. He claimed to have been a little agitated psychomotor. He was in a euthymic mood as well. He has a sufficient memory for both short- and long-term retention. He has clear cognitive talents and shows tremendous attention. He exhibits typical thought patterns and perspectives. The patient exhibits fear, obsessive-compulsive disorder symptoms, and excessive worry.
A: The patient exhibits signs that are typical of autism spectrum disorder.
P: For this patient, applied behavior analysis was recommended as an intervention to support the development of desired behaviors and discourage undesired activities to encourage the acquisition of various abilities.
- Schizophrenia
Name: G.F.
Age: 18 years old
Gender: Female
Diagnosis: Schizophrenia
S: To continue her therapy, an 18-year-old female patient with schizophrenia is looking for a follow-up appointment at the clinic. Since receiving the diagnosis five months ago, the patient has received medication and psychotherapy as part of her treatment. She and her mother visited the facility today for routine follow-up checkups. After exhibiting symptoms, including disordered speech, auditory hallucinations, and visual hallucinations, the patient was diagnosed with schizophrenia.
O: The patient was adequately attired. She gave time, space, events, and oneself a lot of weight. She denied having had any recent experiences with hallucinations, delusions, or illusions. Denies intended suicide or attempted suicide before. Her concept was original. She showed no abnormal habits, including tics or avoiding eye contact.
A: Based on the diagnostic findings, it seems that the client’s schizophrenia symptoms have stabilized.
P: It was recommended that the patient participate in cognitive behavioral therapy sessions that addressed real-world issues such as relationships, goals, difficulties, and coping mechanisms.
- Bipolar Disorder
Name: V.L.
Age: 31 years old
Gender: Male
Diagnosis: Bipolar Disorder
S: The patient, a male Caucasian patient 31 years old, first reports long-lasting bouts of high mood. Based on the frequent bouts of heightened mood, bipolar disorder, especially the manic subtype, was diagnosed in the patient. Delusions, euphoria, elevated enthusiasm, increased activity, and intentional action were the symptoms the patient exhibited. The patient had signs of depression, including weariness, a bad mood, and a diminished interest in routine tasks. The patient had excessive sleep, poor focus and decision-making, reduced appetite, and irritation during these periods.
O: The patient was adequately attired. He had a profound awareness of his thoughts and emotions and a discerning sense of his environment’s temporal and spatial dimensions. He exhibited perceptive insight. A cognitive disability afflicts him. The patient unequivocally denies any evidence suggesting suicide ideation. However, he affirms the validity of self-destructive behaviors. Refuses to acknowledge the possibility of causing harm to others.
A: The patient exhibits mania and depression symptoms, which are consistent with bipolar disorder.
P: Potential treatment options include family-focused therapy, cognitive behavioral therapy, and interpersonal and social rhythm therapy. To optimize therapeutic success, patients should complete both medication therapy and psychotherapy.
- General Anxiety Disorder
Name: E.C.
Age: 33 years old
Gender: Female
Diagnosis: GAD
S: The 33-year-old female presented to the clinic with symptoms of anxiety, low self-esteem, and negative habitual thinking patterns. In addition, the patient has headaches, palpitations, tiredness, stiffness in the shoulders and neck, racing thoughts, panic attacks, bowel abnormalities, melancholy, nightmares, loneliness, dizziness, insomnia, and feelings of inadequacy. The patient reports that her nightmare frequency has grown to four times per week, and other symptoms occur virtually every day.
O: The female patient is well-clothed for her age. She shows concentration and a correct understanding of her surroundings, including people, place, and time. Her conduct is usual. She cooperated and communicated well throughout the interview. She has a moderate functional disability. Denies the existence of hallucinations or delusions.
A: According to the DSM-V diagnostic criteria, the patient’s symptoms are compatible with Major Depressive Disorder.
P: Medication was prescribed in addition to psychotherapy treatments, including mindfulness training and cognitive-behavioral therapy.
- Insomnia
Name: D.K.
Age: 39 years old
Gender: Female
Diagnosis: Insomnia
S: A 39-year-old Caucasian female was sent to the clinic by her physician. The patient’s sleeplessness has deteriorated despite the initial diagnosis of severe depressive disorder, leading the doctor to refer her for additional psychiatric examination. She has been experiencing constant sadness. She also mentioned having difficulty falling asleep. The decrease in her appetite caused a significant daily drop in his energy levels. In addition, she admitted to having passive suicidal thoughts.
O: The patient was dressed appropriately for the clinic. Her speaking tempo was slowed, but the volume remained constant. She reported feeling depressed. The client denied any instances of illusions, delusions, or hallucinations. She maintained direct gaze contact throughout the examination. She had a forward-thinking mentality. She frankly shared her experience with suicide ideation without any specific plan or effort.
A: Given the patient’s continued antidepressant therapy, our primary emphasis is on managing her sleeplessness.
P: The patient should consider combining cognitive-behavioral therapy with her medication. Cognitive Behavioral Therapy for Insomnia is a complete treatment that addresses problems with both getting asleep and staying asleep.
- Anorexia Nervosa
Name: Y.U.
Age: 24 years old
Gender: Female
Diagnosis: Anorexia Nervosa
S: The patient is a 23-year-old Asian girl who presented to the clinic with amenorrhea and significant weight loss in recent months. Furthermore, she claims to have persistent exhaustion and sleeplessness problems. She sometimes has constipation and stomach pain. She is unable to eat despite being hungry. She displays discomfort about her weight. There are no recorded medicine or food sensitivities.
O: All significant physiological markers are within normal ranges except for a body mass index of 16.7. The physical examination reveals signs such as thin hair, no menstruation, dry skin, swollen arms, and a blue tinge to the fingers. The abdominal examination indicates constipation and sensitivity. The patient exhibits indications of hunger and debility. The psychological assessment indicates a significant amount of pain.
A: The patient’s medical documents show a diagnosis of anorexia nervosa.
P: Consider managed weight gain and talk therapy as potential treatments.
- Enuresis Disorder
Name: F.V.
Age: 7 years old
Gender: Male
Diagnosis: Enuresis Disorder
S: A 7-year-old Asian child has outstanding physical health and no significant social concerns. The patient goes through conventional developmental stages, except nocturnal enuresis. According to the patient’s mother, the patient continues to wear pull-ups at night. The patient denies having any instances of urinary incontinence throughout the day. He denies having any bowel accidents during the day or night. The patient’s primary objective is to attend sleepover parties with his buddies. Nonetheless, he feels embarrassed since his friends may decline his invitation due to his nocturnal enuresis. While at home, he plays with his toys but shows signs of sadness.
O: A complete genital examination was carried out to discover the underlying cause of the patient’s nocturnal enuresis. The doctor palpated the renal and suprapubic areas to determine the presence of an enlarged bladder or kidney. The feces were scientifically analyzed to determine his texture and the presence of blood. A thorough neurological evaluation was conducted, which included a visual inspection and physical assessment of the lumbosacral spine. The findings did not provide a conclusive cause for the patient’s hyperhidrosis.
A: The patient’s examination aimed to identify the underlying reason for his nightly bedwetting.
P: The Three Step Program was implemented and consisted of three main components. Initially, parents were given assurance, and the child was motivated. Additionally, bladder retention and behavior training were used. Finally, parents were actively involved in the treatment process, assisting the child in applying the gained methods and resolving family conflicts.
- Major Depressive Disorder
Name: G.Z.
Age: 21 years old
Gender: Female
Diagnosis: MDD
S: An elder sister took a 21-year-old Caucasian girl to a psychiatric clinic for a mental checkup. She had a medical history of depression throughout her early teens, and she utilized antidepressant medication as a kind of treatment. Nonetheless, when she started college, she stopped taking her medication due to concerns about potential scrutiny from her peers. Nevertheless, she denies the existence of nightmares. During the mental assessment, the patient demonstrated symptoms such as sleepiness, decreased appetite, weeping, poor focus, low motivation, social anxiety, and fatigue.
O: When the patient enters the examination room, she seems well-groomed and dressed adequately for her age. Her intense eye contact and efficient communication throughout the interview demonstrated her exceptional ability to cooperate in responding to questions. She exhibits a high level of situational awareness, including understanding her surroundings, the people around her, and the present time frame. She shows practical communication skills by maintaining a constant tone and intensity. Her understanding is ongoing. Her long-term and short-term memory are intact.
A: The patient meets the DSM-V’s criteria for Major Depressive Disorder (MDD).
P: The patient was informed that cognitive behavioral therapy, interpersonal therapy, and supportive therapy, in addition to pharmaceutical treatment, were the most effective kinds of psychotherapy for controlling major depressive disorder and generalized anxiety disorder.
- Separation Anxiety Disorder (SAD)
Name: R.F.
Age: 12 years old
Gender: Male
Diagnosis: separation anxiety disorder
S: A 12-year-old boy and his mother visited the psychiatric unit for a mental health evaluation. The patient’s mother states that he has constantly shown anxiety and excessive concern about minor issues, such as her possible death or failing to pick him up from school. There is no apparent trigger for the patient’s widespread anxiousness. The patient’s mother shows preference toward his younger sibling. He regularly demonstrates rebellious conduct, such as throwing items at home and school, endangering his safety. He suffers from sleeplessness owing to repeated nightmares at night.
O: The patient is in good general health and retains his sense of self, place, and time. The patient contributes by correctly answering questions and constantly maintaining visual engagement. The patient has a positive attitude and stands up straight. The patient effectively delivers the information with clarity and eloquence. While seeing his mother, he exhibits depressive behavior and has long-term difficulties. He has heightened awareness, explicit remembering, and appropriate cognitive ability.
A: The patient has symptoms that match the diagnostic criteria for separation anxiety disorder.
P: Start the patient on cognitive behavioral therapy. The primary purpose of cognitive-behavioral therapy is to assist parents and children in developing the skills necessary to transform dysfunctional thinking and behavior.
- Alcohol Use Disorder
Name: T.B.
Age: 41 years
Gender: Male
Diagnosis: Alcohol use disorder
S: A 41-year-old Hispanic man came to the clinic for a usual follow-up consultation. After being diagnosed with alcohol consumption disorder, the patient had both psychotherapy and pharmaceutical therapies over five months. The patient reported getting a diagnosis of the condition after experiencing a variety of symptoms consistent with alcohol consumption. The client acknowledged a three-year history of excessive alcohol drinking. Despite his efforts at sobriety, he battled to manage his excessive drinking. He voiced anxiety about his inability to curb excessive alcohol usage.
O: The patient is appropriately clothed. He maintained a self-aware, socially conscious attitude toward himself, people, and diverse events. He did not exhibit any aberrant behaviors, such as tics. The client’s mind content remained unaffected. He denied any recent experiences with illusions, delusions, or hallucinations. He denied any mention of suicide ideas, attempts, plans, or intentions. The patient’s speech exhibited the usual tone, pace, content, and volume characteristics.
A: Alcohol use disorder symptoms have been steadily improving. He meets the DSM-V criteria, which supports this diagnosis.
P: The patient was advised that joining an anonymous alcohol support group would make sobering up easier, and he agreed. It was recommended that the client continue with her treatment. He had a follow-up appointment scheduled for four weeks later.