PRAC 6635 WEEK 10 Assignment 1 : Clinical Hour and Patient Logs
PRAC 6635 WEEK 10 Assignment 1 : Clinical Hour and Patient Logs
Clinical Logs
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.
PRAC 6635 WEEK 10 Assignment 1 Clinical Hour and Patient Logs
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-
PRAC 6635 WEEK 10 Assignment 1 Clinical Hour and Patient Logs
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.