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PRAC 6635 WEEK 6 Assignment : Clinical Hour and Patient Logs

PRAC 6635 WEEK 6 Assignment : Clinical Hour and Patient Logs

Clinical Logs

Major Depression

Age: 45 years

Diagnosis: Major depression

S: A.R is a 45-year-old male who has been undergoing treatment for depression in the psychiatry unit. Today was the client’s fourth visit. He was diagnosed with major depression four months ago and has been on psychotherapy and using pharmacological interventions for symptom management. The client was diagnosed with major depression due to a number of symptoms. They included having suicidal thoughts and attempting to commit suicide. The patient also experienced depressed mood most of the time throughout the day. He lacked the energy to engage in his social and occupational activities. His appetite had also reduced significantly leading to low food intake, fatigue and changes in body weight. The patient also reported having trouble in making decisions as well as concentrating even on simple tasks. His spouse brought him for psychiatric review where he was diagnosed with major depression. He has been using Zoloft 75 mg orally per day and has been attending group psychotherapy.

O: The client appeared appropriately dressed for the occasion. He was oriented to self, place, time and events. The mood was elevated. He was future oriented. His speech volume and rate was normal. His judgment was intact. He denied recent history of suicidal thoughts, plans or attempts. The client also denied illusions, hallucinations, and delusions. He was satisfied that the treatment has been effective in improving his distressing symptoms.

A: The patient is responding positively to the treatment. The increase of Zoloft dosage from 50 mg to 75 mg has been effective. The patient has tolerated the new medication regime.

P: The patient was advised to continue with the current medication regime. He was also informed to continue with the monthly group psychotherapy sessions. He will be reviewed in one months’ time to det

PRAC 6635 WEEK 6 Assignment  Clinical Hour and Patient Logs
PRAC 6635 WEEK 6 Assignment  Clinical Hour and Patient Logs

ermine his response to treatment.

Major Depression

Name: B.X

Age: 46 years

Diagnosis: Major Depression

S: B.X is a 46-year-old female who was referred to the psychiatric unit by her family physician. The physician felt that B.X could be experiencing a psychiatric disorder, increasing the need for her review in the unit. The client came

PRAC 6635 WEEK 6 Assignment Clinical Hour and Patient Logs
PRAC 6635 WEEK 6 Assignment Clinical Hour and Patient Logs

with a number of complaints. One of them was persistently low moods throughout the day, most of the day. The client also felt hopeless in life and often guilty that she had not accomplished the things she wanted in her life. The client also reported experiencing persistent insomnia. The insomnia often led to her fatigue during the day in her workplace. The client also complained that her appetite had declined significantly. She had lost over 5 kg in weight over the last four months. The family of the client were worried that her health was deteriorating so fast that she needed medical attention. Most recently, the patient expressed intent to commit suicide. She had a well-developed plan that she intended to use in committing suicide. Based on the above complaints, the client was diagnosed with major depression.

O: The client is poorly dressed for the occasion. Her orientation to self and place is altered. The patient’s mood is depressed. The speech is reduced in terms of rate and volume. The judgment of the client is also altered. She reports suicidal thoughts and plans. She denied hallucinations, illusions and delusions.

A: The client experiences symptoms of major depression. The client should be started on pharmacological intervention to improve her symptoms. She also needs close follow-up to determine the effectiveness of the medication.

P: The client was prescribed Zoloft 50 mg orally per day to manage symptoms of depression. She was scheduled for a follow-up visit after one month.

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Bipolar Disorder

Name: C.A

Age: 33 years

Diagnosis: Bipolar Disorder

S: C.A is a 33-year-old male who was diagnosed three months ago with bipolar disorder. The patient has been on follow-up visit to determine his response to treatment. The patient is currently on psychotherapy and use of pharmacological interventions. The client was diagnosed with bipolar disorder three months ago due to a number of complaints. They included mood swings characterized by high and low moods. The patient reported that he experienced mixed feelings of elevated moods and depressed moods. The patient reported feeling hopeless, guilty or sad and losing interest in things when he was depressed. The depression alternated with explosion of moods characterized by high energy, euphoria, insomnia, and being easily irritable. The client also reported fatigue and difficulties in concentrating during depressive episodes of the disorder. Based on the above, the patient was diagnosed with bipolar disorder and has been on pharmacological treatment and psychotherapy.

O: The client appeared appropriately dressed for the occasion. The orientation of the client to place, self, time and events was intact. The mood of the client was normal with absence of euphoria. The speech was of normal rate and volume. The client denied recent history of suicidal thoughts, plans, and intent. The client also denied illusions, hallucinations, and delusions.

A: The client appears to be responding positively to the treatment. The client expressed optimism with the treatment interventions. The symptoms of bipolar disorder are now mild.

P: The client was advised to continue with the current dose of medications alongside attending psychotherapy sessions on a monthly basis.

Schizophrenia

Name: B.D

Age: 40 years

Diagnosis: Schizophrenia

S: B.D is a 40-year-old male who was brought to the unit as a referral by his physician. The patient came to the unit with a number of symptoms that led to his diagnosis with schizophrenia. One of the symptoms that the patient had was delusions. The client had altered sense of self and others. The patient also hallucinated as well as disorganized speech. The emotional expression of the client was also impaired. The above symptoms were reported to have affected the ability of the client to function in his social and occupational roles. The impaired functioning could not be attributed to any cause such as drug or substance abuse or any medical condition. The symptoms led to the patient being diagnosed with schizophrenia.

O: The patient appeared poorly groomed. His orientation to self, place, and events were altered. The client also demonstrated mutism during the assessment. The mood of the client was depressed. The client reported delusions and hallucinations. He denied history of suicidal thoughts, plans, or attempts.

A: The cognitive ability of the client appears altered. The patient requires assistance in the development of his sense of self and others. The aim of treatment should be on the management of symptoms.

P: The client was initiated on psychotherapy and prescribed pharmacological medications to manage symptoms. The patient was to be reviewed after four weeks to determine his response to treatment.

Insomnia

Name: D.A

Age: 23 years

Diagnosis: Insomnia

S: D.A is a 23-year-old female who was brought to the unit as a referral by her primary care physician. The primary care physician believed that D.A had a health problem that the psychiatric team could address. The history taken from the client showed that the client had a three-month history of sleeping problems. The client reported having trouble in falling asleep and maintaining sleep at night. She also reported that she always laid awake for long periods at night. She also noted that she finds it hard to get back to sleep whenever where wakes up at night. The client also noted that her energy levels had decline significantly over the past few days. The decline in energy was attributed to the lack of sleep that affected her ability to engage in her daily routines. Based on the above symptoms, the client was diagnosed with insomnia.

O: The patient was dressed appropriately for the occasion. Her orientation to self, place, time, and events were intact. The client appeared tired during the assessment due to lack of sleep. The speech was of normal rate and volume. The judgment was intact with the absence of delusions, hallucinations, and illusions. The client denied any history of suicidal thoughts, plans, or attempts.

A: The client appeared tired due to lack of sleep in the previous night. The patient therefore needed assistance on ways of achieving healthy sleep to maintain optimum health and functionality.

P: The patient was initiated on individual psychotherapy session. She was provided health education on ways of achieving quality sleep and maintaining it. She was also educated on the dietary and physical activity routines that she needed to overcome insomnia. She was scheduled for a follow-up visit after two weeks to assess the effectiveness of the interventions.

Insomnia

Name: E.F

Age: 30 years

Diagnosis: Insomnia:

S: E.F is a 30-year-old male who came to the clinic for his second follow-up visit. The client was diagnosed with insomnia three months ago and has been on psychotherapy sessions. The patient was diagnosed with insomnia after he presented to the unit with a number of symptoms. One of them was difficulty in falling asleep and maintaining sleep. The client also reported frequent episodes of waking up while asleep and finding it hard to get sleep afterwards. The client also reported sleeping during the day due to the lack of enough sleep at night. The energy levels of the client during the day were significantly reduced. As a result, he was worried that his productivity was not to the expected level in his organization. Due to the above complaints, the patient was diagnosed with insomnia, and has been undergoing 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 ‘significantly improved.’ The judgment of the client was intact. He denied any history of delusions, hallucinations, and illusions. He also denied any history of suicidal thoughts, attempts, and plans.

A: The symptoms of insomnia being experienced by the client have significantly improved. The psychotherapy sessions are effective in addressing the needs of the client. The coping abilities are as per the developed treatment goals.

P: The decision to continue with psychotherapy sessions was upheld. The treatment will be terminated in the next session should a further improvement in symptoms be noted.

Alzheimer’s disease

Name: F.Y

Age: 76 years

Diagnosis: Alzheimer’s disease

S: F.Y is a 76-year-old client who has been undergoing treatment in our unit due to Alzheimer’s disease. The client was diagnosed with Alzheimer’s disease six months ago and has been on follow-up care since then. The client was diagnosed with the disease due to a number of symptoms. One of the symptoms was memory impairment. The patient reported symptoms of memory impairment that included forgetting names of family members, things, and places. The patient also got lost in his familiar places. There was also a change in his personality where he began being aggressive and highly irritable. There was also the evidence of changes in the executive functions of the client. The client would also find it hard in selecting the words to use for his expression. There was also the evidence of increased anxiety being experienced by the client. The anxiety was also associated with mild depressive symptoms that included disinhibition, changes in sleep and appetite, and delusions. Based on the above symptoms, the client was diagnosed with Alzheimer’s disease and has been on treatment.

O: The client appeared appropriately dressed for the occasion. His orientation to self, time, space, and others were intact. The client’s memory of recent and past events was also moderate. The client reported mild symptoms of anxiety. His speech was normal in rate and volume. He denied recent history of hallucinations, delusions, and illusions. He also denied history of suicidal thoughts, plans or attempts.

A: There is moderate improvement in the cognitive functioning of the client. The family reports significant improvement in symptoms of Alzheimer’s disease.

P: The patient was advised to continue with the current medications. He was scheduled for a follow-up visit by the end of the month.

Attention Deficit Hyperactive Disorder

Name: F.A

Age: 9 years

Diagnosis: Attention Deficit Hyperactive Disorder

S: F.A is a 9-year-old male who has been undergoing treatment in the unit for ADHD. The client was diagnosed with ADHD one year ago and has been on treatment and regular follow-up in the clinic. Today, his parents brought F.A for the regular follow-up sessions. The client was diagnosed with ADHD due to a number of complaints. One of them was lack of attention alongside symptoms of impulsivity and hyperactivity for more than six months after being enrolled in school. The symptoms of impulsivity were reported to affect negatively the social and academic performance of the client. The client also demonstrated the above symptoms both in school and at home. The teacher had reported that the client day dreamed and seemed distant while in class. He also failed to complete his assignments on time. He was also reported not to engage actively in complex learning activities that required creativity and critical thinking. A further assessment of the client showed that the symptoms were not attributable to any cause, hence, the diagnosis with ADHD.

O: The client appeared appropriately dressed. His orientation to self, others, time and space was intact. His attention span was reduced. The client demonstrated flight of ideas. The teacher reported that his daydreaming had stopped with the interests of the client on learning activities improved significantly.

A: There is moderate improvement in the symptoms of ADHD.

P: The parents of the client were advised to continue with the medications and attend the monthly follow-up visits.

Post-Traumatic Stress Disorder

Name: G.A

Age: 49 years

Diagnosis: Post-traumatic stress disorder (PTSD)

S: G.A is a 49-year-old female who has been undergoing treatment in the unit due to PTSD. The client was diagnosed with PTSD two months ago following the loss of her elder daughter in a road accident. The client came to the unit with a number of complaints that aligned with those of PTSD. The symptoms include nightmares of the accident and avoidance of any circumstances that related to the events that led to the accident. The client also experienced flashbacks of the events alongside intensive distress when exposed to similar environments that led to the accident. There was the presence of negative belief about herself and others and diminished interest in things that she liked before the loss. The level of irritability was also reported to have increased after the accident. The additional symptoms that led to the diagnosis included insomnia, difficulties in concentration and engaging in reckless behaviors that included binge consumption of alcohol.

O: The patient appeared appropriately dressed for the occasion. She was oriented to self, space, time, and events. The client’s mood was mildly depressed. The speech was normal in rate and volume. The judgment was intact. The client denied illusions, hallucinations, and delusions. She also denied suicidal thoughts, plans, and attempts.

A: There have been moderate improvements in the symptoms of PTSD. The client also appears to tolerate the prescribed medications and psychotherapy.

P: The decision to continue with the current dosage of Zoloft was adopted. This was due to the moderate improvement in symptoms. The client was also advised to continue with the monthly group psychotherapy sessions to improve the effectiveness of the adopted treatments.

Alcohol Abuse Disorder

Name: T.Y

Age: 57 years

Diagnosis: Alcohol Abuse Disorder

S: T.Y is a 47-year old male that was diagnosed with alcohol abuse disorder three months ago. The patient came today for his regular checkups on a monthly basis. The client has been on pharmacological management of alcohol addiction and engagement in cognitive behavioral therapy and alcohol anonymous group. The client was diagnosed with substance abuse disorder because of a number of symptoms that he had at time of his admission. They included the hazardous use of alcohol. It also included the rise in social and inter-personal problems when he took alcohol. The client’s family also reported that the patient had neglected his social and occupational roles due to alcohol addiction. The patient also experienced withdrawal symptoms when he stopped taking alcohol. The other symptoms included binge consumption of alcohol, craving, and spending too much time in looking for and consuming alcohol.

O: The patient appears poorly dressed for the occasion. His hair was unkempt. The orientation of the patient to self, others, and time was intact. The mood appeared depressed. He experienced flight of ideas. He denied history of hallucinations, illusions, and delusions. He also denied suicidal thoughts or attempts.

A: The patient exhibits mild improvement in the symptoms when compared to those seen in the last visit. The patient also reports experiencing mild withdrawal symptoms.

P: The dosage of medication currently being used by the client was doubled to achieve moderate to optimum therapeutic effect. The patient was advised to continue with the psychotherapy sessions as well as participating in alcohol anonymous group. The client is to be reviewed after four weeks in the unit.