PRAC 6635 WEEK 7 Assignment : Clinical Hour and Patient Logs
PRAC 6635 WEEK 7 Assignment : Clinical Hour and Patient Logs
Post-Traumatic Stress Disorder
Name: A.A
Age: 58 years
Diagnosis: Post-traumatic stress disorder
S:A.A is a 58-yer-old male who has been undergoing treatment for post-traumatic stress disorder in the unit. A.A was diagnosed with post-traumatic stress disorder five months ago following a road tragic accident where he lost his daughter. The patient began experiencing the symptoms of the disorder five months after the accident. The patient initially came to the unit with a number of complaints. One of them was the reccuent, intrusive and involuntary distressing memories of the accident. He reported that the recurrent nature of the distressing memories had extended to his dreams. He reported to dream about the accident and seeing his daughter in distress. The patient also had symptoms of dissociation that included flashbacks of the accident and avoidance of any stimuli that was associated with the traumatic event. The patient had also started blaming himself for the accident. He often felt hopeless and guilty that he could have done better to prevent the incident. Based on the above symptoms, A.A was diagnosed with post-traumatic stress disorder. He has been on a
PRAC 6635 WEEK 7 Assignment Clinical Hour and Patient Logs
ntidepressants and psychotherapy.
O: The patient appeared appropriately dressed for the occasion. He was oriented to place, self, time and events. The self-reported mood of the client was ‘I am okay, treatment has been effective.’ The speech of the patient was normal in rate and volume. The patient denied delusions, illusions, and hallucinations. He also denied suicidal thoughts, attempts and plans.
A: The patient has improved significantly. The symptoms of post-traumatic stress disorder are now minimal.
P: There has been remarkable improvement in the symptoms of post-traumatic stress disorder. The psychotherapy sessions were terminated. The patient was advised to continue with treatment.
Major Depression
Name: A.C
Age: 40 years
Diagnosis: Major depression
S: A.C is a 40-year-old female who came to the unit as a referral by her primary care physician. The physician referred the patient to the unit for psychiatric assessment. The client demonstrated symptoms that aligned with
PRAC 6635 WEEK 7 Assignment Clinical Hour and Patient Logs
those of major depression. Accordingly, the client reported that she felt sad most of the days throughout the year. She also experienced feelings of guilt and dissatisfaction with the things she had accomplished in her life. The client also reported difficulties in sleeping. She also expressed that she felt easily fatigued. The fatigue had affected her ability to perform optimally in her place of work. The patient also reported changes in body weight. She narrated that her body weight had reduced by 5 kg in the last three months. She attributed the weight loss to changes in her dietary habits as she had lost her appetite. Based on the above symptoms, the patient was diagnosed with major depression.
O: The patient appears poorly dressed for the occasion. She also appeared tired. Her mood was flat. Her orientation to self, time, and events were intact. The judgment of the patient was intact. She denied illusions, delusions, and hallucinations. She also denied history of suicidal attempts, thoughts or plans.
A: The patient has mild symptoms of depression. The focus of treatment should be placed on preventing the progression of symptoms. The patient should also be assisted to develop effective skills for managing the distressing symptoms.
P: The patient was prescribed Zoloft 50 mg orally per day for one month. The aim of administering Zoloft was to improve the mood of the patient. Decisions such as increasing the dosage of the medication or initiating her on cognitive behavioral therapy sessions will largely depend on her response to treatment.
Major Depression
Name: B.A
Age: 34 years
Diagnosis: Major Depression
S: B.A is a 34-year-old male who has been undergoing treatment for major depression in the unit. The patient was diagnosed with major depression two months ago and has been on treatment and psychotherapy. The client had presented with a number of symptoms that led to his diagnosis with major depression. Firstly, the patient reported that he always felt extremely sad. His sadness persisted for almost all the days in his life prior to the diagnosis. The patient also reported to have experienced significant increase in his appetite. This led to weight gain. He also experienced easy irritability and found it difficult to concentrate on things or make decisions. There was also the history of suicidal attempt. B.A had attempted to kill himself by overdosing himself with paracetamol since he felt he was useless. The above led to him being brought to the unit where he was diagnosed with major depression and initiated on treatment.
O: The patient appeared appropriately dressed for the occasion. His orientation to self, time, others and events were intact. The patient’s mood was elated. His judgment was intact. His speech was of the normal rate and volume. He denied illusions, hallucinations, and delusions. He however reported an incident of suicidal thought in the last week. He denied any suicidal plans.
A: The treatment has produced minimal improvement in the symptoms experienced by the patient. The patient is at an increased risk of self-harm.
P: The dosage of Zoloft was increased to 100 mg orally per day. The patient was advised to continue with the psychotherapy sessions. The family was informed to notify the hospital should the patient experience any abnormal symptoms.
Insomnia
Name: B.D
Age: 31 years
Diagnosis: Insomnia
S: B.D is a 31-year-old female who has been on treatment in the unit for insomnia. The patient was diagnosed with insomnia a month ago and has been on psychotherapy treatment. The patient was diagnosed with the condition due to a number of complaints that aligned with those of insomnia, as stated in DSMV. One of the symptoms was the persistent and chronic dissatisfaction with the quality and quantity of sleep. The accompanying symptoms included difficulty in initiating sleep, maintaining sleep, and awakening at night and finding it hard to return to sleep. The patient also reported that disturbance in sleep was affecting significantly her ability to perform her social, educational, and occupational roles. The difficulty in sleep was not attributed to any condition, medication or substance use, hence, the diagnosis with insomnia.
O: The patient appeared well groomed for the occasion. She was oriented to place, time, self and events. The patient described her mood as ‘normal.’ Her judgment was intact with the absence of illusions, delusions, and hallucinations. The client denied any recent issues with sleep.
A: Psychotherapy appears to be effective in improving the quality and quantity of sleep for the client. The patient is also adhering to the recommended behavioral interventions that she needs to embrace to improve her quality of sleep.
P: The patient was advised to continue with the psychotherapy sessions. She is due for the next follow-up visit in four weeks’ time.
Binge Eating
Name: C.D
Age: 21 years
Diagnosis: Binge eating
S: C.D is a 21-year old female who came to the unit as a follow-up client. The client was diagnosed with binge eating one month ago and has come for her second psychotherapy session. The client was diagnosed with binge eating due to a number of complaints. One of them was the recurrent episodes of uncontrolled consumption of high amounts of food beyond the normal. The patient reported lacking control over her binge eating during the episodes. The patient also reported binge eating to be associated with eating faster than normal, eating until uncomfortably full, and eating large amounts of food even if not hungry. The patient expressed significant shame and distress with her eating habits. As a result, she used to hide while eating due to embarrassment and felt disgusted with her eating. The above complaints led to the client being diagnosed with binge eating disorder and has been undergoing cognitive behavioral therapy in the unit.
O: The client appeared appropriately dressed for the occasion. She was oriented to self, space, time, and events. The client’s mood was normal. Her judgment was intact. She expressed some confidence on herself. She reported reduction in incidences of binge eating. She denied illusions, hallucinations and delusions. She denied suicidal thoughts, attempts and plans.
A: The patient is responding well to psychotherapy. Her eating habits have improved significantly.
P: The client was advised to continue with cognitive behavioral therapy sessions. She is to be assessed for further response after four weeks.
Schizophrenia
Name: C.Y
Age: 37 years
Diagnosis: Schizophrenia
S: C.Y is a 37-year-old male that came to the unit as a referral by his family physician. The family physician felt that the client had a psychiatric problem that required management by the psychiatric team. The client presented with a number of symptoms that led to his diagnosis with schizophrenia. One of the symptoms that the client presented with to the hospital was a false belief of his identity. The patient believed that he was the president of the United States. He believed that he could direct the activities of the state as well as those of the institution. The patient was also reported to demonstrated disorganized behaviors. The behaviors included engaging in activities that were not appropriate for his age. He also demonstrated diminished emotional expression and easy irritability. The above symptoms were reported to have caused significant disturbance to the patient and the family as well as his functioning in inter-personal relations and work. The symptoms were reported to have started six months ago, with worsening intensity.
O: The patient appeared poorly groomed. His orientation to space, time and others was altered. The judgment of the client was also altered. He demonstrated flight of ideas. The patient was delusional. He denied illusions and hallucinations. He also denied suicidal thoughts, attempts and plans.
A: The patient has distorted cognitive functioning. The treatment should be aimed at restoring his sense of self and stabilization of emotions.
P: The patient was started on antipsychotics. The patient was also started on cognitive behavioral therapy. The aim was to manage the symptoms of schizophrenia and improve the patient’s physical, psychological, and inter-personal functioning.
Bipolar Disorder
Name: D.X
Age: 33 years
Diagnosis: Bipolar Disorder
S: D.X is a 33-year-old male who has been undergoing treatment in the facility due to bipolar disorder. The patient was diagnosed with bipolar disorder a month ago and has been on treatment and psychotherapy. The patient presented with a number of symptoms that led to his diagnosis with bipolar disorder. The symptoms included elevated and expansive mood when the patient would feel that he was in control of everything. The patient also experienced easy irritability and difficulty in concentrating or making decisions. The symptoms were presented in most of the days and almost every day. The patient reported additional symptoms during this period. The symptoms included lack of sleep, increased talkativeness, and being easily distracted. The patient also engaged significantly in goal directed activities and impulsive behaviors. The client was worried that the episodes of the above symptoms had a negative effect on his social and occupational functioning. As a result, he has been on treatment with the aim of improving his symptoms and functioning.
O: The patient was dressed appropriately for the occasion. He was oriented to self, time, space and others. The patient reported that his moods have become manageable. His level of anxiety was minimal. His judgment was intact. The speech was of normal rate and volume. The client denied illusions, delusions, and hallucinations. He also denied suicidal thoughts, attempts and plans.
A: The treatment appears to be effective in facilitating symptom management. The client demonstrated moderate improvement in symptoms.
P: The client was advised to continue with the current treatment modalities. The client was scheduled for a follow-up care after a month.
Histrionic Personality Disorder
Name: E.A
Age: 25 years old
Diagnosis: Histrionic personality disorder
S: E.A is a 25-year-old female who came to the facility for the second follow-up visit after she was diagnosed with histrionic personality disorder. The client was diagnosed with the disorder a month ago and has been on psychotherapy. She was diagnosed with histrionic personality disorder due to a number of complaints. Firstly, the client reported that her friends complained about her unbearable character. The peers informed her that she had attention seeking behaviors that needed to be addressed by the medical team. The client acknowledged the concerns by her peers. She agreed experiencing significant discomfort in circumstances where others did not give her attention. The client also reported experiencing rapid shift in her expression of emotions when with her peers. She was concerned about the way she appeared and would spend considerable time in ensuring that she dressed appropriately to draw attention of others. The client also complained for being easily influenced by circumstances or others. The client was worried that the above symptoms were beyond her control, hence, the need for assistance from the healthcare team. The patient was diagnosed with histrionic personality disorder and enrolled to group psychotherapy.
O: The patient appeared appropriately dressed for the occasion. She was oriented to self, others, time and space. The judgment of the client was intact. She reported normal mood. She reported some improvements in her sense of identity.
A: The use of cognitive behavioral therapy appears to be effective in helping the client develop her self-identity.
P: The client was advised to continue with the group psychotherapy sessions. She was scheduled for a follow-up care after one month.
Insomnia
Name: G.A
Age: 34 years
Diagnosis: Insomnia
S: G.A is a 34-year-old male who came to the unit as a referral by his physician. The client came with a number of complaints that led to his diagnosis with insomnia. Firstly, the client reported having trouble in getting asleep and maintaining sleep. He complained that his quantity and quality of sleep was poor. This was despite him using medications to enhance sleep. The client also reported waking up at night and finding it hard to fall asleep. The lack of sleep was reported to have affected his productivity. For example, he reported to often fall asleep during the day. He also reported that he finds it difficult for him to concentrate in undertaking his social and occupational activities. He was worried that the sleep problem was worsening over time. The above symptoms led to the diagnosis of insomnia.
O: The client was well groomed for the occasion. He was oriented to place, self, time and events. The client appeared tired during assessment as evidenced by frequent yawning. The mood of the client was flat. His speech rate and volume was normal. His judgment was intact. He denied illusions, delusions, and hallucinations. He also denied history of suicidal thoughts, plans, or attempts.
A: The client appears to suffer from the effects of insomnia. The patient should be initiated on treatment to enable him achieve the desired quality and quantity of sleep.
P: The client was started on individual psychotherapy. He was also educated on the behavioral interventions that he needed to embrace to improve the quality and quantity of sleep. This included educating him on the importance of avoiding caffeinated drinks, engaging in active physical activity in the evening, and avoiding distractors during bedtime.
Borderline Personality Disorder
Name: G.A
Age: 22 years old
Diagnosis: Borderline personality disorder
S: G.A is a 22-year-old female who came to the unit for her second follow-up visit. She was diagnosed with borderline personality disorder and has been undergoing group psychotherapy. The patient was diagnosed with the disorder due to a number of presenting complaints. One of them was the intense fear of being abandoned. The client feared that her boyfriend would abandon her and would embrace extreme interventions to ensure that it does not happen. The client also reported history of unstable relationships. The instability of relationships was attributed to her believe that her boyfriends were not caring. The client reported that she did not understand herself anymore. She could experience periods of intense stress where she found herself engaging in risky behaviors such as binge drinking of alcohol and careless driving. Due to the above complaints, the patient was diagnosed with borderline personality disorder and has been on treatment.
O: The client appeared appropriately dressed for the occasion. She was oriented to place, self, time and events. Her judgment was intact. She reported improvement in her emotions. She denied suicidal thoughts, attempts, and plans.
A: The client has improvement in symptoms of borderline personality disorder. Dialectic therapy should be introduced to improve outcomes.
P: The patient was advised to continue with the psychotherapy sessions. Dialectic therapy was introduced to the psychotherapy sessions. The client was scheduled for the next follow-up care at four weeks’ time.