PRAC 6635 WEEK 8 Assignment : Clinical Hour and Patient Logs
Walden University PRAC 6635 WEEK 8 Assignment : 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
Major Depression
Name: A.L
Age: 32 years
Diagnosis: Major Depression
S: A.L is a 32-year-old 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 A.L 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 50 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.
Major Depression
Name: A.M
Age: 45 years
Diagnosis: Major Depression
S: A.M is a 45-year-old female that came to the unit today for her regular follow-up visits. Today was the client’s
fourth follow-up visit to the hospital. The client was previously diagnosed with major depression and has been undergoing pharmacological and psychotherapy treatment. The client was diagnosed with major depression due to a number of symptoms. The symptoms included feeling sad in most of the days and hopeless. The client also reported lack of sleep in most of the days with increased appetite. The client also found it hard to make decisions or concentrate. Her level of irritability was significantly elevated. The client had also developed suicidal ideations, which predisposed her to self-harm. As a result, she was brought to the unit where she was diagnosed with major depression and initiated on treatment.
O: The patient appeared appropriately dressed for the occasion. Her orientation to self, time, space and events were normal. The self-reported mood of the client was ‘better.’ The speech of the client was normal in terms of rate and volume. The judgment of the client was intact. The client denied illusion, delusions, and hallucination. The patient also denied suicidal thoughts, plans, and attempts.
A: The symptoms of depression have improved significantly. The treatments adopted for the patient have been effective.
P: The psychotherapy sessions were terminated, as the treatment objectives had been achieved. The client was advised to continue with the prescribed pharmacological treatments.
Schizophrenia
Name: A.P
Age: 32 years
Diagnosis: Schizophrenia
S: A.P is a 32-year-old male who has been undergoing treatment in the unit for schizophrenia. The patient was diagnosed with the disorder two months ago and has been on pharmacological treatment. The patient was diagnosed with it after he presented with a number of symptoms that related to those of schizophrenia. The symptoms included those that related to disturbance in cognition, behavior and responsiveness. Firstly, the patient had presented with false identity of self. He believed that he was the president of the United States. The patient also had abnormal speech that was characterized by mutism. There was also the evidence of tremors and tics. The patient also had some symptoms of depression such as lack of energy, being socially withdrawn and suicidal thoughts. The above symptoms had affected significantly the ability of the patient to engage in his social and occupational roles. Based on the symptoms, he was diagnosed with schizophrenia.
O: The patient appeared appropriately dressed for the occasion. His orientation to self, place, time, and events were intact. The patient demonstrated mild anxiety. The speech was of normal rate and volume. The client denied illusions, delusions, and hallucinations. The patient also denied suicidal thoughts, plans, and intentions.
A: There has been moderate improvement in the symptoms of schizophrenia. The disordered cognition and behaviors have also been managed effectively.
P: The decision to continue with the treatment was made. The patient was advised to come for a follow-up visit after four weeks. A decision on whether the dosage of the medication will be reduced or increased will be made based on his response to treatment.
Post-Traumatic Stress Disorder
Name: B.L
Age: 38 years
Diagnosis: Post-Traumatic Stress disorder
S: B.L is a 38-year-old male that came to the unit as a referral by his family practitioner. The client came with symptoms that led to his diagnosis with post-traumatic stress disorder. The patient reported that the symptoms that he experienced began after he was involved in a road accident. The symptoms included experiencing distressing memories of the accident. He also experienced distressing dreams about the accident. There was the evidence of flashbacks and avoidance of any stimuli that related to the accident. The experience led to increased anger and anxiety in the patient. He also experienced increased irritability and difficulty in making decisions. Based on the above symptoms, the client was diagnosed with post-traumatic stress disorder.
O: The patient appeared poorly dressed for the occasion. His orientation to self, time, others, and place were intact. The mood of the patient was depressed. He appeared distant during the assessment. The patient’s judgment was intact. The patient denied hallucinations, delusions, and illusions. He also denied suicidal thoughts, plans, and attempts.
A: The patient is experiencing symptoms of moderate post-traumatic stress disorder. The patient should be assisted to manage his mood and cope with his experiences.
P: The patient was initiated on antidepressants. He was also initiated on group cognitive behavioral therapy. The aim was to improve his moods and coping with distressing symptoms. He was scheduled for a follow-up visit after four weeks.
Post-Traumatic Stress Disorder
Name: B.T
Age: 22 years
Diagnosis: Post-Traumatic Stress disorder
S: B.T is a 22-year-old female who came to the unit for her follow-up visit. She was diagnosed with post-traumatic stress disorder four months ago and has been on pharmacological and cognitive behavioral therapy treatments. The client had come to the unit as a referral by her physician. The client presented with a number of symptoms that developed following her involvement in a road accident that led to the death of her spouse. The symptoms included dreams about the accident and flashbacks. She also reported being distressed when she remembered the ordeal. The patient also reported being detached from her feelings. She could not understand who she was anymore. The patient also reported that her interest in things that she used to enjoy previously had diminished significantly. The patient also reported that the symptoms had adversely affected her ability to function in her workplace and her expected family roles. Based on the above symptoms, she was diagnosed with post-traumatic stress disorder and initiated on antidepressants and cognitive behavioral therapy.
O: The client appeared appropriately dressed for the occasion. Her orientation to self, others, time, and events were intact. The self-reported mood of the client was ‘I am feeling better nowadays.’ The speech of the client was normal in terms of rate and volume. The judgment was intact. The client denied illusions, delusions, and hallucinations. She also denied suicidal thoughts, attempts, and plans.
A: The patient appears to be responding well to the adopted treatment options. The symptoms of depression have improved significantly.
P: The decision that the client continues with the current treatments were made. The decision was based on the moderate improvement in symptoms. The client will be reviewed after four weeks.
Insomnia
Name: C.L
Age: 36 years
Diagnosis: Insomnia
S: C.L is a 36-year-old client who has been undergoing treatment in the unit for insomnia. The client was diagnosed with insomnia two months ago and is on psychotherapy. The client was diagnosed with the disorder following a number of complaints. The complaints included the lack of sleep for the past six months. The client reported that he found it hard to fall asleep and maintain sleep. His quality and quantity of sleep had worsened significantly. The poor quality of sleep was despite his use of sleep enhancing drugs. The client also reported to experience awakening at night, which was followed by difficulties in getting back to sleep. The lack of sleep had affected his ability to function optimally in his social and occupational roles. The patient also reported that his ability to concentrate and make sound decisions was significantly affected. He was worried that he would lose his job because of the declining productivity. There was also the complaints of falling asleep during the day due to lack of sleep at night. Based on the above, the client was diagnosed with insomnia and has been undergoing psychotherapy sessions for insomnia.
O: The patient appeared well groomed for the occasion. His orientation to self, place, time, and events were intact. The client mood was normal. His judgment was intact. He denied illusions, hallucinations, and delusions. He also denied suicidal thoughts, plans, and attempts.
A: The client is responding well to psychotherapy. He reports improvement in the quality and quantity of sleep. His productivity and ability to concentrate have also improved significantly.
P: The decision the client to continue with psychotherapy sessions was made. He will be reviewed after one month.
Alcohol Abuse Disorder
Name: D.A
Age: 40 years
Diagnosis: Alcohol abuse disorder
S: D.A is a 40-year-old male who has been undergoing treatment in the unit due to alcohol abuse disorder. The patient was diagnosed was the disorder three months ago and has been undergoing pharmacological, psychotherapy, and alcohol anonymous group therapies. The patient was diagnosed with the disorder following her presentation to the unit with a number of symptoms. The symptoms included binge drinking of alcohol for a long period. The patient also reported that he could not overcome the urge to take large amounts of alcohol. The patient also expressed interests in stopping alcohol intake. However, he found it unsuccessful and ended up taking large amounts of alcohol every other period. The binge consumption of alcohol was reported to have affected the ability of the patient to fulfil his social and occupational roles. It had also led to problems in his inter-personal relations. The patient also had strong carvings for alcohol. Based on the above complaints, the patient was diagnosed with alcohol abuse disorder.
O: The patient appeared appropriately dressed for the occasion. His reported mood was improved. The client reported reduced distress due to alcohol cravings. The orientation of the client to self, others, time and events were intact. The judgment of the client was intact. The client denied hallucinations, illusions, and delusions. He also denied suicidal thoughts, attempts, and plans.
A: The client reports improvement in his cravings for alcohol. He has been participating actively in cognitive behavioral therapy and alcohol anonymous group.
P: The patient was advised to continue with the current treatment. The decision was based on the improvement in symptoms of alcohol abuse disorder.
Attention Deficit Hyperactive Disorder (ADHD)
Name: Y.L
Age: 10 years
Diagnosis: ADHD
S: Y.L is a 20-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 with complaints that included inattention, hyperactivity and impulsivity. The symptoms that accompanied the above complaints 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 Y.L’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.
Alzheimer’s Disease
Name: M.A
Age: 72 years
Diagnosis: Alzheimer’s disease
S: M.A is a 72-year-old client who has been undergoing treatment in the unit due to Alzheimer’s disease. The client was diagnosed with Alzheimer’s disease four years ago and has been undergoing treatment in the unit. The information given by her granddaughter showed that the client presented initially to the unit with a number of complaints. One of the complaints was the decline in the memory of the client. The client could not remember the names of places and her family members. The client occasionally got lost in her familiar places. The client also demonstrated increased agitation and irritability. The client also experienced loss of short-term memory and long-term memory. The patient also experienced changes in her sleep patterns, with increased episodes of insomnia. The patient also experienced progressive loss in her bowel and bladder control. Based on the above symptoms, the client was diagnosed with Alzheimer’s disease and has been undergoing treatment.
O: The patient appeared appropriately dressed for the occasion. She was oriented to self and place. She was not oriented to time and events. The client exhibited loss of long-term memory. The client denied illusions, delusions, and hallucinations. She also denied suicidal thoughts, attempts, and plans. The granddaughter reported improvement in client’s orientation to her familiar environments. Bladder and bowel incontinence had also resolved.
A: The client appears to be improving with the adopted treatments. There has been remarkable improvement in cognitive and behavioral functioning. The level of agitation and irritability has also improved significantly. There has also been an improvement in her social functioning.
P: The adopted treatment has been effective in improving the management of symptoms being experienced by the patient. A decision to continue with the current treatment was adopted for the patient. The patient was to be reviewed after two months to determine her response to treatment.
General Anxiety Disorder
Name: H.L
Age: 24 years
Diagnosis: Generalized Anxiety Disorder
S: H.L is a 24-year-old male who came to the clinic for his second follow-up visit for generalized anxiety disorder. The patient was diagnosed with generalized anxiety disorder after he presented to the unit with a number of symptoms. One of the symptoms was the excessive worry of things that were beyond his control. The patient reported that the excessive worry occurred in most days almost every day for the last six months. The client also reported about his inability to control the excessive worry. The excessive worry was associated with several symptoms. The symptoms included restlessness, easy fatigability, difficulty in concentration, and irritability. The patient also reported symptoms of insomnia and difficulties in engaging in social and occupational activities. The above symptoms were not attributable to any other cause such as substance abuse, disease, or medication use. The client was therefore diagnosed with generalized anxiety disorder and has been undergoing individual psychotherapy in the unit.
O: The patient was well groomed for the occasion. He was oriented to self, place, time, and events. The self-reported mood of the client was ‘there is significant improvement in my worries.’ The speech of the client was of normal rate and volume. The symptoms of anxiety were mild. The judgment of the client was intact. He denied hallucinations, illusions, delusions, and suicidal thoughts, attempts, or plans.
A: The client appears to be responding positively to psychotherapy sessions. The client’s ability to control his worry has also improved significantly.
P: The decision to continue with the treatment was made. This was based on the improvement in symptoms of generalized anxiety disorder.
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.