PRAC 6635 WEEK 8 Assignment : Clinical Hour and Patient Logs
PRAC 6635 WEEK 8 Assignment : 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
PRAC 6635 WEEK 8 Assignment Clinical Hour and Patient Logs
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
PRAC 6635 WEEK 8 Assignment Clinical Hour and Patient Logs
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.