PRAC 6635 WEEK 9 Assignment : Clinical Hour and Patient Logs
PRAC 6635 WEEK 9 Assignment : Clinical Hour and Patient Logs
Clinical Logs
Alzheimer’s Disease
Name: B.S
Age: 70 years
Diagnosis: Alzheimer’s disease
S: B.S is a 70-year-old client who has been on treatment in the unit for Alzheimer’s disease. The patient was diagnosed with the disease a year ago and has been coming to the unit for regular checkups. The client was diagnosed with Alzheimer’s disease due to some symptoms that aligned with those of the disorder. The symptoms included a significant decline in his memory. The client reported that he started experiencing gradual loss of memory, as he could not remember the names of his family members and his familiar places. The client also reported getting lost in his home town, which increased his risk of ham. There was also the complaints by the family members that B.S was easily agitated and irritated by others and events. There was the history of loss of short-term and intermediate memory. The symptoms were reported to be worsening on a daily basis, leading to the client being brought to the setting for further assessment. He was diagnosed with Alzheimer’s disease and has been on treatment.
O: The patient appeared well groomed for the occasion. His orientation to self, time, others, and events were intact. The self-reported mood of the client was ‘normal.’ The client’s experience of long-term and short-term memory was negative. The client denied any suicidal thoughts, illusions, hallucinations, and delusions. The reports of insomnia were also reported to have declined significantly.
A: The client has continued to show positive improvement in the symptoms of Alzheimer’s disease. The treatment has been effective in improving his cognitive abilities.
P: The decision to continue with the current treatment modalities was adopted. This was attributed to the improvement in symptoms following the treatment.
General Anxiety Disorder
Name: D.D
Age: 28 years
Diagnosis: Generalized anxiety disorder
PRAC 6635 WEEK 9 Assignment Clinical Hour and Patient Logs
S: D.D is a 28-year-old male who came to the unit as a referral by his physician for assessment. The physician felt that D.D was exhibiting symptoms that he felt that required the management by the psychiatrist. The client came
PRAC 6635 WEEK 9 Assignment Clinical Hour and Patient Logs
with a number of complaints. The symptoms included experiencing excessive worry that was beyond his control. The client reported that he felt excessive worry of failing to achieve his life dreams. He also feared impending doom. The client also reported that the feelings of worry were associated with symptoms that included easy fatigability, irritability, restlessness, and difficulties in concentrating. The patient also reported that he has been experiencing hardships in sleeping and engaging in his assigned social and occupational roles. Further assessment of the client ruled out any drug or substance abuse or medical condition that could have been attributed to the symptoms. The above symptoms aligned with those of generalized anxiety disorder, hence, the diagnosis.
O: The client was well dressed for the occasion. His orientation to self, place, time, others, and events were intact. The self-reported mood of the client was ‘I excessively worried about myself.’ The client appeared tired due to lack of enough sleep in the previous night. The client denied history of suicidal thoughts, plans, or attempts. He also denied history of hallucinations, illusions, and delusions.
A: The client is experiencing moderate symptoms of generalized anxiety disorder. He should be assisted to overcome his fears and live a positive and healthy life.
P: The client was started on group psychotherapy. He was also educated on behaviors that he needed to achieve quality and quantity sleep. He was scheduled for a follow-up visit after four weeks.
Insomnia
Name: F.F
Age: 26 years
Diagnosis: Insomnia
S: F.F is a 26-year-old female who was referred to the psychiatric unit by her physician. The client felt that the symptoms that the client experienced required review by the psychiatric team rather than the medical team. F.F came with a number of complaints that led to her diagnosis with insomnia. The complaints included the lack of enough sleep for the past seven months. the client reported that she has been finding it extremely hard for her to fall asleep. She also finds it hard to maintain sleep once asleep. There were also the complaints of awakening at night and finding it hard to get back to sleep. The client also noted that the quality and quantity of sleep was not improving despite her use of over the counter medications to improve sleep. The lack of adequate and quality sleep was affecting the performance and productivity of the client. She reported that it has been difficult for her to remain attentive during the day due to daydreaming. She also reported challenges of making sound decisions and being easily irritated. The above complaints led to her being diagnosed with insomnia.
O: The client appeared well dressed for the occasion. She appeared tired from the lack of sleep the previous night. The mood of the client was flat. The client denied illusions, hallucinations, and delusions. She also denied suicidal thoughts, attempts, and plans.
A: The client appears to be suffering from the lack of enough and quality sleep. She needs to be assisted to develop effective skills for improving her sleeping habits.
P: The client was initiated on individual psychotherapy. She was also educated on habits that she needed to adopt to improve her quality and quantity of sleep.
Insomnia
Name: G.F
Age: 32 years
Diagnosis: Insomnia
S: G.F is a 32-year-old male who has been undergoing treatment in the unit due to insomnia. The client was diagnosed with insomnia three months ago and has been on psychotherapy. The client was diagnosed with the disorder following a number of complaints that aligned with those of insomnia. The complaints included the severe lack of sleep for four months. The client reported that his quality and quantity of sleep had declined significantly. He often found himself awake most of the nights almost on a daily basis. The client also reported that he could fall asleep during the day in his workplace due to lack of sleep. The client also reported that the persistent, severe lack of sleep had affected his ability to concentrate and was easily irritable. The client denied any use of medications, medical condition, or substance abuse that could have been contributing to the lack of sleep. Therefore, he was diagnosed with insomnia and initiated on treatment.
O: The client appeared appropriately dressed for the occasion. He was oriented to self, place, time and events. The mood of the client was improved from the last visit. His insomnia was reported to have also improved. The client denied illusions, hallucinations, and delusions.
A: The client appears to be responding well to treatment. His symptoms of insomnia have significantly improved.
P: The decision that the client to continue with psychotherapy sessions was made due to his response to treatment. The client will be assessed in four weeks’ time.
Major Depression
Name: H.A
Age: 43 years
Diagnosis: Major depression
S: H.A is a 43-year-old male who came to the clinic as a referral by his physician. The physician referred him for psychiatric review for symptoms that he felt that aligned with those of major depression. The client raised a number of complaints during the assessment. One of the complaints was the persistent feeling of sadness in most days throughout the day. The client reported that his mood was always depressed. He did not like participating in social activities, as he was socially withdrawn. He also started being absent from his workplace because he found it not interesting anymore. The client also reported that he no longer has appetite for food. The changes in appetite have led to a drastic loss of weight. The client also noted that he suffers from insomnia, which has affected his ability to perform optimally in his social and occupational roles. Due to the above symptoms, the client was diagnosed with major depression and initiated on treatment.
O: The client appeared poorly dressed for the occasion. He was underweight for his age. The orientation of the client to self, place, time, and events were intact. The self-reported mood of the client was ‘depressed.’ The client denied illusions, hallucinations, and delusions. He also denied suicidal thoughts, attempts, and plans. He was future oriented.
A: The client demonstrates symptoms of mild depression. He should be assisted in improving his mood, social and occupational functioning.
P: The patient was initiated on antidepressants and psychotherapy. He was to be reviewed after four weeks.
Major Depression
Name: Z.Y
Age: 34 years
Diagnosis: Major depression
S: Z.Y is a 34-year-old female that came today to the unit for her regular checkup. The client was diagnosed with major depression and has been on antidepressants and psychotherapy treatments. The client was diagnosed with the disorder following a number of complaints she presented with to the unit. One of the symptoms was the persistent feeling of hopelessness. She felt that she had no value in life and wanted to commit suicide. The client also reported being socially withdrawn. She locked herself in her room most of the times to help her avoid contact with people in her environment. The client also reported an increase in her appetite. The increased appetite led to weight gain due to high food intake. The client also had trouble in concentrating. She was easily irritable. The quality and quantity of sleep also declined, as she complained of insomnia for the past seven months prior to treatment. The above symptoms were noted to have affected adversely the ability of the client to perform optimally in her social and occupational roles. Therefore, she was diagnosed with major depression and initiated on treatment.
O: The client was appropriately dressed for the occasion. Her self-reported mood was ‘I am now better.’ The orientation to self, place, time, and events were intact. She denied any illusions, delusions, ad hallucinations. The client also denied any recent experience of suicidal thoughts, plans, and attempts.
A: The client has responded well to the treatment. There is moderate improvement in the symptoms of depression.
P: The decision to continue with the current treatment was made because of the moderate improvement in symptoms. The client will come for her checkup after 4 weeks.
Post-Traumatic Stress Disorder
Name: K.I
Age: 38 years
Diagnosis: Post-traumatic stress disorder
S: K.I is a 38-year-old male who came to the unit for his regular follow-up visits. He was diagnosed with post-traumatic stress disorder three months ago and has been on antidepressants and group psychotherapy. The client was diagnosed with the disorder following the development of some symptoms associated with a traumatic event that he experienced. The symptoms that the client experienced included distressing flashbacks about the trauma and nightmares. The client also engaged in avoidance of any stimuli that was associated with the trauma. There was also the evidence of increased irritability, difficulty in concentration and anger in the client. The client was worried that his ability to make informed decisions in the workplace was affected since he found it difficult to concentrate on details. The distressing symptoms of the traumatic experience had affected significantly his ability to engage in his social and occupational activities.
O: The client was dressed appropriately for the occasion. His orientation to self, others, events, and environment were intact. The client reported that his mood had stabilized following the use of antidepressants and group psychotherapy interventions. The judgment of the client was intact, as he denied illusions, delusions and hallucinations. The client further denied any recent experiences of suicidal thoughts, plans, or attempts.
A: The client is responding well to the treatment. His level of social and occupational functioning has improved significantly.
P: The client was advised to continue with the current medications and participate in the group psychotherapy sessions. He was to be reviewed for further response to treatment after four weeks.
Borderline Personality Disorder
Name: D.S
Age: 24 years
Diagnosis: Borderline personality disorder
S: D.S is a 24-year-old female that came to the unit for treatment for her uncontrolled behaviors. The client reported a number of symptoms that led to her diagnosis with borderline personality disorder. The symptoms included a pervasive pattern of instability in her relationships. She also reported to be over disturbed by her self-image. The client also reported experiencing excessive fear of being abandoned by her boyfriend. As a result, she often uses behaviors such as self-harm to ensure that the boyfriend does not leave her. The client also reported instances of impulsivity where she engaged in substance abuse and excessive spending of her finances. In some cases, she reported to experience suicidal behaviors and severe feelings of being empty. Based on the above symptoms, the client was diagnosed with borderline personality disorder and initiated on treatment.
O: The client appeared appropriately dressed for the occasion. The client self-expressed mood was that I am anxious. The orientation of the client to self, place, time and events were intact. The judgment was intact as evidenced by the absence of illusions, delusions, and hallucinations. The client reported a recent incident of suicidal attempt as a way of coercing her boyfriend to remain loyal to her. She denied current suicidal plans and thoughts.
A: The client has distorted self-identity. She should be assisted to develop effective coping mechanisms with impulsivity and distorted self-identity.
P: The client was initiated on individual psychotherapy session. She is to be reviewed for response to treatment after four weeks.
Schizoaffective Disorder
Name: G.S
Age: 30 years
Diagnosis: Schizoaffective disorder
S: G.S is a 30-year-old female who came for her follow-up visit today. G.S was diagnosed with schizoaffective disorder and has been on treatment. She was diagnosed with the disorder after she presented with a number of symptoms. The symptoms included an altered perception of self. She considered herself an army personnel and could order her family members. The client also experienced symptoms of major depression, which alternated with mania. The symptoms of major depression included loss of appetite, feeling sad always, socially isolated, and having suicidal thoughts. The symptoms altered with impulsivity where the client felt the need to engage in multiple activities and achieve goals within a short period. The client also reported that the above symptoms affected her ability to function optimally in her social and occupational roles. Further assessment showed that the symptoms were not attributed to substance abuse, medication or a medical condition. The client was therefore diagnosed with schizoaffective disorder and initiated on antipsychotics.
O: The client appeared well groomed for the occasion. The client had normal orientation to self, others, time, and space. The judgment of the client was intact. She denied recent experiences of illusions, delusions, and hallucinations. The client also denied recent experiences of suicidal ideations, thoughts, and plans. The thought content of the client was future oriented.
A: The client appears to be responding well to the treatment. There has been moderate improvement in the symptoms of psychosis. The client expresses increased interest to complete the treatment regime.
P: The client was advised to continue with the current treatment. This was attributed to the moderate improvement in her symptoms of schizoaffective disorder.
Schizophrenia
Name: H.F
Age: 40 years
Diagnosis: Schizophrenia
S: H.F is a 40-year-old male who has been undergoing treatment in the unit for schizophrenia. The patient was diagnosed with the disorder three 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 disturbance in cognition, behavior and responsiveness. The patient presented with false identity of self. He believed that he was a nurse, yet he was a driver in a local manufacturing company. The patient also had abnormal speech that was characterized by repetition of words. 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.