PRAC 6645 WEEK 3 Assignment 1: Clinical Hour and Patient Log
PRAC 6645 WEEK 3 Assignment 1: Clinical Hour and Patient Log
Clinical Logs
Major Depression
Name: D.R
Age: 33 years
Diagnosis: Major depression
S: D.R is a client who came to the psychiatric department today for her follow-up visit after being diagnosed with major depression three months ago. The patient has been on antidepressants and group psychotherapy. The client had been diagnosed with major depression due to the symptoms that she presented with to the unit. The symptoms included persistent feelings of guilt and worthlessness. The client felt sad in most days almost throughout the day. She felt that her mood was depressed in most of the times almost every day. She also complained of lack of energy to engage in her activities of the daily living and professional work. D.R had also reported a significant withdrawal from others, as she preferred spending her time indoors. There was also the complaint of decline in her appetite. She also noted that her energy levels were consistently low, as she felt fatigued in engaging in an activity. She had however denied suicidal thoughts, plans
PRAC 6645 WEEK 3 Assignment 1 Clinical Hour and Patient Log
, or attempts. D.R was diagnosed with major depression and has been undergoing treatment in the unit.
O: The client was dressed appropriately for the occasion. Her orientation to self, others, time and events were intact. Her self-reported mood was ‘better than the other months.’ Her speech was normal in terms of rate and volume. She denied illusions, delusions, and hallucinations. She also denied suicidal thoughts, attempts, and plans.
A: The client is responding well to the treatment. The symptoms of major depression have improved significantly.
P: The client was advised to continue with the current treatments, as they were effective in improving the symptoms of major depression. The client was scheduled for a follow-up visit after four weeks.
Major Depression
Name: M.A
Age: 52 years
Diagnosis: Major depression
S: M.A is a 52-year-old male client who has been undergoing treatment in the facility for major depression. He came today for his eighth follow-up visit. He was diagnosed with major depression nine months ago and has been on psychotherapy and antidepressant treatments. The client recalled that he was diagnosed with major depression after
PRAC 6645 WEEK 3 Assignment 1 Clinical Hour and Patient Log
he presented with symptoms of severe mood depression to the unit. The symptoms included persistent sadness for more than four months. He also felt severe guilt that he had not achieved his dreams at his current age. He also noted that his quality and quantity of sleep had declined considerably, as he could remain awake in most nights throughout the night. His appetite had also increased considerably. The client also noted that he was preoccupied with thoughts of committing suicide. He however did not have any plans of committing it. The symptoms had affected his ability to work productively in his workplace as a truck driver. The symptoms were not due to substance abuse, medical condition or medication. As a result, he was diagnosed with major depression and has been undergoing treatment in the facility.
O: The client appeared well groomed for the occasion. He was well oriented to self, others, time and events. His judgment was intact. His self-reported mood was, ‘I am healed, I no longer experience any symptoms of depression.’ The client denied illusions, delusions, and hallucinations. He also denied suicidal thoughts, plans, and intent.
A: The client has demonstrated sustained improvement in the symptoms of depression. His participation in the group psychotherapy sessions has been remarkable.
P: The participation of the client in the group psychotherapy sessions was terminated since the treatment objectives had been achieved. He was advised to continue with the antidepressants treatment. He was scheduled for a follow-up visit after four weeks.
Schizophrenia
Name: Z.R
Age: 38 years
Diagnosis: Schizophrenia
S: Z.R is a 38-year-old female that has been undergoing treatment in the unit due to schizophrenia. She was diagnosed with the disorder three months ago and has been on pharmacological and psychotherapy treatments. Today she came to the unit for her regular follow-up visits. Z.R recalled that she was diagnosed with schizophrenia after she started experiencing abnormal symptoms. Her spouse had brought her for the psychiatric visit. The symptoms included seeing imaginary things, hearing voices, and having a disorganized speech. The client also had started experiencing lack of emotional expression, as she could not understand the needs and feelings of others. The client also reported that the symptoms had affected severely her level of functioning in areas that included interpersonal relations, work, and self-care. The symptoms had persisted for more than five months. The family could not attribute the symptoms to other causes such as medication use, medical conditions, or substance abuse. As a result, she was diagnosed with schizophrenia and initiated on treatment.
O: The client appeared well groomed for the occasion. She was oriented to space, time, events, and self. She denied any recent experience of illusions, delusions, and hallucinations. She also denied any abnormality in speech content, volume and rate. She denied suicidal thoughts, attempts, and plans.
A: The client is responding well to the treatment. The symptoms of schizophrenia have improved significantly.
P: The client was advised to continue with the current treatments. She was scheduled for a follow-up visit after one month.
Anorexia Nervosa
Name: N.O
Age: 20 years
Diagnosis: Anorexia nervosa
S: N.O is a 20-year-old female client that came to the unit today for psychiatric assessment for what she felt that it was not a medical condition. The client complained of a wide range of symptoms that led to her diagnosis with anorexia nervosa. The symptoms included restriction of dietary intake relative to her body requirement. She was worried that the restrictive intake of food had led to a significant loss of body weight when compared to the expected weight of her age and sex. The client also reported intense fears towards gaining weight or becoming fat. As a result, her body weight and shape disturbed her significantly and consistently ensured that she did not add any weight. She was however not aware of the adverse effects of low body weight on her health. The restriction in dietary intake had lasted more than four months. The client reported that she engaged in other behaviors such as purging to ensure that she did not gain weight. Based on the above, the client was diagnosed with anorexia nervosa and initiated on treatment.
O: The client was well dressed for the clinical visit. She was however, underweight when compared to the developmental milestones for her age and gender. The client denied illusions, delusions, and hallucinations. Her judgment was intact. She denied suicidal thoughts, attempts, and intent.
A: The client is experiencing severe symptoms of anorexia nervosa.
P: The client was initiated on psychotherapy sessions to develop effective knowledge and skills for managing her eating disorder. She was scheduled for a follow-up visit after four weeks.
Obsessive Compulsive Disorder
Name: N.C
Age: 31 years
Diagnosis: Obsessive-compulsive disorder
S: N.C is a 31-year-old female who came to the clinic for assessment for psychiatric review. N.C reported that she often experiences intrusive, unwanted behaviors. The behaviors are associated with considerable anxiety and distress. The unwanted, intrusive behaviors and thoughts were beyond her control. This was despite her using diversion strategies to overcome them. The client also reported compulsive behaviors that included frequent hand washing that are time consuming in nature. She always feared that her hands are contaminated and required to be washed to prevent infections. N.C was worried that her obsessions and compulsive behaviors were causing her considerable distress as well as impairment in social and occupation functioning. Further assessment of the client showed that the above symptoms could not be attributed to any other mental disorder such as depression and mania. It was also not attributed to medication, substance abuse, or medical condition. It was identified during the assessment that the client recognized that the obsessive-compulsive beliefs were untrue and needed to be addressed for his improved social and occupational functioning. The above symptoms led to the development of a diagnosis of obsessive-compulsive disorder.
O: The client appeared well groomed for the occasion. The orientation of the client to self, others, events, and time were intact. Thought content and process were intact. She denied illusions, delusions and hallucinations. She also denied suicidal thoughts, plans and attempts. Her speech was of normal rate and volume.
A: The client is ready to engage in treatment interventions that will enable her to overcome her obsessive and intrusive behaviors.
P: The client was initiated on group psychotherapy sessions. The client was to be followed up for response of treatment after one month.
Post-Traumatic Stress Disorder
Name: S.W
Age: 49 years
Diagnosis: Post-traumatic stress disorder
S: S.W is a 49-year-old female nurse that came to the unit for her regular follow-up visits after she was diagnosed with post-traumatic stress disorder. The client was diagnosed with the disorder seven months ago and has been on antidepressant and psychotherapy treatments. She was diagnosed with the disorder following her experience with a road accident that led to death of all the passengers, with her being the only survivor. The client reported a number of symptoms that led to her being diagnosed with post-traumatic stress disorder. They included the persistent recurrence of the distressing memories about the traumatic event. She also reported experiencing distressing dreams that related to the accident. There was also the report of flashbacks and intense distress following the exposure of the patient to the stimuli that related to the event. The client also demonstrated avoidance behaviors of the stimuli that related to the traumatic event. The symptoms had a negative effect on the ability of the client engage in her occupational and family roles. As a result, she was diagnosed with post-traumatic stress disorder and has been on treatment in the unit.
O: The client was dressed appropriately for the occasion. She was oriented to self, others, time and events. Her judgment was intact. She denied illusions, delusions, and hallucinations. She also denied suicidal thoughts, attempts, and plans. She also denied avoidance behaviors and distressing emotional experiences associated with the accident.
A: There have been consistent improvement in the symptoms of post-traumatic stress disorder.
P: The participation of the client in group psychotherapy sessions was terminated with her consent since the treatment objectives had been achieved. She was advised to continue with antidepressant treatment. She was scheduled for a follow-up visit after one month.
Generalized Anxiety Disorder
Name: O.T
Age: 25 years
Diagnosis: Generalized anxiety disorder
S: O.T is a 25-year-old client that came to the psychiatric unit for assessment today for health problem. The client reported symptoms that related to those of generalized anxiety disorder. The symptoms included excessive worry and anxiety of unknown outcomes for more than five months. She was worried that her employer was likely to terminate her employment due to her inability in achieving some of the monthly targets. The client reported that her inability to control the excessive worry and anxiety. There were a number of accompanying symptoms for the excessive worry and anxiety. They included tremors, palpitations, chest pains, restlessness, and difficulty in concentrating in tasks. The client denied any history of medication use, medical condition or substance abuse. As a result, she was diagnosed with generalized anxiety disorder and initiated on treatment.
O: The client appeared well dressed for the occasion. She was anxious throughout the assessment. She denied illusions, delusions, and hallucinations. She also denied suicidal thoughts, plans, and attempts. Her speech was normal in terms of rate and volume.
A: The client is experiencing symptoms of generalized anxiety disorder that are beyond her control.
P: The client was initiated on group psychotherapy sessions to equip her with competencies needed to overcome excessive fear and anxiety. She was scheduled for a follow-up visit after one month to determine her response to treatment.
Generalized Anxiety Disorder
Name: E.M
Age: 33 years
Diagnosis: Generalized anxiety disorder
S: E.M is a 33-year-old client that came to the psychiatric unit for her follow-up assessment today. E.M was diagnosed with generalized anxiety disorder four months ago and has been on group psychotherapy treatment in the facility. The client was diagnosed with the disorder after she reported symptoms that related to those of generalized anxiety disorder. The symptoms included excessive worry and anxiety of unknown outcomes for six months. She was worried of the fact that her husband was likely to leave her because of her self-perception of not meeting his expectations. She also reported excessive fear about the possibility of failing her examinations, as she was a master’s student in a local university. The client complained that she was unable to control her excessive fear and anxiety. There were a number of accompanying symptoms for the excessive worry and anxiety. They included tremors, chest pains, sweating, restlessness, and muscle pains. The client denied any history of medication use, medical condition or substance abuse. As a result, she was diagnosed with generalized anxiety disorder and has been on group psychotherapy treatment.
O: The client appeared well dressed for the occasion. She denied illusions, delusions, and hallucinations. She also denied suicidal thoughts, plans, and attempts. Her speech was normal in terms of rate and volume. She reported that her anxiety and excessive worry were now under control.
A: The client demonstrates sustained improvement in her symptoms.
P: The client’s participation in the group psychotherapy was terminated since the treatment objectives had been achieved. She was scheduled for a follow-up visit after two months to determine her progress.
Substance Use Disorder
Name: K.M
Age: 40 years
Diagnosis: Substance use disorder
S: K.M is a 0-year-old client who came to the unit for his second follow-up visit. The client was diagnosed with alcohol use disorder three months ago and has been on pharmacological treatment, group psychotherapy and participating in Alcohol Anonymous group. The client was diagnosed with the disorder presented with complaints that included the persistent intake of larger amounts of alcohol for a long period. The client also reported of intent to stop binge alcohol consumption, which has been unsuccessful. He noted that withdrawal symptoms often made it difficult for him to stop alcohol abuse. There was also the complaint that the client engaged in activities that enabled him to obtain alcohol. This included selling his properties to get money for purchasing alcohol. Alcohol addiction was noted to have caused a significant decline in the social and occupational productivity of the client. The other symptoms that the client had included unsatisfied craving for alcohol and use of alcohol despite the interpersonal and social problems associated with alcohol. As a result, he was diagnosed with substance use disorder and initiated on treatment.
O: The client was well groomed for the occasion. His orientation to self, others, time and events were intact. The client reported that his participation in the group psychotherapy and alcohol anonymous group was effective in reducing his alcohol cravings. He denied illusions, delusions, and hallucinations. He also denied suicidal thoughts, attempts and plans.
A: The client is responding well to the adopted treatments.
P: The client was advised to continue with the current treatment approaches and participation in Alcohol Anonymous group.
Bipolar Disorder
Name: A.R
Age: 46 years
Diagnosis: Bipolar Disorder
S: A.R is a 46-year-old female who came to the unit for his fourth follow-up visit. She was diagnosed with bipolar disorder and has been on pharmacological treatment. She had come to the unit with complaints that included increased experience of inflated self-esteem. She also reported grandiosity. Her inflated self-esteem was characterized by the decrease in the need for sleep. There was also the report by spouse that the client had started experiencing increased talkativeness, racing thoughts, difficulties in concentrating, and being easily distracted. The client’s engagement in goal-directed activities has increased significantly. The client also reported mild symptoms of depressive bipolar disorder. The symptoms included depressed mood, loss of interest, weight gain, easy fatigability, and feelings of worthlessness. As a result, she was diagnosed with bipolar disorder with severe mania and mild depressive episodes.
O: The client appeared well groomed for the occasion. She reported improvements in her mood. The client was aware of self, time, others and events. She denied illusions, delusions, and hallucinations. She also denied suicidal attempts, plans, or ideas.
A: The client is demonstrating positive improvement in her symptoms of bipolar disorder.
P: She was advised to continue with the current treatment. The client was scheduled for a follow-up visit after one month.