PRAC 6645 WEEK 5 Assignment 1 : Clinical Hour and Patient Logs
Walden University PRAC 6645 WEEK 5 Assignment 1 : Clinical Hour and Patient Logs-Step-By-Step Guide
This guide will demonstrate how to complete the Walden University PRAC 6645 WEEK 5 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 5 Assignment 1 : Clinical Hour and Patient Logs
Whether one passes or fails an academic assignment such as the Walden University PRAC 6645 WEEK 5 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 5 Assignment 1 : Clinical Hour and Patient Logs
The introduction for the Walden University PRAC 6645 WEEK 5 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 5 Assignment 1 : Clinical Hour and Patient Logs
After the introduction, move into the main part of the PRAC 6645 WEEK 5 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 5 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 5 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 5 Assignment 1 : Clinical Hour and Patient Logs
Major Depression
Name: A.A
Age: 40 years
Diagnosis: Major depression
S: A.A is a 40-year old client that was brought today to the unit by his family for history of self-harm by cutting his hands. The client reported that he felt useless about his life, as he has not achieved anything unlike his peers. The client reported that he always has suicidal thoughts. Today in the morning, he tried to commit suicide by cutting his arm. The client also reported that his mood was highly depressed. He did not want to interact with people and often locked himself indoors. The spouse reported that A.A does not concentrate in what he does. He easily gets irritated with things. The client also reported that his energy levels were low in most of the days. He attributed the low energy to his reduced dietary intake, as he was worried that he lacked appetite. Due to the above complaints, the client was diagnosed with major depression and initiated on treatment.
O: The client appears poorly groomed for the occasion. He maintains minimal eye contact during the assessment. His orientation to self, others, place, time and events were intact. A.A denied hallucinations, illusions, and delusions. His speech was normal in rate and volume. He reported recurrent suicidal thoughts with plans and one attempt. The judgment is intact with thoughts that are future oriented.
A: The assessment findings show that the client is experiencing severe symptoms of depression and is at risk of self-harm.
P: The client was admitted for inpatient monitoring. He was prescribed antidepress
ants, antibiotics, and wound cleaning. He would be initiated on psychotherapy once stabilized
Major Depression
Name: E.R
Age: 29 years
Diagnosis: Major depression
S: E.R is a 29-year-old client that came to the unit today for his follow-up visit. The client was diagnosed with major depression three months ago and has been on antidepressants and psychotherapy. E.R recalled that he was diagnosed with major depression after he came to the unit with several complaints. They included persistent feelings
of depressed mood always and lack of pleasure and interest. E.R also reported that he was finding it hard to concentrate in his social and occupational roles. He also felt worthless, as he believed that he was not performing to the expectations of the organization where he was employed. E.R had also experienced difficulties in falling asleep and maintaining sleep. There was also the complaints of suicidal thoughts and attempts. The above symptoms had affected significantly his ability to perform in his social and occupational roles. A further assessment had revealed that the symptoms were not due to a medical condition, medication, or substance use. As a result, he was diagnosed with major depression and initiated on antidepressants and psychotherapy sessions.
O: The client appeared well groomed for the session. He was alert during the assessment. He reported that his mood had improved significantly following the adopted treatments. He denied illusions, delusions, and hallucinations. His speech rate and volume were intact. He denied any recent experience of suicidal thoughts, attempts, and intentions.
A: The client is responding well to the treatment.
P: The client was advised to continue with the treatment, as positive improvement in symptoms was being reported. He was scheduled for a follow-up visit after four weeks.
Post-traumatic Stress Disorder
Name: A.N
Age: 39 years
Diagnosis: Post-traumatic stress disorder
S: A.N is a 39-year old female that came to the unit today for her first visit. She came as a referral by her physician for further assessment for what he felt that she was suffering from a mental problem. The client reported that she has been feeling low since her husband died through a road accident six months ago. The accident occurred when she was with him. A.N reported that she always experiences flashbacks and nightmares related to the accident. She also tries so much to avoid any situation that is related to the events that led to the accident, as it arouses the depressive symptoms. A.N also reported that her appetite had declined significantly over the past three months. Her engagement in the activities of the daily living was significantly reduced. A.N could not attribute to the above symptoms to any cause such as medication use, substance abuse or medical condition. As a result, she was diagnosed with post-traumatic stress disorder and initiated on treatment.
O: The client appeared appropriately dressed for the occasion. She did not demonstrate any abnormal behaviors. Her speech was of normal rate and volume. Her self-reported mood was depressed. She declined illusions, delusions, and hallucinations. She also declined suicidal thoughts, plans, and attempts. Her thoughts were future oriented.
A: The client is experiencing moderate symptoms of post-traumatic stress disorder.
P: The client was prescribed antidepressants. She was also initiated on group psychotherapy sessions to help her cope with the depressive symptoms. She was scheduled for the next follow-up visit after four weeks.
Insomnia
Name: E.D
Age: 34 years
Diagnosis: Insomnia
S: E.D is a 34-year old male that came to the unit today for his follow-up visit after he was diagnosed with insomnia six months ago. E.D recalled that he was diagnosed with the disorder because of his sleep-related problems. Accordingly, he was persistently experiencing an acute shortage of quality and quantity sleep. He was always finding it hard to fall asleep. He was worried that he experienced frequent awakenings whenever he found little sleep. He also noted that it was becoming hard for him to fall back after the awakenings. E.D could often find himself dozing off during the day due to the lack of enough sleep the previous days. The lack of sleep was taking a toll on him, as he was underperforming in his place of work. He was also find it hard to concentrate in his part time studies. When probed further, E.D denied any history of medication use, medical condition , or substance abuse, which could have contributed to the problem. As a result, he was diagnosed with insomnia and has been on individual psychotherapy sessions.
O: The client appeared dressed appropriately for the occasion. He was oriented to self, time, place, and events. He was alert and maintained the normal eye contact throughout the assessment. The client denied illusions, delusions, and hallucinations. He also denied suicidal thoughts, attempts, and plans.
A: The individual psychotherapy sessions have been effective so far. The desired treatment outcomes have been achieved.
P: The psychotherapy sessions were terminated with the consent of the client since the desired outcomes of treatment had been achieved. The client was scheduled for a follow-up visit after two months.
Binge Eating Disorder
Name: Z.P
Age: 24 years
Diagnosis: Binge eating disorder
S: Z.P is a 24-year old client that has been undergoing treatment in the unit for binge eating disorder. She was diagnosed with the disorder seven months ago and has been on individual psychotherapy sessions. Z.P reported that she was diagnosed with the disorder after she complained of abnormal eating habits. They included eating a large amount of food that is beyond those of the expected age. Z.P was worried that binge eating would affect her, as she found it difficult to control it. Z.P also reported that binge eating had affected her sense of self-identity. She was embarrassed to eat in the presence of others, as she felt that her abnormal eating of huge amount of foods were shameful. Z.P was worried that her problem was likely to predispose her to health problems such as obesity, low self-esteem, and hypertension, hence, her intention to seek professional support. Z.P was diagnosed with binge eating disorder and initiated on individual psychotherapy.
O: Z.P appeared appropriately dressed for the occasion. She was oriented to self, place, time and events. She denied any history of illusions, delusions, and hallucinations. Her level of identity was improved. She denied suicidal thoughts, attempts, and plans.
A: Psychotherapy sessions have been effective. The client reports that she now has control over her abnormal eating habits. She has sustained improved symptom improvements for the last three months.
P: The individual psychotherapy sessions were terminated with the consent of the client. The treatment objectives have been achieved. She was scheduled for a follow-up visit after three months.
Alcohol Use Disorder
Name: K.C
Age: 33 years
Diagnosis: Alcohol use disorder
S: K.C is a 33-year old client that has been undergoing treatment in the unit due to alcohol use disorder. He was diagnosed with the disorder eight months ago and has been on pharmacological treatment, psychotherapy, and participating in Alcohol Anonymous group. K.C recalled that he was diagnosed with alcohol use disorder because of his excessive alcohol intake. He was used to overconsumption of alcohol, which was becoming hard for him to control. K.C had tried to stop alcohol abuse by participating in Alcohol Anonymous group but often lost the motivation due to the severe effects of withdrawal symptoms. The client was also increasingly worried that alcohol abuse had affected significantly his binge consumption of alcohol. The alcohol abuse had affected his social and occupational health, as he was no longer productive. His wife had also threatened to leave him due to his alcohol abuse. The abuse of alcohol could not be attributed to any other cause besides peer pressure and its dependence. Therefore, he was initiated on pharmacological and psychotherapy treatments and has been participating in Alcohol Anonymous group sessions.
O: The client appeared appropriately dressed for the occasion. He was oriented to others, self, time, and events. He did not show any abnormal movements such as tremors. His mood was normal. He denied illusions, delusions, and hallucinations. He also denied suicidal thoughts, attempts, and plans.
A: K.C has demonstrated optimum improvement in his symptoms. He no longer consumes alcohol. He has gained control over the withdrawal symptoms. He no longer craves for alcohol. He has been an active member of Alcohol Anonymous group sessions.
P: The use of pharmacological and psychotherapy sessions were terminated as the outcomes of the treatment had been achieved. He was advised to continue with Alcohol Anonymous group sessions. He was scheduled for a follow-up visit after one month to determine his response to treatment.
Generalized Anxiety Disorder
Name: R.O
Age: 32 years
Diagnosis: Generalized anxiety disorder
S: R.O is a 32-year old client that came to the unit for her regular follow-up visits. She was diagnosed three months ago with generalized anxiety disorder. The diagnosed was reached after she raised several complaints that related with those of the disorder. They include excessive worry and anxiety about her performance in her workplace. She also had persistent, excessive fear of an impending doom. She had reported that the excessive fear and worry were beyond her control. She reported that she often avoided stimuli that were likely to predispose her to further worries and anxiety. The accompanying symptoms that the client reported included chest pain, shortness of breath, tremors, and sweating. The psychiatric mental health nurse could not attribute the complaints to medication use, substance abuse and medical condition. R.O was worried that the symptoms were likely to affect further her social and occupational functioning if she did not get the support that she needed. As a result, she was diagnosed with generalized anxiety disorder and initiated on group psychotherapy treatment.
O: The client appeared well groomed for the occasion. She was oriented to self, others, time and events. She was alert during the assessment and maintained normal eye contact. She reported mild anxiety. She denied illusions, delusions, and hallucinations. She also denied suicidal thoughts, attempts and plans.
A: The client is responding well to psychotherapy treatment. She has developed moderate coping skills for excessive worry and anxiety.
P: The client was advised to continue with the group psychotherapy sessions. She was scheduled for a follow-up visit after four weeks.
Psychosis
Name: C.B
Age: 43 years
Diagnosis: Psychosis
S: C.B is a 43-year old female who has been undergoing treatment in the unit due to psychosis. The client was diagnosed with the condition two months ago and has been on psychotherapy. The client came to the unit with a number of symptoms. They included difficulties in concentrating and depressed mood, sleeping too much and excessive worry. She also reported being excessively suspicious of others and hearing voices. The client’s speech was disorganized. Based on the above history, the client was diagnosed with psychosis and has been on individual psychotherapy sessions.
O: The client appeared today appropriately dressed for the occasion. She was oriented to self, place and time. The speech of the client was of normal rate and volume. She demonstrated mild anxiety during the assessment. The client denied any history of delusions, hallucinations, illusions, and suicidal thoughts, attempts or plans.
A: The client demonstrates improvement in the symptoms of psychosis when compared to the previous encounter with her. The client also demonstrated improved mood and wellbeing.
P: It was recommended that the client continue with the current individual psychotherapy sessions. The client was to be re-assessed after one month to determine his response to treatment.
Bipolar Disorder
Name: E.X
Age: 38 years
Diagnosis: Bipolar disorder
S: E.X is a 38-year-old client that came to the unit for his third follow-up visit. He was diagnosed with bipolar disorder and has been on treatment. He was diagnosed with bipolar disorder after he presented to the unit with complaints that included periods of elevated mood. The mood elevation was characterized by behaviors that that included over activity, engaging in goal-directed initiatives, excitement, euphoria and delusions. There was also the alternation of the above symptoms with periods where the client would feel to be significantly depressed. The depressive symptoms included lack of energy, too much sleeping, difficulties in concentrating and making decisions. The depressed mood could happen almost every day for a specific period such as two weeks, followed by elated mood. Further examination of the client had revealed that the symptoms were not severe to cause any impairment in the normal functioning of the client. As a result, he was diagnosed with bipolar disorder and initiated on treatment.
O: The client appeared appropriately dressed for the occasion. He was oriented to self, place, time and events. His judgment was intact. He denied any recent experience of delusions, hallucinations, illusions, suicidal thoughts, plans, and attempts.
A: The client is responding well to the adopted treatments. He also denies any side or adverse effects to the prescribed medications.
P: The client was advised to continue with the current treatments because of the improvement in symptoms and tolerability of the treatments. He was scheduled for a follow-up visit after one month.
Schizophrenia
Name: A.S
Age: 40 years
Diagnosis: Schizophrenia
S: A.S is a 40-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. A.S recalled that she was diagnosed with schizophrenia after she started experiencing symptoms that included seeing imaginary things, hearing voices, and having a disorganized speech. 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 four months. 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. Her thought content was future oriented. She did not demonstrate any abnormal behaviors such as avoidance of eye contact and tics.
A: The treatment has been effective due to the improvement in symptoms. The client is also satisfied, as she has not experienced any side effects with the treatments.
P: The client was advised to continue with the current treatments, as the desired improvements were being achieved. She was scheduled for the next follow-up visit after four weeks.
Sample Answer 2 for PRAC 6645 WEEK 5 Assignment 1 : Clinical Hour and Patient Logs
Post-Traumatic Stress Disorder (PTSD)
Name: G.H
Age: 7 years old
Gender: Male
Diagnosis: PTSD
S: G.H. is a 7-year-old boy who has ADHD and PTSD. Over the last two years, the patient’s mother indicated that her kid has been suffering severe behavioral outbursts and hostility, as well as frequent instances of heightened startle, increased alertness, sleeping issues, behavioral reenactment, and hypervigilance. When the youngster was just four years old, the patient’s father perished in a vehicle accident two years ago. The patient has been having nightmares about the vehicle accident and screaming in the middle of the night ever since. However, the patient denies any delusions, hallucinations, or self-harming behavior.
O: The patient entered the room looking well-dressed. He appeared slightly preoccupied yet alert to person, time, and location. His mental process is sound, and he has enough short and long-term memory. He, on the other hand, fidgets a lot and shows indications of intense nervousness. He denies having suicidal thoughts or engaging in self-harming behavior. He also denies any form of delirium or hallucination. Reports, behavioral reenactment, and hypervigilance are all examples of this.
A: Even though the majority of his symptoms suggested ADHD, the patient did not fulfill the DSM-V diagnostic criteria. He does, however, qualify for the PTSD diagnosis as a result of his father’s death in a vehicle accident as a traumatic event.
P: Trauma-focused cognitive behavior therapy, or TF-CBT, is widely regarded as the gold standard treatment for PTSD in children and adolescents.
Intermittent explosive disorder (IED)
Name: S.D
Age: 56 years old
Gender: Female
Diagnosis: Intermittent explosive disorder (IED)
S: S.D., a 56-year-old female patient, arrives at the clinic complaining of a bad temper. She professes to be grumpy most of the time, especially around this time of year. She’s been having trouble sleeping and has recently gained weight. Her focus has suffered significantly, and she is frequently bored. She becomes bored with her pals, making it difficult for her to maintain them.
O: A medical checkup indicates no indications of physical problems. An evaluation of one’s mental state indicates Well-dressed, tidy, erect posture, and maintains eye contact. Speech: Fluent, yet a touch rushed at times. Movement: agitated and anxious. At the moment, I was unhappy and upset, and I was irritated. Thought and perception: Ideas follow one another. Her thoughts, however, are delusory. Attitude and insight: the patient is cooperative and appears to be aware of her current mental health situation. The Patient Denies Suicide Attempts or Thoughts of Damage to Self or Others: The patient denies any suicidal attempts or thoughts of harm to self or others. The patient appears dissatisfied and despondent, according to the examiner. Cognitive Abilities: During the assessment, the patient was easily distracted.
A: According to the DSM-V criteria, the patient qualifies for this diagnosis because she has recurring behavioral outbursts demonstrating an inability to control violent impulses. Because the patient was raised by an alcoholic mother, he or she may have had a terrible experience. She also claims to have lost her temper, which is an excellent indicator of an IED.
P: Reduces violence while enhancing adherence to therapy. Coping abilities and self-esteem are improved via improvisation. Encourage social engagement. Interact with clients and their families.
Social Anxiety Disorder (Social Phobia)
Name: Z.X
Age: 21 years old
Gender: Male
Diagnosis: SAD
S: Z.X is a 21-year-old African American male patient who came to the clinic claiming to be sad and experiencing increasing stress at school. The patient spends most of his time indoors, alone, playing video games. Z.X has always been considered timid by his pals, who usually struggle to identify something they have in common. He is frequently referred to as “stupid” since he does not engage in conversation. The patient, on the other hand, professes to be terrified to speak for fear of what others would think of him. He also reports having issues with raising his hand in class or confronting his teachers in cases of bullying. He denies having suicidal or homicidal thoughts.
O: The findings of the mental status test show that the patient is well-dressed in age-appropriate apparel. He is aware and focused on person, place, and time. His motor activity is average. During the interview, he is cooperative and talked in a clear and regular tone. His mood is depressed. He has a restricted appearance and exceptional intellect and judgment. His memory is intact, and his cognitive process is ordinary. His functional condition, on the other hand, is moderately degraded.
A: According to the DSM-V diagnostic criteria, the patient has separation anxiety disorder because he prefers to stay indoors and finds it difficult to communicate with friends owing to excessive worry about what people think of him.
P: Encourage the client to take part in relaxation methods including deep breathing, gradual muscular relaxation, guided imagery, meditation, and so on. Consider CBT for positive reframing, decatastrophizing, and assertiveness training.
Bulimia Nervosa
Name: C.V
Age: 15 years old
Gender: Female
Diagnosis: Bulimia Nervosa
S: C.V. is a 15-year-old female patient who was brought to the clinic by her mother, who complained that her daughter has been exhibiting strange eating patterns since returning home around 6 months ago. Her mother alleges that the patient has been devouring enormous amounts of food when alone, and that food wrappers have been discovered stashed in her chamber. She is concerned that her daughter would vomit as a result of the heavy eating sessions. She also verifies that after a substantial meal, the patient usually isolates herself in the restroom for 15-30 minutes. When queried about her eating habits, the patient stated that she had lost control. She claims to experience profound sorrow after overeating, which causes her to vomit. She claims to experience profound sorrow after overeating, which causes her to vomit at the end of the day. She also claims to be overweight and despises herself. She denies having any additional medical issues. Except for contraceptive pills, she is not currently using any prescriptions. She claims she has no allergies. Denies any history of eating issues in his family.
O: The patient’s vital signs were taken, and they were all within normal ranges. Her abdomen was examined and found to be normal. A blood amylase level of 140 Units/L and a serum potassium level of 3.8 Meq/L were found in the lab. To examine the patients’ eating problems, further screening instruments such as the Eating Attitudes Test (EAT) and the SCOFF mnemonic questionnaire were used.
A: Subjective findings from the patient suggest increased eating and induced vomiting. The objective findings show that there is no substantial reason for the patient’s behaviors. The patient was diagnosed with bulimia nervosa based on the findings of the eating disorder screening instruments.
P: Psychotherapy, whether individual, family, or group, is advised. Behavior therapy focuses on changing behaviors such as overeating. Refer the patient to a dietitian for appropriate dietary intervention.
Gender Dysphoria
Name: B.N
Age: 19 years
Gender: Male
Diagnosis: GD
S: B.N. is a 19-year-old Asian male patient who arrived at the psychiatric unit on his own for a mental examination and has a history of ADHD. The patient recalls attending the clinic for an annual evaluation the previous year, during which the primary care physician discovered no health problems. The patient admits to having sexual relations with males but is hesitant to discuss the subject, indicating that he is terrified to reveal his sexual orientation to his mother. His father, on the other hand, disapproves of his dressing up like his sister and wearing makeup with her. He is usually melancholy, expressing that he wishes he had been born like his sister. Denies any previous history of sexually transmitted illnesses.
O: The patient looks to be attentive and aware of time, location, and person. His vital signs are normal, and he has no physical symptoms such as blood in his stool, diarrhea, constipation, headache, or fever. The patient is depressed and feels awkward disclosing his sexuality during the interview. He claims to dislike the way he was created. Denies hallucinations or suicidal ideation.
A: The patient exhibits indicators of sexual identification, as he affirms being homosexual while also wishing to be like her sister and dress like her. He is hesitant to discuss the situation with his parents. He meets the criteria for gender dysphoria.
P: Refer the patient to a therapist for counseling and consideration of surgery or hormonal therapy as per the patient’s preference.
Nightmare disorder
Name: N.M
Age: 8 years old
Gender: Female
Diagnosis: nightmare disorder
S: N.M. is an 8-year-old female patient who came to the clinic with her mother, complaining of recurrent nightmares. The patient’s mother claims that her daughter slept quite well, but in the middle of the night, she would sit up in bed and start screaming extremely loudly. Mom kid is frequently afraid and swats a lot during such periods, according to her. She claims that the incidents happen three to four times every week and last around five minutes each. During regular evenings, she says that the patient sleeps for roughly 10 hours. She claims that the patient is currently refusing to sleep in her bed and has joined them with her spouse. She denies using any medicine to alleviate these problems.
O: During the interview, the 8-year-old is awake, active, and agreeable. She looks to be well-fed and hydrated. She claims she had nightmares much of the night, believing she was going to die. Denies any suicidal or self-harming behavior.
A: The patient is going through typical growth phases and has no history of trauma or injury. She doesn’t have any other physical symptoms. According to the DSM-V diagnostic criteria, the patient qualifies for the diagnosis of nightmares disorder since she has 3 to 4 episodes of nightmares lasting around 5 minutes.
P: Recommend five sessions of CBT to teach sleep hygiene, and relaxation tactics, and to handle nightmares therapeutically through exposure and rescripting.
Unspecified Disruptive, Impulse-Control, and Conduct Disorder
Name: M.A
Age: 12 years old
Gender: Male
Diagnosis: Unspecified Disruptive, Impulse-Control, and Conduct Disorder
S: The 12-year-old male patient was accompanied to the clinic by his mother because of his increasingly disruptive behavior at school and at home. Her mother claims that he has been the most difficult to handle for her two children. She says that the patient is quickly irritated, readily agitated, and resistant to any changes in his routine. He is often in disagreements with his older sister about trivial matters. At school, he disrespects his teachers and even steals toys from his classmates. He frequently fails to do his schoolwork and, sometimes, refuses to attend school. The patient, on the other hand, sleeps and eats well.
O: With exceptional articulation, the 12-year-old youngster is active, aware, and responds to practically all demands. He does, however, fiddle with instruments on occasion. His tone, coordination, reflexes, and strength are all acceptable. Has a limited attention span and can be obstinate at times. Shows the potential for damage to others. Denies engaging in self-harming behavior.
A: The patient exhibits symptoms of conduct disorder, oppositional defiant disorder, and intermittent explosive disorder according to the DSM-V diagnostic criteria, but does not satisfy the threshold for any of these diagnoses. The major diagnosis was thus Unspecified Disruptive, Impulse-Control, and Conduct Disorder.
P: Reduces violence while enhancing adherence to therapy. Coping abilities and self-esteem are improved via improvisation. Encourage social engagement. Interact with clients and their families.
Major Depressive Disorder (MDD)
Name: K.L
Age: 37 years old
Gender: Female
Diagnosis: MDD
S: K.L., a 37-year-old Caucasian female, was admitted to the psychiatric unit for examination. She has a history of severe depressive illness, which she has been treating with amitriptyline, but which she claims is no longer working. The patient claims to be lonely and to have lost interest in formerly enjoyable hobbies. She also suffers nightmares, exhaustion, feelings of worthlessness, and suicide ideation. She states that she is contemplating suicide at the moment. Denies auditory and visual hallucinations as well as a history of suicide ideation.
O: The patient appears to be in good health and is dressed appropriately. She, on the other hand, appears depressed and uninterested in the interview. She is anxious, yet she walks steadily. Her speaking is clear, with the appropriate tone and loudness. Her demeanor is decent yet uninteresting. Even though the procedure is still in place. Denies having hallucinations or delusions. Her short-term and long-term memories are both intact. Her perspective is correct. Confirms suicidal thoughts but denies ever trying suicide.
A: The patient meets the DSM-V criteria for MDD because she has a sad mood, sleeping issues, psychomotor agitation, exhaustion, loss of interest, worthlessness, and suicidal thinking.
P: Consider cognitive behavioral treatment (CBT), interpersonal therapy, or supportive therapy for the patient.
Attention-Deficit/ Hyperactivity Disorder (ADHD)
Name: D.F
Age: 10 years old
Gender: Male
Diagnosis: ADHD
S: The patient is a 10-year-old Caucasian male who presented to the clinic accompanied by his mother complaining of abnormal behavior. The child displays symptoms of inattention, hyperactivity, and impulsivity for the past month which has been worsening over time. The child is also disruptive and unable to finish the work assigned by either his teacher or mother. The child is however able to appropriately understand instructions. The patient’s mother also denies her son being defiant. The cognitive symptoms occur at different times throughout the day, and reprimanding seems to be the only temporary alleviating factor.
O: The child is well nourished with vital signs within normal range. He is alert and well-oriented appropriate for her age. His mood is congruent with content, despite his hasty responses to questions asked. He seems restless and fidgets a lot. He is unable to concentrate for a long time, or even maintain eye contact. Denies suicidality or self-injurious activities.
A: Based on the finding of the mental status examination, in line with the DSM-V diagnostic criteria, the patient qualifies for the primary diagnosis of ADHD. He is positive for inattention, hyperactivity, and impulsivity. The differential diagnosis for the patient includes oppositional defiant disorder and an autism spectrum disorder.
P: Consider using psychotherapy instead of medicine. Behavioral therapy can assist the child in reducing hyperactivity, impulsivity, and inattention.
Child Language Disorder (Autism)
Name: K.L
Age: 6 years old
Gender: Male
Diagnosis: child language disorder (autism)
S: K.L. is a 6-year-old Asian male youngster who was referred to the clinic after attending a few group speech-language therapy sessions at a local private speech clinic. During the interview, the youngster was animated and in a good mood. The prior treatment session, according to the mother, was held in a school format, and the youngster was frequently off-topic. The patient’s mother argues that the treatment sessions are ineffective and that she would want to consider using medicine to control her child’s condition.
O: Based on the findings of the mental status evaluation, the patient’s participation in turn-taking was fairly suitable, although with minor deficiencies that need extra therapy. His auditory closure, capacity to express action or emotions, ability to answer questions rationally, ability to offer specifics about known items and ability to perform simple problem-solving tasks were all recognized as impairments. There were no additional indicators of mental disease in the patient.
A: The patient was reported to have difficulty answering logical questions and taking turns, as well as providing specifics about known items, which led to the diagnosis of child language disorder (autism).
P: Advise the patient to continue with the group speech-language therapy sessions.
Substance Use Disorder
Name: L.Q
Age: 18 years old
Gender: Female
Diagnosis: Substance Use Disorder/PTSD
S: L.Q is an 18-year-old female patient who arrived at the clinic with her mother, complaining of heroin addiction. She has been using heroin for the past two years, using 10-14 stamp bags every day. The patient was advised to go to rehab, but she refused. She verifies a lack of self-esteem, self-worth, sadness, hopelessness, helplessness, and insight. She was sexually abused by her uncle from the age of 5 to 12 years. To cope with the event, she began using marijuana, then pain relievers, and finally heroin. She admits to self-harming behaviors such as cutting herself and a history of PTSD. She also sells sex for drugs and tested positive for hepatitis C. The mother is an alcoholic, and the father died of an opiate overdose at the age of 30.
O: The patient is well-dressed and dressed appropriately for his age. She is aware of people, places, and times. She has a depressed expression on her face. When discussing anything that makes her uncomfortable, such as being sexually molested by her uncle, she avoids eye contact and looks across the room. Her mental process is intact, and she responds to queries with a trembling voice. She validates feelings of worthlessness, helplessness, hopelessness, and poor self-esteem. She demonstrates a lack of understanding and confirms a history of PTSD and self-harming activities. She, on the other hand, denies having hallucinations or suicidal thoughts.
A: The patient almost certainly has PTSD and SUD. As a result of being sexually molested by her uncle, she has a history of PTSD. She has admitted to consuming IV heroin for the previous two years.
P: Advise the patient to consider group cognitive behavioral therapy. The patient can also benefit from substance use support group sessions. Consider rehabilitation when the patient is ready.
Bipolar disorder
Name: W.E
Age: 16 years old
Gender: Female
Diagnosis: Bipolar Disorder
S: W.E. is a 16-year-old female patient who has come to the psychiatric clinic for a mental health evaluation today. She claims she has been taking drugs on and off since she does not believe she needs them. She believes they are suffocating her. P.T. claims that she suffers from depression 4-5 times a year, which prevents her from working at her aunt’s bookstore. She claims to have days when she doesn’t want to get out of bed and feels drained of energy and ambition. Furthermore, her inventiveness fades, making her feel worthless. People say she is sad, but she believes she is simply fatigued.
O: The findings of the mental status evaluation showed that the patient is tidy and suitably dressed for the weather and occasion. Alert. Keeps eye contact and uses suitable facial expressions. Her communication is clear, typical in volume and tempo, and goal-oriented. Her reasoning is reasonable and consistent. There are no hallucinations, delusions, compulsions, obsessions, or suicidal thoughts. The patient’s capacity to recognize the repercussions of her behavior is restricted.
A: The patient exhibits symptoms compatible with the DSM-V criteria for Bipolar disorder, such as times of creative episodes interspersed by periods of feeling crashed. Manic episodes last a week and are characterized by minimal need for sleep, extremely high activity levels, excessive goal-focused activities such as painting and writing, dangerous enjoyable sexual behaviors, and distractibility. Her depressed bouts are also characterized by poor energy levels, low drive, a lack of interest in her interests, and thoughts of worthlessness.
P: Provide a low-stimulus setting wherever feasible (e.g., quiet, dim lighting). Advise the patient to consider psychotherapeutic approaches such as psychoeducation, CBD, and support therapy.