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PRAC 6645 WEEK 6 Assignment 1 : Clinical Hour and Patient Logs

PRAC 6645 WEEK 6 Assignment 1 : Clinical Hour and Patient Logs

Clinical Logs

Major Depression

Name: Y.Y

Age: 28 years

Diagnosis: Major depression

S: Y.Y is a client who came to the psychiatric department today for her follow-up visit after being diagnosed with major depression eight months ago. The patient has been on antidepressants and group psychotherapy. She was diagnosed with major depression due to the symptoms that included persistent feelings of guilt and worthlessness. The client reported feeling 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. There was also the complaint of decline in her appetite. She also noted that her energy levels were cons

PRAC 6645 WEEK 6 Assignment 1  Clinical Hour and Patient Logs
PRAC 6645 WEEK 6 Assignment 1  Clinical Hour and Patient Logs

istently low, as she felt fatigued in engaging in an activity. She had however denied suicidal thoughts, plans, or attempts. Y.Y 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 was normal. 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 client is tolerating treatment. The symptoms of major depression have improved as expected in the treatment plan.

P: Psychotherapy sessions were terminated with consent from the client. The client was advised to continue using antidepressants.  She was scheduled for a follow-up visit after four weeks.

 

Major Depression

Name:

Age: 43 years

Diagnosis: Major depression

S: A.A is a 43-year-old client that came to the unit as a self-referral, as perceived abnormal mental health and wellbeing.  The client reported that he felt hopeless in life and wanted to take his life. The feelings of hopelessness

PRAC 6645 WEEK 6 Assignment 1 Clinical Hour and Patient Logs
PRAC 6645 WEEK 6 Assignment 1 Clinical Hour and Patient Logs

persisted in most days throughout the day. He also experienced depressed mood in most days. He reported that he has trouble in falling asleep. His appetite had declined significantly leading to his lack of energy in most of the days. He also reported having suicidal thoughts without plans. He noted that his ability to make decisions and concentrate had worsened significantly over the past month. The symptoms were not attributable to any medical condition, medication or substance abuse. As a result, he was diagnosed with major depression and initiated on treatment.

O: The patient appeared poorly groomed for the occasion. His had slowed speech. His self-reported mood was depressed. The client denied illusions, delusions, and hallucinations. His thought content was future oriented. He reported suicidal thoughts without a plan or attempt.

A: The client is experiencing symptoms of major depression.

P: The client was initiated on antidepressants and group psychotherapy to help improve mood and coping skills of the client with depressive symptoms. He was scheduled for a follow-up visit after four weeks.

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Major Depression

Name: Z.Y

Age: 33 years

Diagnosis: Major depression

S: Z.Y is a 33-year-old female that came today to the unit for her regular checkup after being diagnosed with major depression three months ago and has been on antidepressants and psychotherapy treatments. One of the symptoms that led to her diagnosis with major depression was the persistent feeling of worthlessness, which made her contemplate committing suicide. The client also reported that she preferred spending her time indoors and alone. The client also reported a decrease in her appetite, which led to weight loss and lack of energy in most of the days. There was also the complaint of lack of concentration and difficulty in making decisions. The client also complained that she experienced insomnia for the last one week prior to the hospital visit. The above symptoms were noted to have affected adversely the ability of the client to perform optimally in her social and occupational roles. As a result, she was diagnosed with major depression and initiated on treatment.

O: The client was appropriately dressed for the occasion. Her self-reported mood was ‘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 treatment appears to be effective in managing depressive symptoms. The client also reports positive experience with psychotherapy sessions.

P: The client was advised to continue with the current treatments and schedule for a follow-up visit after one month.

Insomnia

Name: C.H

Age: 40 years

Diagnosis: Insomnia

S: C.H is a 40-year-old male who has been undergoing treatment in the facility due to insomnia. C.H was diagnosed with insomnia seven months ago after he presented to the clinic with a number of complaints. They included the lack of quality and quantity sleep for the last four months prior to the hospital visit. He also complained that he found it difficult to maintain sleep once he fell asleep. There were also the complaints that the sleep disturbance had affected significantly his ability to concentrate in his occupational activities. He was worried that his productivity and performance would have worsened if the condition was not managed. Further assessment of the client had revealed that the symptoms were not attributed to any factors such as medication use, medical condition or substance abuse. He was therefore diagnosed with insomnia and initiated on treatment.

O: The patient appeared well groomed for the occasion. His orientation to self, others, time and events were intact. His judgment was also intact, as he denied illusions, delusions and hallucinations. The client also denied suicidal thoughts, attempts and plans. The speech was of normal rate and volume.

A: The client reported consistent improvement in the quality and quantity of sleep for the last three months. The treatment has been effective in improving his symptoms of insomnia.

P: The treatment was terminated with consent from the client. The treatment outcomes had been achieved. The client was scheduled for a follow up visit after two months.

 

 

Insomnia

Name: K.R

Age: 32 years

Diagnosis: Insomnia

S: K.R is a 32-year-old client that came to the unit today for his first clinical visit. The client came with complaints of lack of quality sleep. He reported the persistent lack of quality and quantity sleep. The client reported that he found it hard to fall asleep and maintain it despite using sleep enhancing medications. The client also reported that he often fell asleep during the day at his workplace due to lack of sleep the previous nights. The lack of quality and quantity sleep was affecting his performance in workplace, as he always felt that he did not have enough energy to undertake his assigned duties. The client denied any history of medical conditions, drug, or substance abuse that could have contributed to the symptoms. As a result, he was diagnosed with insomnia and initiated on individual psychotherapy sessions.

O: The client appeared dressed appropriately for the occasion. His orientation to self, others, time, and events were normal. His judgment was intact. He appeared tired during the assessment. He maintained normal eye contact. His speech was of normal rate and volume. He denied illusions, hallucinations, and delusions. He also denied suicidal thoughts, attempts and plans.

A: The client is experiencing the symptoms of insomnia. The symptoms are affecting his ability to engage in the activities of the daily living.

P: The client was initiated on individual psychotherapy. He was educated about the importance of minimizing caffeine intake towards bedtime. He was also educated about the importance of avoiding distractors during bedtime. He was educated about the need for routines such as physical activity in the evening to boost the quality of sleep. He was scheduled for a follow-up visit after one month.

 

 

Post-Traumatic Stress Disorder

Name: K.T

Age: 25 years

Diagnosis: Post-traumatic stress disorder

S: K.T is a 25-year-old male client who came to the unit today for his regular follow-up visits for post-traumatic stress disorder. He was diagnosed three months ago with the disorder and has been undergoing treatment. The client reported that his problems started after he was involved in a road accident.  He experienced symptoms that included flashbacks and nightmares about the accident. He also reported avoidance of any stimuli that related to the accident. K.T further reported persistent experience of emotional distress following the accident. The family members of the client had also noted that he was becoming easily irritated, experiencing difficulties in sleeping and concentration. Therefore, they brought him to the unit where he was diagnosed with post-traumatic stress disorder and initiated on treatment.

O: The client was well groomed for the occasion. His orientation to self, others, environment, and events were intact. He reported improved mood since the last visit. His level of judgment was intact. He denied suicidal thoughts, plans or attempts, illusions, delusions, and hallucinations.

A: The client is responding positively to the treatment. He is also tolerating the medications, as evidenced by the minimal side effects of the antidepressants.

P: The client was advised to continue with the treatments and scheduled for a follow-up visit after one month

 

 

Post-Traumatic Stress Disorder

Name: A.N

Age: 38 years

Diagnosis: Post-traumatic stress disorder

S: .A.N is a 38-year-old client that came to the unit for her regular follow-up visits after she was diagnosed with post-traumatic stress disorder seven months ago. She has been using antidepressants to manage her mood and psychotherapy to cope with the depressive symptoms. A.N was diagnosed with post-traumatic stress disorder after she was sexually abused two years ago. 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 ordeal. 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.

A: The client continues to tolerate the prescribed treatment. She has developed the desired coping skill with depressive symptoms.

P: The client’s participation in psychotherapy sessions was terminated because the treatment objectives had been achieved. She was advised to continue with the antidepressants. She was scheduled for a follow-up visit after two months.

 

 

Generalized Anxiety Disorder

Name: B.K

Age: 24 years

Diagnosis: Generalized anxiety disorder

S: .B.K is a 24-year-old female who came to the department with complaints of excessive fear and worry of the unknown. According to her, she had been experiencing intensive anxiety and fear of things over the past three months. She feared that she might contract an infection as well as failing in her college examinations. The excessive fear had made it difficult for her to concentrate in her academics. The additional complaints that she raised were that she getting fatigued easily and lacked control over her excessive worry and fears. The excessive fear and anxiety could not be attributed to any cause such as medical condition, medication, or substance use and abuse. As a result, she was diagnosed with generalized anxiety disorder and initiated on treatment.

O: The client appeared appropriately dressed for the occasion. She was oriented to place, time, and self. The speech rate and volume were normal. The self-reported mood of the client was ‘I am so anxious, and fear something bad might happen to me.’ The client denied any history of hallucinations, delusions, and illusions. The memory of the client was intact.

A: The client is experiencing severe symptoms of generalized anxiety disorder. The symptoms have affected her social and academic functioning.

P: The client was started on group psychotherapy sessions with the aim of equipping her with effective skills that she could use to manage her excessive worry and anxiety. She was scheduled for the next follow-up visit after one month.

 

 

Bipolar Disorder

Name: P.A

Age: 34 years

Diagnosis: Bipolar Disorder

S: P.A is a 34-year-old female who has been undergoing treatment in the facility due to bipolar disorder. She was diagnosed with bipolar disorder six months ago and has been on psychotherapy and antidepressants treatments. P.A reported that she was diagnosed with bipolar disorder after she experienced a number of health problems. They included an expansive mood that was characterized by the patient feeling that he was in control of everything. P.A also reported that he was easy irritable and agitated. She also found it difficult to concentrate in tasks.  The patient reported additional symptoms included lack of sleep, increased talkativeness, and being easily distracted. The patient also engaged significantly in goal directed activities and impulsive behaviors. The client was worried that the episodes of the above symptoms had a negative effect on his social and occupational functioning. As a result, she was diagnosed with bipolar disorder and has been on treatment with the aim of stabilizing his mood.

O: P.A was dressed appropriately for the occasion. She was oriented to self, time, space and others. Her judgment was intact. The speech was of normal rate and volume. She denied illusions, delusions, and hallucinations. She also denied suicidal thoughts, attempts and plans.

A: The desired treatment objectives have been achieved. The response of the client to the treatment has been positive.

P: Psychotherapy sessions were terminated, as the treatment objectives had been achieved. The client was advised to continue with pharmacological treatment. She was scheduled for follow-up visit after four weeks.

Alcohol Use Disorder

Name: M.A

Age: 32 years

Diagnosis: Alcohol use disorder

S: M.A is a 32-year-old male who came to the clinic today for his regular follow-up visit. He was diagnosed with alcohol use disorder three months ago and has been undergoing treatment. The diagnosis was reached after he presented with a number of complaints. One of them was binge consumption of alcohol that was beyond his control. The binge consumption of alcohol was despite his efforts such as abstaining from it, which were unsuccessful. The client also reported that alcohol abuse had affected his social and occupational functioning adversely. It has also affected the stability of his family, as it was at a verge of collapsing. The socioeconomic wellbeing of his family has also been affected adversely. Therefore, he was diagnosed with alcohol use disorder and initiated on treatment.

O: The patient was dressed appropriately for the occasion. His orientation to self, others and events were intact. He did not demonstrate any abnormal behaviors such as tremors. His thought content was intact. He denied any recent history of illusions, delusions, and hallucinations. He also denied suicidal thoughts, attempts, plans, and intent. His speech was normal in terms of tone, rate, content and volume.

A: The client is responding positively to the treatment.

P: The client was advised to continue with the treatment and scheduled for a follow-up visit after four weeks.