PRAC 6645 WEEK 7 Assignment 1 : Clinical Hour and Patient Logs
Walden University PRAC 6645 WEEK 7 Assignment 1 : Clinical Hour and Patient Logs-Step-By-Step Guide
This guide will demonstrate how to complete the Walden University PRAC 6645 WEEK 7 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 7 Assignment 1 : Clinical Hour and Patient Logs
Whether one passes or fails an academic assignment such as the Walden University PRAC 6645 WEEK 7 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 7 Assignment 1 : Clinical Hour and Patient Logs
The introduction for the Walden University PRAC 6645 WEEK 7 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 7 Assignment 1 : Clinical Hour and Patient Logs
After the introduction, move into the main part of the PRAC 6645 WEEK 7 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 7 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 7 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.
Stuck? Let Us Help You
Completing assignments can sometimes be overwhelming, especially with the multitude of academic and personal responsibilities you may have. If you find yourself stuck or unsure at any point in the process, don’t hesitate to reach out for professional assistance. Our assignment writing services are designed to help you achieve your academic goals with ease.
Our team of experienced writers is well-versed in academic writing and familiar with the specific requirements of the PRAC 6645 WEEK 7 Assignment 1 : Clinical Hour and Patient Logs assignment. We can provide you with personalized support, ensuring your assignment is well-researched, properly formatted, and thoroughly edited. Get a feel of the quality we guarantee – ORDER NOW.
Sample Answer for PRAC 6645 WEEK 7 Assignment 1 : Clinical Hour and Patient Logs
Clinical Logs
Major Depression
Name: R.W
Age: 34 years
Diagnosis: Major Depression
S: R.W is a 34-year-old client that was brought to the unit by his relatives for psychiatric review. The client was brought with history of suicide attempt. The family reported that the client was found when he was trying to kill himself by hanging. History taking from the client and the family members was done. The client reported that he wanted to kill himself, as he felt that he life was useless. He felt that he had not been successful when compared to his peers. The client also noted that his mood has been depressed for almost everyday. The depressed mood had made it difficult for him to engage in his activities of the daily living, as the family reported him to be socially withdrawn. The family also reported that his interest in things had diminished significantly. The family reported that R.W appeared fatigued in most of the days. R.W reported that he lacked appetite and has been forcing himself to eat. The client reported suicidal thoughts and attempt. He denied any suicidal plan now. Based on the above complaints the client was diagnosed with depression and initiated on treatment.
O: The client appeared poorly dressed for the occasion. He reported that his mood was depressed. The client was oriented to self, others, time, and events. He denied illusions, delusions, and hallucinations. He reported suicidal thoughts and attempts. He denied current suicidal plans. The client does not have a current suicidal plan. His speech was reduced in terms or rate and volume.
A: The client is experiencing severe symptoms of depression. The client requires treatment to improve his mood and functioning.
P: The client was admitted for further observation. He was prescribed antidepressants to manage the depressive symptoms he was experiencing.
Major Depression
Name: A.A
Age: 43 years
Diagnosis: Major Depression
S: A.A is a 43-year-old client that came to the unit for her second follow-up visit, after she was diagnosed with depression two months ago. The client recalled that she was diagnosed with depression following a number of symptoms. One of the symptoms is that she was experiencing depressed mood in most of the days for every day. The client was also socially isolated as he lacked interest in things and pleasure. She attributed the lack of pleasure and interest to her depressed mood had made it difficult for her to engage in his activities of the daily living, as the family reported him to be socially withdrawn. A.A also reported that her appetite had increased significantly. She was eating more than normal for the last few weeks. Her ability to make decisions was also significantly affected. He level of irritability was also high, as she found that she was easily irritable. Based on the above, the client was diagnosed with major depression and initiated on psychotherapy and antidepressants.
O: The client appeared appropriately dressed for the occasion. She reported that his mood was not depressed today, as it was last time. The client was oriented to self, others, time, and events. She denied illusions, delusions, and hallucinations. She denied suicidal thoughts and attempts. She denied current suicidal plans. The client does not have a current suicidal plan. Her speech was reduced in terms or rate and volume.
A: The symptoms of depression have improved. The client reports that the treatment has been effective, as she experiences minimal depressive symptoms.
P: The client was advised to continue with the current treatment. She was also advised to come for a follow-up visit after four weeks.
Major Depression
Name: Z.X
Age: 50 years
Diagnosis: Major Depression
S: Z.X is a 50-year-old client that came to the unit for his fifth follow-up visit for depression. The client was diagnosed with depression six months ago after he started becoming suicidal. The client reported that his suicidal symptoms had persisted for over a month, after which he was brought for psychiatric assessment. Some of the symptoms he had during the first hospital visit included suicidal thoughts and attempts and depressed mood. The client also reported that he was experiencing insomnia in most of the days. He also felt worthless. The family had noted that the client was socially withdrawn. He did not have interest in things and lacked pleasure. He was also easily irritated. Based on the above complaints the client was diagnosed with depression and initiated on treatment.
O: The client appeared appropriately dressed for the occasion. His self-reported mood was ‘better.’. The client was oriented to self, others, time, and events. He denied illusions, delusions, and hallucinations. He denied suicidal thoughts, plans and attempts.
A: The client reports continuous improvement in his symptoms of depression. The improvements have been sustained for the last four months. The client denies any adverse or side effects related to the treatment.
P: The client demonstrates sustained improvement in symptoms. Psychotherapy sessions were continued with consent from the client. He was advised to continue with antidepressants. He was scheduled for a follow-up visit after four weeks.
Major Depression
Name: P.A
Age: 38 years
Diagnosis: Major Depression
S: P.A is a 38-year-old client that came to the unit for her third follow-up visit for major depression. The client reported that she was diagnosed with major depression four months ago after she presented to the hospital with a number of symptoms. The symptoms included depressed mood in most of the days. She also reported feeling helpless and having thoughts of committing suicide. The client also noted that she lack interest in pleasurable things or experiences. There was also a significant decline in her appetite and lacked energy. Her ability to make informed decisions had also declined considerably. The client denied suicidal thoughts, plans and attempts. Based on the above complaints the client was diagnosed with depression and initiated on treatment.
O: The client appeared appropriately dressed for the occasion. She reported that her mood was no longer depressed. The client was oriented to self, others, time, and events. She denied illusions, delusions, and hallucinations. She also denied suicidal thoughts, attempts and plans. Her speech was normal in terms of volume and rate.
A: The client is demonstrating continued improvement in symptoms of depression. She is also tolerating the treatment.
P: The client was advised to continue with psychotherapy sessions and antidepressants. She was scheduled for a follow-up visit after four weeks.
Delusional Disorder
Name: R.T
Age: 30 years
Diagnosis: Delusional disorder
S: R.T is a 30-year-old female client that came to the unit as a referral by her family physician for psychiatric assessment. The physician felt that the client had symptoms that were not attributed to a medical condition. The client had persistent thoughts that her supervisor at workplace was deeply in love with her but had not expressed his feelings. The client noted that the client demonstrated his feelings towards her by assigning him simpler task in the organization. When asked whether the supervisor had expressed his feelings or subjected her to any sexual abuse, the client noted that she had a boyfriend as well as the supervisor who was married. The client also reported that her manager was jealous about the fact that the supervisor was in love with her. As a result, she believed that the manager wanted to lay her off from the organization. Further history taking from the client showed that the client has a history of bipolar disorder that has been managed using medications. Based on the above, the client was diagnosed with delusional disorder and initiated on treatment.
O: The client appeared dressed appropriately for the occasion. She was oriented to place, time, and self. She denied illusions and hallucinations. She was delusional. She denied any history of suicidal thoughts, plans, and attempts. Her speech was normal in terms of rate and volume.
A: The client is experiencing symptoms of delusional disorder. In specific, she is suffering from erotomania and grandiose disorders.
P: The client was initiated on individual psychotherapy to address the delusions. The client was scheduled for a follow-up visit after four weeks.
Bipolar Disorder
Name: H.O
Age: 32 years
Diagnosis: Bipolar Disorder
S: H.O is a 32-year-old client that came to the unit for her sixth follow-up visit. She has been undergoing treatment in the unit for bipolar disorder. She was diagnosed with the disorder seven months ago after she presented to the unit with complaints that included periods of elevated mood. She reported that the elevated mood was associated with abnormal behaviors that that included engaging in goal-directed initiatives, excitement and delusions. The symptoms alternated with those of depression such as the lack of energy, insomnia, difficulties in concentrating and feelings of worthlessness. The depressed mood could happen almost every day for a specific period such as one month, followed by elated mood. The client was worried that the above symptoms were affecting significantly her ability to engage in the activities of the daily living, social and occupational roles. The symptoms were also not associated with drug use, medical problem or substance and alcohol abuse. As a result, she was diagnosed with bipolar disorder and initiated on treatment.
O: The client appeared appropriately dressed for the occasion. She was oriented to self, place, time and events. Her judgment was intact. She denied any recent experience of delusions, hallucinations, illusions, suicidal thoughts, plans, and attempts.
A: The client continues to show stabilized improvements in the symptoms of depression. The client notes that she tolerates the treatments well.
P: The psychotherapy sessions were terminated due to the realization of the desired treatment objectives. She was advised to continue with the prescribed medications. The client was scheduled for a follow-up visit after four weeks.
Insomnia
Name: M.O
Age: 32 years
Diagnosis: Insomnia
S: M.O is a 32-year-old male who has been undergoing treatment in the facility due to insomnia. Today, he came to the unit for the fourth follow-up visit. The client recalled that he was diagnosed with insomnia after he presented with symptoms that included the lack of quality and quantity sleep for the last six months prior to the visit to the clinic. He experienced difficulties in sleeping and maintaining sleep. The difficulties in sleeping had affected significantly his ability to engage in activities of the daily living, social, and occupational roles. The client was worried that his productivity would decline further should the symptoms not be controlled. Additional assessment of the client had revealed that the symptoms were not attributed to any factors such as medication use, medical condition or substance abuse. As a result, he was 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: There is continued improvement in the symptoms of insomnia since the last visit. The client reports that he has been engaging in behavioral interventions that improve the quality and quantity of his sleep.
P: The client was advised to continue with group psychotherapy sessions. He was advised to come for a follow-up visit after four weeks. The treatment would be terminated should the patient demonstrate sustained improvement in symptoms.
Post-traumatic stress disorder
Name: D.D
Age: 28 years
Diagnosis: Post-traumatic stress disorder
S: D.D is a 28-year-old client that came to the unit for her regular follow-up visits after she was diagnosed with post-traumatic stress disorder six months ago. She has been on antidepressant and psychotherapy treatments. She was diagnosed with the disorder following her experience with a road accident. The client raised a number of symptoms that included the persistent recurrence of the distressing memories about the traumatic event. 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: The adopted treatment interventions have been effective in managing the depressive symptoms of post-traumatic stress disorder. The client reports improved tolerability to the treatment.
P: Group psychotherapy sessions were terminated with consent from the client. She was advised to continue with antidepressant treatment. She was scheduled for a follow-up visit after one month.
Alcohol Abuse Disorder
Name: J.H
Age: 47 years
Diagnosis: Alcohol Abuse Disorder
S: J.H is a 47-year-old male who came to the clinic today for his regular follow-up visit after being diagnosed with alcohol abuse disorder and has been undergoing treatment. The client was diagnosed with the disorder after he came to the unit with complaints of 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. 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. 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.
Schizophrenia
Name: E.F
Age: 36 years
Diagnosis: Schizophrenia
S: E.F is a 36-year-old female that came to the unit for her follow-up visit. She was diagnosed with schizophrenia seven months ago and has been undergoing treatment. The diagnosis was reached after she came with complaints of seeing imaginary things and hearing voices. The client 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. The symptoms could not be attributed to other causes such as medication use, medical condition, and 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. Her thought content was future oriented. She did not demonstrate any abnormal behaviors such as avoidance of eye contact and tics.
A: The treatment objectives have been achieved. The client has demonstrated sustained improvement in symptoms for the last three visits.
P: The participation of the client in psychotherapy sessions was terminated. She was advised to continue with antipsychotics. She was scheduled for the next follow-up visit two months.
Bulimia Nervosa
Name: M.M
Age: 21 years
Diagnosis: Bulimia Nervosa
S: M.M is a 21-year old female that came to the unit for follow-up visit after being diagnosed with bulimia nervosa three months ago. The client was diagnosed with the disorder after she came to the unit with complaints that included eating large amounts of food within short periods. She also reported to lack control over the amount of the food that she was eating. The client also reported engaging in behaviors such as self-induced vomiting, diuretics, and participating in strenuous exercises to reduce weight. Based on the above complaints, the client was diagnosed with bulimia nervosa and has been on psychological treatment.
O: The client appeared well groomed for the occasion. Her orientation to space, time and self was intact. The client had thought process that was future oriented. The client also had normal rate and volume of speech. The client denied any history of hallucinations, delusions, illusions, and suicidal thoughts and ideations.
A: The client reports improvement in symptoms. The client is optimistic that the psychotherapeutic treatments have been effective.
P: The client was advised to continue with psychotherapy sessions, as the symptoms have improved significantly with the adopted interventions.
Sample Answer 2 for PRAC 6645 WEEK 7 Assignment 1 : Clinical Hour and Patient Logs
- Schizophrenia Spectrum and Other Psychotic Disorders
Name: G.H
Age: 45 years old
Gender: Female
Diagnosis: Schizophrenia Spectrum and Other Psychotic Disorders
S: G.H. is a 45-year-old Caucasian female who was admitted to the psychiatric hospital at the request of her sister. The patient stated that she frequently feels as though somebody is observing her from outside the window. She believes she can hear them. As she stated, these encounters had been going on for weeks. The patient alleges that when watching television, persons on it seek to murder her by poisoning her meals. Denies using medicines or having a history of seizures. There were no reports of suicidal thoughts or self-harming conduct.
O: Examinations of the patient’s mental health demonstrate that she is well-oriented in time, location, and person. She, on the other hand, appears disturbingly uncomfortable. She cooperates during the interview, although she is often distracted and has a limited attention span. Her mental process has been hampered. She seemed to be depressed. Has adequate short-term and long-term memory. She also exhibits symptoms of delusion and delirium. Denies having suicidal thoughts or engaging in self-harming actions.
A: The patient has schizophrenia disorder because she exhibits bizarre actions as a result of a lack of contact with reality. She also has hallucinations, delirium, and disordered speech, and thinking, indicating that she meets the DSM-V criteria for this condition.
P: Engage the patient in realistic activities such as card games, writing, drawing, rudimentary arts and crafts, or listening to music. CBT sessions that focus on real-life plans, concerns, relationships, and coping skills are advised.
- Major Depressive Disorder (MDD):
Name: B.E
Age: 14 years old
Gender: Male
Diagnosis: MDD
S: B.E. is a 14-year-old white male patient who was brought into the clinic by his mother because he was depressed. Her mother claims that the patient stopped taking his medication since it made him feel horrible. He was diagnosed with ADHD at the age of six and has been on and off medication for mood problems ever since. The patient denies using any illegal drugs. He complains of useless sensations and claims to hear voices from time to time, making it difficult for him to sleep. She withdraws from friends and often misses school because she does not want to be evaluated or discussed by her peers. She is depressed and lonely.
O: The patient arrived at the psychiatric unit in a great mood and dressed appropriately for his age. Despite being agreeable with the assessment, he avoids eye contact. He appears furious and dejected, even crying at points during the test. His influence varies just slightly. His energy level has decreased and he appears restless. His speech is age-appropriate, relaxed, and combative. He also thinks slowly but coherently. He occasionally shows indications of weariness with poor attention for a lengthy period. The patient has no memory problems since he recalls events correctly. Person, time, and place orientation are all intact. The patient shows no signs of causing harm to himself or others. He denies having suicidal thoughts, hallucinations, or deliria.
A: According to DSM-V diagnostic standards, the patient meets the criteria for MDD based on the described signs and symptoms.
P: Encourage people to vent their feelings and devise alternative coping mechanisms for their anger and frustration. CBT and family therapy are also acceptable psychotherapeutic techniques.
- Alzheimer’s Disease
Name: T.C
Age: 66 years old
Gender: Male
Diagnosis: Alzheimer’s Disease
S: T.C. is a 66-year-old Asian male who was brought in for mental examination by his daughter because he was forgetful. She claims that the patient has misplaced his auto keys multiple times. She further notes that when the patient goes to the store, he occasionally gets lost and asks for assistance. According to his daughter, the patient states that he began forgetting approximately two years ago and that it has become worse since then. The patient denies having any of the related symptoms. There are no hallucinations or delirium.
O: A physical examination revealed that the patient seems healthy and cooperative during the assessment, with a cheerful demeanor. He has no chills, fever, tiredness, or recent weight fluctuations. The CN II-VII and the DTR are not affected, according to a neurological assessment. Denies experiencing a headache, syncope, or dizziness. Confirms growing memory loss over the last two years.
A: The patient has been experiencing deteriorating memory loss for the last two years, indicating Alzheimer’s disease in its terminal stages as the primary diagnosis.
P: Reality-orienting approaches will assist patients to become more aware of themselves and their surroundings. Exercise, guided meditation, and massage are examples of supplementary and alternative therapy.
- Generalized Anxiety Disorder
Name: K.D
Age: 9 years old
Gender: Male
Diagnosis: GAD and SAD
S: The 9-year-old child and his mother were brought to the clinic for mental assessment. The patient’s mother states that her kid has been worried about death most of the time and is even frightened to go to school. The youngster claims to be terrified of his family member being injured by criminals, dying in a vehicle accident, or being pulled into a black hole. When he goes to school, he is scared of being apart from them. His instructor states that he is unable to concentrate at school, which has a negative impact on his academic achievement. Denies having melancholy or hallucinations.
O: The patient looked to be well-groomed. He is aware of his surroundings, time, and self. The rate and volume of speaking are both normal. During the interview, he appears anxious and fidgets a lot. With the sight of her mother, he is cooperative. His short and long-term memory are age-appropriate. His attention span is limited. Denies engaging in self-harming behavior.
A: Based on the patient’s symptoms and mental state assessment findings, the patient meets the DSM-V diagnostic criteria for both generalized anxiety disorder and separation anxiety disorder.
P: Applied Behavior Analysis (ABA) is recommended to encourage desired behaviors and discourage unwanted ones to develop a range of talents.
- Alcohol use disorder
Name: S.K
Age: 33 years old
Gender: Male
Diagnosis: AUD
S: S.K. is a 33-year-old Caucasian man who presented to the clinic with a history of alcohol intoxication, alcohol use problem, and a ruling out of anxiolytic and sedative use disorder, accompanied by his father. According to the father, the patient has auditory hallucinations, hubris, a lack of sleep, and the ability to damage himself and others. His most recent visit to the clinic occurred in April of this year. The guy claims he had a nail puncture wound on his arm earlier today and is demanding a tetanus injection. During the current appointment, the patient denies having sleep problems, being sad, having poor energy, or having a loss of appetite. He also rejects suicidal thoughts while admitting to a history of suicide attempts.
O: Upon assessment, the patient appears depressed and preoccupied, with threats to harm everyone. He does, however, answer questions during the interview in a nasty tone. He seemed disturbed. His demeanor is suitable yet uninteresting. Even though the procedure is hampered. His father claims that the patient has been hearing voices, has been having sleeping issues and has been depressed, which the patient denies. His short-term and long-term memories are both intact. His perspective is correct. Suicide thoughts can be confirmed by a history of suicidal attempts.
A: Based on his history of alcohol intoxication and suicidal ideation by Tylenol overdose, the patient satisfies the DSM-V criteria for this illness. He also went to the clinic in a slurred manner, even though he denies using any.
P: Suggest to the patient that he or she try group cognitive behavioral treatment. Substance abuse support group sessions can also be beneficial to the patient. When the patient is ready, consider rehabilitation.
- Obsessive Compulsive Personality Disorder (OCPD)
Name: D.G
Age: 10 years old
Gender: Male
Diagnosis: OCPD
S: D.G. is a 10-year-old white male patient who came in with his mother for a mental examination. The patient is constantly washing his hands and is scared to even touch his classmates for fear of infecting him. During the early stages of the Covid-19 epidemic, the patient’s mother’s elder sister died from the virus. Since then, the patient has been terrified of acquiring the infection and has been continuously washing his hands. He has been reclusive at school and has been unable to play with his classmates. He also prefers to spend his time at home indoors.
O: The patient’s cognitive function was normal after a mental status examination. He denies having anxiety or depression symptoms. He is, nevertheless, lonely and terrified of social interaction. He occasionally acknowledges having caught the virus through dreams. Denies engaging in self-harming behavior.
A: According to the DSM-V diagnostic criteria, the patient met the criteria for Obsessive Compulsive Personality Disorder (OCPD).
P: Suggest to the patient that psychotherapy treatments such as psychoeducation, CBD, and support therapy be considered. Cognitive restructuring is a strategy that assists clients in recognizing negative ideas and feelings and replacing them with constructive patterns of thinking.
- Bipolar Disorder Mixed Episodes
Name: M.G
Age: 23 years old
Gender: Female
Diagnosis: Bipolar Disorder with Mixed Episodes
S: M.G. is a 23-year-old female patient who came to the psychiatric unit for a check-up on her mental condition. She claims that her psychiatric drugs are causing her to lose her identity. She was diagnosed with bipolar illness in her teens after being unable to sleep for 4 to 5 days and experiencing auditory hallucinations. She states she is unsure of which medicine she is on, but she has experienced depression at least four to five times every year since the diagnosis. Associated symptoms include fatigue, loss of interest, and a sense of worthlessness. The patient denies feeling frightened, disturbed, or experiencing nightmares. She, on the other hand, verifies illusion and hallucination.
O: Further examination of the patient revealed that she has an appealing appearance and is fairly confident in responding to questions during the interview. Her mental process is well structured, and she speaks clearly and fluently. She, on the other hand, appears preoccupied, her attitude shifting depending on the topic of conversation. She demonstrates ordinary understanding and judgment. Her short- and long-term memory are both intact. She denies having suicidal thoughts or engaging in self-harming behavior. She, on the other hand, verifies illusion and hallucination.
A: The patient satisfies the DSM-V criteria for Bipolar Disorder with Mixed Bouts because she has a depressive mood, recent episodes of hypomania and mania, psychomotor slowness, lost interest, a sense of worthlessness, low energy levels, and recurring thoughts of death.
P: Suggest talk therapy or CBT. Discuss with the patient how to overcome her troublesome feelings, attitudes, and behaviors during therapy sessions.
- Rumination Syndrome
Name: D.J
Age: 19 years old
Gender: Female
Diagnosis: Rumination Syndrome
S: D.J. is a 19-year-old African-American male patient who came to the clinic with complaints of frequent meal regurgitation. Since the regurgitation began, he has also complained of sleeping difficulties, dizziness, bloating, nausea, and pain. He, on the other hand, denies experiencing diarrhea, swallowing difficulty, or discomfort. He maintains that the symptoms began after he was removed from his mother, who was unfairly imprisoned for drug charges. He denies any family history of drug abuse or any other psychological problem. He denies having used any medicine to treat his problems. He has no history of chronic illnesses or hospitalization. He verifies eating a good diet and exercising regularly. He confirms that he has seasonal allergies.
O: The physician conducted a thorough physical examination, which revealed abdominal distention. The abdomen, on the other hand, was not tender. The lab findings were normal. A psychiatric assessment reveals a sad mood and significant stress as a result of the patient’s mother, his only parent, being imprisoned. The patient also demonstrated feelings of worthlessness, loneliness, and separation from others.
A: According to the subjective data, the patient has rumination syndrome. The objective statistics show no evidence of GERD, but rather high stress as a result of the psychological examination. The patient’s rumination condition might have been caused by stress.
P: Help the patient develop nutritious eating habits and identify emotions and develop coping techniques. Assist the patient in dealing with body image concerns.
- Posttraumatic Stress Disorder (PTSD)
Name: T.R
Age: 49 years old
Gender: Female
Diagnosis: PTSD
S: T.R. is a 49-year-old female patient who came to the psychiatric unit complaining of poor mental health and frequent nightmares following her husband’s death. The lady admitted to having regular flashbacks of her husband’s death. She also claims she can’t sleep at night because she sees him in her dreams. She is depressed and believes she should have died as well so they could be united in paradise. She has been unable to work and claims that she no longer attends church, alleging that God did not assist her when her husband was dying. Other symptoms include negative impacts, self-isolation, and feelings of worthlessness. The patient denies any previous mental health issues. She admits to having suicidal thoughts from time to time, but she has never attempted suicide. Denies engaging in self-harming behavior.
O: The patient was appropriately dressed for the visit. Her mood is gloomy, with regular complaints about why she needs to remain living while her spouse is no longer alive. Her short-term and long-term memories were both intact. Her cognitive process was complete. Denies any suicidal or self-harming behavior. However, she admits to having suicidal thoughts.
A: The patients match the DSM-V diagnostic criteria for post-traumatic stress disorder as a result of her husband’s death, which she describes as a painful event.
P: Suggest to the patient that he or she try group cognitive behavioral treatment. Prolonged exposure treatment and eye movement desensitization and reprocessing therapy are also indicated to assist in controlling the patient’s PTSD symptoms.
- Attention-Deficit Hyperactivity Disorder (ADHD)
Name: M.K
Age: 9 years old
Gender: Female
Diagnosis: ADHD
S: M.K., an 8-year-old girl, arrives at the psychiatric unit exhibiting symptoms of attention deficit hyperactivity disorder (ADHD). Given the patient’s presenting signs and symptoms, the mother and class instructor were requested to complete the ADHD questionnaire. She exhibits symptoms of short-term memory loss and difficulty paying attention. She is frequently forgetful and must be reminded to finish her schoolwork. She also fidgets a lot, which interferes with her attention. The patient agrees that her ADHD symptoms began as soon as she started school. Daydreaming is one of the other symptoms. The patient has never been prescribed medication for the present ailment and has no history of developmental issues. Because of the patient’s fidgety symptoms, the primary care practitioner states that the patient has decent sleeping habits but rather a poor eating.
O: The patient enters the room dressed appropriately for her age. Unable to keep eye contact. Time, person, and place are all well-organized. She can’t get comfortable on the chair since she fidgets a lot. Unable to focus for a lengthy amount of time. The impact is complete and consistent with a depressed state. With evidence of daydreaming, he is easily sidetracked. Short-term memory is impaired, while long-term memory is unaffected. There are no indicators of delusion or delirium. There is no evidence of possible danger to oneself or others.
A: The child is eight years old and exhibits the majority of the symptoms listed in the DSM-V, justifying the diagnosis of ADHD.
P: Instead of taking medicine, think about trying psychotherapy. Behavioral therapy can assist the child in reducing hyperactivity, impulsiveness, and inattention.
- Enuresis Disorder
Name: J.V
Age: 7 years old
Gender: Male
Diagnosis: Enuresis Disorder
S: J.V. is a 7-year-old child who is healthy and has no social issues. Except for one issue, the patient’s growth phases are fully intact. He has never been able to achieve nocturnal dryness. The patient, according to the mother, still wears pull-ups at night. The patient states that he has no trouble remaining dry during the day. He also denies having any bowel movements at any time of day or night. His primary issue is that he wants to go to sleepovers with his friends, but he is embarrassed that they will reject him because of his bedwetting. At home, he plays with his toys but appears depressed. He has no history of any other health issues. There are no allergies.
O: A comprehensive physical examination of the patient’s genitalia was performed to establish the source of his bedwetting. By palpating the renal and suprapubic regions, the doctor sought an enlarged bladder or kidney. In the lab, his excrement was also tested for hard texture or blood. A neurological examination was also performed, as well as an examination and palpation of the lumbosacral spine. However, the data did not point to a specific reason for the patient’s bedewing.
A: The purpose of the patient evaluation was to determine the underlying cause of the patient’s nocturnal enuresis. To assess the integrity of the S2-4 spinal reflex arc, the anal wink and the patient’s ability to stand on his or her toes were used.
P: Encourage the child while reassuring the parents. Encourage bladder retention training (drink more in the morning and early afternoon, reduce the number of times you urinate during the day, try to hold for at least eight hours, and interrupt urination (stop-start training)) and behavior modification.
- Insomnia
Name: M.X
Age: 33 years old
Gender: Female
Diagnosis: Insomnia and MDD
S: M.X is a 33-year-old female patient who came to the clinic complaining about negative automatic thinking, anxiety, and poor self-esteem. She also experiences nightmares, feelings of loneliness, dizziness, difficulty falling asleep, feelings of inferiority, headache, palpitations, dizziness, weariness, stiff shoulders/neck racing thoughts, panic attacks, bowel disruption, and melancholy. She does, however, note that the dreams have become more regular, around four times per week, while the other symptoms have become virtually every day.
O: The findings of the mental examination show that the patient is aware and well-oriented in person, place, and time. Her mother’s activities are routine. During the interview, she is cooperative and talked in a clear and regular tone. Her disposition is depressed. She has a restricted appearance and exceptional perception and judgment. Her memory is intact, and her mental process is ordinary. Her functional condition, on the other hand, is somewhat degraded. Denies hallucinating or delusions.
A: According to the DSM-V diagnostic criteria, she is eligible for the diagnosis of MDD, which she has previously managed. However, the major focus of this appointment is on controlling the patient’s sleeplessness.
P: Suggest CBT teaches sleep hygiene and relaxation techniques to enhance the patient’s sleeping quality and length.