PRAC 6645 WEEK 9 Assignment 1 : Clinical Hour and Patient Logs
PRAC 6645 WEEK 9 Assignment 1 : Clinical Hour and Patient Logs
Clinical Logs
Post-traumatic Stress Disorder
Name: K.P
Age: 39 years
Diagnosis: Post-traumatic stress disorder
S: K.P is a 39-year-old male client who came to the unit today for his regular follow-up visits for post-traumatic stress disorder. He was diagnosed five months ago with the disorder and has been undergoing treatment. His mental health problems started following his involvement in a road accident. He had come for the first visit with complaints that included flashbacks and nightmares about the accident. He also avoided any stimuli that related to the accident. K.P further reported being easily irritated,
PRAC 6645 WEEK 9 Assignment 1 Clinical Hour and Patient Logs
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. His self-reported mood was normal. 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
Generalized Anxiety Disorder
Name: H.S
Age: 29 years
Diagnosis: Generalized anxiety disorder
S: H.S is a 32-year old client that came to the unit for her sixth visit after being diagnosed with generalized anxiety
PRAC 6645 WEEK 9 Assignment 1 Clinical Hour and Patient Logs
disorder seven months ago. The diagnosed was reached after she raised several complaints that included 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. The accompanying symptoms that the client reported included chest pain, shortness of breath, tremors, and sweating. The symptoms could not be attributed causes such as medication use, substance abuse and medical condition. H.S noted that the symptoms of excessive worry and anxiety were affecting negatively her productivity at workplace. 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 control over her anxiety. She denied illusions, delusions, and hallucinations. She also denied suicidal thoughts, attempts and plans.
A: The client has developed effective coping strategies for managing her anxiety disorder.
P: Psychotherapy sessions were terminated with consent from the client, since the treatment objectives had been achieved.
Post-traumatic Stress Disorder
Name: T.Y
Age: 32 years
Diagnosis: Post-traumatic stress disorder
S: T.Y is a 32-year old female that came to the unit today for her second visit after being diagnosed with post-traumatic stress disorder. She was diagnosed with it after she started feeling low since her husband died through a road accident six months ago. T.Y 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. Her productivity in both social and occupational roles had reduced significantly. T.Y 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. Her speech was of normal rate and volume. Her self-reported mood was normal. She declined illusions, delusions, and hallucinations. She also declined suicidal thoughts, plans, and attempts. Her thoughts were future oriented.
A: The client is demonstrating moderate improvement in symptoms of depression. She is also tolerating treatment.
P: The client was advised to continue with the prescribed treatment and psychotherapy sessions. She was scheduled for the next follow-up visit after four weeks.
Post-traumatic Stress Disorder
Name: A.D
Age: 42 years
Diagnosis: Post-traumatic stress disorder
S: A.D is a 42-year-old female client who came to the unit with complaints of feeling mentally depressed after the death of her spouse. She reported that she always experiences flashbacks of the events that led to the death of her husband. She also experienced nightmares and avoidance of any stimuli or events that led to his death. Those close to A.D reported that she experienced abnormal behaviors that included the presence of exaggerated negative thoughts about the world, negative affect, decline in interest in activities, and self-isolation. The family members had noted that the client was becoming easily irritated, experiencing difficulties in sleeping and concentration. Based on the above, A.D was diagnosed with post-traumatic stress disorder and initiated on treatment.
O: The client was well groomed for the occasion. Her orientation to self, others, environment, and events were intact. Her mood was depressed. Her level of judgment was intact. She denied suicidal thoughts, plans or attempts, illusions, delusions, and hallucinations.
A: The client is experiencing moderate symptoms of post-traumatic stress disorder.
P: The client was initiated on antidepressants and group psychotherapy. Antidepressants were prescribed to help the client improve her mood. Group psychotherapy aimed at helping the client cope with the distressing symptoms of post-traumatic stress disorder. She was scheduled for the next follow-up visit after four weeks.
Depression
Name: C.D
Age: 28 years
Diagnosis: Depression
S: C.D is a client who came to the psychiatric department today for her follow-up visit after being diagnosed with major depression three months ago. She was diagnosed with major depression due to the symptoms that included persistent feelings of guilt and worthlessness. She also reported feeling depressed in most days almost throughout the day. She also complained of lack of energy to engage in her activities of the daily living and professional work. She noted that her appetite had increased significantly. She also experienced difficulties in concentrating and making decisions. She also reported insomnia for the last two months prior to the first hospital visit. She had however denied suicidal thoughts, plans, or attempts. C.D 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 symptoms of major depression have improved as expected in the treatment plan.
P: The client was advised to continue using the current treatments. She was scheduled for a follow-up visit after four weeks. She was to be discontinued on psychotherapy sessions should she demonstrated continued improvements in symptoms in her next visit.
Depression
Name: J.D
Age: 34 years
Diagnosis: Depression
S: J.D is a 34-year-old client that came to the unit today for his follow-up visit after being diagnosed with depression three months ago. She has been on antidepressants and psychotherapy. J.D’s diagnosis with depression as reached after he came initially to the department with complaints of persistent feelings of depressed mood always and lack of pleasure and interest. She also reported that she was finding it hard to concentrate in her social and occupational roles. She also felt worthless and experienced insomnia. J.D also complained of suicidal thoughts and attempts. She however did not have any plans of committing suicide by the time she came to the department for her first visit. The symptoms of depression had affected significantly her functioning and productivity. A further assessment had revealed that the symptoms were not due to a medical condition, medication, or substance use. As a result, she was diagnosed with major depression and initiated on antidepressants and psychotherapy sessions.
O: The client appeared well groomed for the session. She was alert during the assessment. She reported that her mood had improved significantly following the adopted treatments. She denied illusions, delusions, and hallucinations. Her speech rate and volume were intact. She 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. She was scheduled for a follow-up visit after four weeks.
Depression
Name: J.O
Age: 40 years
Diagnosis: Depression
A.A is a 40-year old client that that came today for his fourth follow-up visit for depression. J.O was diagnosed with the disorder five months ago after he came with complaints of feeling worthless in life. He also reported that he always has suicidal thoughts. The client had unsuccessful attempted to commit suicide by consuming organophosphate poison. The client also reported that his mood was highly depressed. He did not want to interact with people and often locked himself indoors. The client also reported that his energy levels were low in most of the days. His appetite had also reduces significantly affecting dietary intake. Due to the above complaints, the client was diagnosed with major depression and initiated on treatment.
O: The client appeared well groomed for the occasion. He maintained normal eye contact during the assessment. His orientation to self, others, place, time and events were intact. He denied hallucinations, illusions, and delusions. His speech was normal in rate and volume. He denied any recent experience of suicidal thoughts, plans or attempts. The judgment is intact with thoughts that are future oriented.
A: The assessment findings show that the symptoms of depression being experienced by the client have improved significantly.
P: The client was advised to continue with the prescribed medications as well as psychotherapy sessions. He was scheduled for a follow-up visit after one month.
Bipolar Disorder
Name: Z.C
Age: 33 years
Diagnosis: Bipolar Disorder
S: Z.C is a 33-year-old client that came to the unit for his fifth follow-up visit for bipolar disorder. He was diagnosed with bipolar disorder after he presented to the unit with complaints that included periods of elevated mood, which was characterized by behaviors that that included over activity, engaging in goal-directed initiatives, excitement, euphoria and delusions. The symptoms alternated with depressive symptoms that included lack of energy, too much sleeping, difficulties in concentrating and making decisions. The symptoms experienced by the client could not be attributed to medical condition, medication use of substance abuse. Additional history taking revealed that the symptoms had distressing effect on the health and wellbeing 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. His thought process was future oriented. He did not demonstrate any abnormal behaviors during the assessment.
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.
Delusional Disorder
Name: C.H
Age: 30 years
Diagnosis: Delusional Disorder
S: C.H is a 30-year-old client that came to the unit with complaints of abnormal behaviors. The client came with her spouse who reported that C.H has been experiencing abnormal behaviors that he felt needed medical attention. The spouse reported that C.H has been experiencing a mix of mental states where she appeared not knowing who she was. One of the symptoms was having an inflated sense of worth. She perceived that she knew everything in the universe. She also kept talking about her encounters with prominent people in the state. She also talked frequently that she had unique talents in her workplace that were not being exploited. In some cases, C.H felt that her supervisor was jealous of her abilities and was planning to terminate her employment. According to the spouse, the complaints were untrue. As a result, she brought her for psychiatric assessment, where she was diagnosed with delusional disorder. She was initiated on psychotherapy sessions.
O: The patient appeared appropriately dressed for the occasion. She did not demonstrate any symptoms of fatigue or weight loss. She experienced flight of ideas during the assessment. She was delusional. She denied history of illusions and hallucinations. She also denied suicidal thoughts, attempts, or plans.
A: The client is delusional. She does not have an accurate understanding of her self-identity.
P: The client was initiated in the group psychotherapy treatment. The aim was to transform her thought processes. She was scheduled for a follow-up visit after four weeks.
Insomnia
Name: J.F
Age: 28 years
Diagnosis: Insomnia
S: J.F is a 28-year-old male that came today to the clinic for his regular assessment. Today was his fourth visit to the unit for psychotherapy sessions. He was diagnosed with insomnia five months ago after he started experiencing persistent difficulties in sleeping. He recalled that he experienced lack of sleep in most of the days for four months prior to coming for his first visit to the unit. J.F noted that he could remain awake mostly throughout the night and getting minimal sleep. In some cases, he slept well but experienced night awakenings that were followed by difficulties in getting back to sleep. He was worried that his sleep problem was affecting his ability to perform optimally in his workplace, as he appeared tired and sleepy during the day. He denied any history of medication use, which could have contributed to the sleep problems. He also denied medical conditions or substance abuse, which could have been associated with the development of the symptoms. He was diagnosed with insomnia and has been undergoing psychotherapy treatments in the facility.
O: The client appeared dressed appropriately for the occasion. There were no signs of fatigue or weight loss. The client appeared oriented to self, others, time, place and events. He denied illusions and delusions. He also denied suicidal thoughts, plans and attempts. His thought process was future oriented.
A: The client has demonstrated optimum improvement in symptom of insomnia. He has developed the desired coping skills.
P: The psychotherapy sessions were terminated, as the treatment outcomes had been achieved. He was informed to visit the clinic should he experience relapse of symptoms of insomnia.