PRAC 6645 Wk 1 Assignment 3: Clinical Hour and Patient Logs
Walden University PRAC 6645 Wk 1 Assignment 3: Clinical Hour and Patient Logs-Step-By-Step Guide
This guide will demonstrate how to complete the Walden University PRAC 6645 Wk 1 Assignment 3: 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 Wk 1 Assignment 3: Clinical Hour and Patient Logs
Whether one passes or fails an academic assignment such as the Walden University PRAC 6645 Wk 1 Assignment 3: 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 Wk 1 Assignment 3: Clinical Hour and Patient Logs
The introduction for the Walden University PRAC 6645 Wk 1 Assignment 3: 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 Wk 1 Assignment 3: Clinical Hour and Patient Logs
After the introduction, move into the main part of the PRAC 6645 Wk 1 Assignment 3: 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 Wk 1 Assignment 3: 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 Wk 1 Assignment 3: 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 Wk 1 Assignment 3: Clinical Hour and Patient Logs
Clinical Logs
Insomnia
Name: A.V
Age: 20 years
Diagnosis: Insomnia
S: A.V is a 20-year-old male who came to the clinic with complaints of persistent lack of sleep. The patient reported that he has been experiencing low quality and quantity of sleep for the last six months. The client reported a number of symptoms. One of the symptoms was persistent dissatisfaction with the quality and quantity of sleep. The client also reported having difficulties in initiating and maintaining sleep. The difficulties were accompanied by awakenings at night and hardships in falling ba
ck to sleep. The patient also reported that he always experienced early-morning awakening that is followed by inability to return to sleep. The disturbances in sleep were reported to have significant distress as well as impairment in social, educational, occupational, academic and behavioral areas of functioning. The insomnia could not be attributed to any condition, medication and alcohol or substance abuse. Based on the above symptoms, A.V was diagnosed with insomnia and initiated on psychotherapy sessions.
O: The client appeared appropriately dressed for the occasion. He was oriented to self, place, time and events. He appeared tired during the assessment due to the lack of sleep. His judgment was intact with the absence illusions, delusions, and hallucinations. He also denied history of suicidal thoughts, attempts and plans.
A: The client has moderate symptoms of insomnia. Insomnia appears to be affecting his ability to engage in his social and educational roles. The client should therefore be assisted to develop skills that will promote quality and quantity sleep.
P: The client was initiated on psychotherapy sessions. The sessions aimed at increasing the knowledge and skills of the client on the use of interventions such as exercising in the evening, avoiding caffeine towards bed time, and switching off lights to enhance sleep quality. He was scheduled for a follow-up visit after four weeks.
Major Depression
Name: Z.C.
Age: 34 years
Diagnosis: Major Depression
S: Z.C is a 34-year-old female who came to the unit as a referral by her family physician. The client was referred for further assessment, as she demonstrated symptoms that the physician felt that they indicated a mental health problem. The client reported a number of complaints. One of them was the persistent feeling of having depressed
mood in most of the days throughout the day. The client also reported that her interest in pleasurable things and events had declined significantly over the past few months. The lost in interest in things had also made her self-isolate from others. Z.C was also worried that she had gained some weight over the past four months despite feeling depressed. She also reported an increase in her appetite. In some cases, she experienced feelings of being worthless and failure in life. She however denied any history of suicidal thoughts, attempts, and plans. Based on the above symptoms, the client was diagnosed with major depression.
O: The client appeared dressed appropriately for the occasion. Her self-reported mood was flat. Her judgment was intact. She had normal speech in terms of rate and volume. The client denied illusions, delusions and hallucinations. She also denied any history of suicidal thoughts, attempts or plans.
A: The client is experiencing moderate symptoms of depression. She should therefore be assisted in managing her mood for her health and wellbeing.
P: The client was started on antidepressants. She was also enrolled for group psychotherapy sessions to enable her develop effective coping skills for managing depression. She was scheduled for a follow-up visit after one month.
Post-Traumatic Stress Disorder
Name: T.X
Age: 37 years
Diagnosis: Post-traumatic stress disorder
S: T.X is a 37-year-old male client who came to the unit today for his regular follow-up visits. The client was diagnosed three months ago with post-traumatic stress disorder. He had presented with a number of symptoms that led to him being diagnosed with the disorder. The symptoms began after he was involved in a road accident. The symptoms were varied and included flashbacks and nightmares about the accident. The client also reported avoidance of any stimuli that related to the accident. He also reported persistent experience of emotional distress following the accident. The client also had some symptoms that related to the negative alteration in his mood and cognition. They included exaggerated negative thoughts about the world, negative affect, decline in interest in activities, and self-isolation. The spouse 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 initiated on treatment.
O: The client was well-groomed for the occasion. His orientation to self, others, environment, and events were intact. His self-expressed mood was ‘better.’ His level of judgment was intact. He denied suicidal thoughts, plans or attempts, illusions, delusions, and hallucinations.
A: The adopted treatment interventions have been effective. There has been moderate improvement in the symptoms of post-traumatic stress disorder.
P: The client was advised to continue with the treatments and scheduled for a follow-up after one month.
Binge Eating Disorder
Name: R.S
Age: 21 years
Diagnosis: Binge eating disorder
S: R.S is a 21-year-old female who came to the unit for her second follow-up visit. She had been diagnosed with binge eating disorder and has been on psychological treatment. The client was diagnosed with the disorder following a number of complaints that she had during her visit to the unit for the first time. The symptoms included recurrent episodes of binge eating. The episodes were characterized by a number of symptoms. They included eating within a discrete period of time food that was perceived more than what most people would eat during that time. She also reported complete lack of control over her eating habits. The binge eating was associated with eating more than normal, eating until feeling uncomfortably full, eating alone or avoiding others during meals, and being disgusted by her eating behaviors. There was also the absence of use of compensatory behaviors such as fasting and purging. The above symptoms led to the diagnosis of binge eating disorder. The client has been undergoing psychotherapy sessions in the unit.
O: The client appeared dressed appropriately for the occasion. She was oriented to self, time, others and events. Her judgment was intact. Her self-reported mood was ‘I feel I have control over my eating problem.’ She denied any instances of altered judgment. He speech was of normal rate and volume.
A: The client is responding well to psychotherapy sessions. She has developed effective skills for managing her binge eating problem.
P: The client was advised to continue with the psychotherapy sessions, as she demonstrated improvement in symptom management. She was scheduled for a follow-up visit after one month.
Schizophrenia
Name: B.B
Age: 40 years
Diagnosis: Schizophrenia
S: B.B is a 40-year-old client who has been undergoing treatment for schizophrenia in the unit. Today, he came to the unit for his regular follow-up visits. He was diagnosed with schizophrenia five months ago after he presented to the unit with a number of symptoms. One of the symptoms was the false belief in his self-identity. B.B believed that he was a professor of a local university. He expressed his interest to lead the implementation of scientific researchers to treat chronic illnesses. However, B.B was a truck driver, hence, altered self-identity. The client also came to the unit with history of disorganized speech. He experienced mutism when he was expressing himself. His ability to express his emotions was significantly diminished. The symptoms the client experienced were not associated with any medical condition, medication or substance abuse. Therefore, he was diagnosed with schizophrenia and initiated on pharmacological and non-pharmacological treatments.
O: The client was dressed appropriately for the occasion. His orientation to self, place, time and events were intact. The client’s self-report mood was normal. The client has reduced speech volume and rate. His judgment was intact, as he denied any recent experience of illusion, delusion and hallucinations. He also denied any recent history of suicide ideation, attempt or plans.
A: The client has responded effectively to the prescribed treatments. The symptoms of delusions have improved.
P: The decision to ensure that the client continues with the current treatment was made due to the moderate improvement in symptoms of schizophrenia. The client was booked for a follow-up visit after a period of one month.
Gambling Disorder
Name: D.A
Age: 43 years
Diagnosis: Gambling disorder
S: D.A is a 43-year-old male who came to the unit seeking assistance for his problem. The client reported a number of problems that led to him being diagnosed with gambling disorder. One of the complaints was recurrent problematic gambling that he experienced for over one-year. According to him, his gambling behaviors were beyond his control and were becoming significantly distressing to his family and him. The client reported the increasing need to gamble with lots of money for him to achieve the excitement that he needed. He also reported that he found it distressing whenever he tried to stop gambling. There was also the high preoccupation of the patient with gambling. He also reported engaging in gambling activities whenever he felt distressed and chases losses by gambling. The gambling behaviors had affected his family’s social and economic wellbeing, hence, the need for seeking professional support.
O: The client was well groomed for the occasion. He was oriented to self, place, time, and events. The client had intact judgment. He denied any history of illusions, hallucinations, delusions, and suicidal thoughts, attempts, or plans. His speech was of normal rate and volume. He did not demonstrate any abnormal movements such as tremors and tics.
A: The client appears psychologically distressed by his pathological gambling. He therefore needs assistance in the adoption of effective knowledge and skills for overcoming the problem.
P: Gambling does not have an approved medication. As a result, the client was enrolled in psychotherapy and gambling anonymous group. He was scheduled for a follow-up visit after one month.
Generalized Anxiety Disorder
Name: R.T
Age: 27 years
Diagnosis: Generalized anxiety disorder
S: R.T is a 27-year-old female that came to the unit for her regular follow-up visits for treatment. She was diagnosed with generalized anxiety disorder four months ago and has been on group psychotherapy sessions. The client was diagnosed with the disorder following a number of complaints that she raised during her initial visit to the unit. The symptoms included excessive worry and anxiety about unknown events that were likely to happen in her life. The excessive worry was reported to occur in most of the days for the last four months. The most feared issues related to her work performance. The client also reported that controlling the excessive worry and anxiety was difficult for her. The symptoms that accompanied the excessive worry and anxiety included muscle pain, restlessness, easy fatigability, and irritability. The excessive worry was reported to have significant adverse effect on the work productivity of the client. The symptoms of generalized anxiety disorder were not associated with any drug or substance and medication use as well as medical condition.
O: The client appears today to be appropriately dressed. She was oriented to self, others, time, and events. The client reported minimal symptoms of worry and anxiety since the last visit. The client also demonstrated intact judgment. Her speech was of normal rate and volume.
A: The client is responding well to the treatment. Her control over worry and anxiety has improved significantly.
P: The decision to continue with the current treatment was reached because the client showed positive response to therapy. A decision to terminate the treatment sessions will be made if additional improvement is noted during the next clinical visit.
Bipolar Disorder
Name: Y.Y
Age: 36 years
Diagnosis: Bipolar Disorder
S: Y.Y is a 36-year-old male who came to the unit for his second follow-up visit. The client was diagnosed with bipolar disorder with mania and has been on pharmacological treatment. The client came to the unit with a number of complaints. One of them was the increased experience of inflated self-esteem. He also demonstrated some symptoms of grandiosity. The client reported that the periods of inflated self-esteem are characterized by the decrease in the need for sleep. He also reported increased talkativeness, racing thoughts, difficulties in concentrating, and being easily distracted. There were also the complaints on the client participating in goal-directed activities, which predisposed him to unwanted consequences. For example, he reported that he often engages in unplanned spending that affects his financial status significantly during the manic episodes. The client also reported mild symptoms of depressive bipolar disorder. The symptoms included depressed mood, loss of interest, weight gain, easy fatigability, and feelings of worthlessness. Based on the above symptoms, the client was diagnosed with bipolar disorder with severe mania and mild depressive episodes.
O: The client appeared well groomed for the occasion. He reported that his mood is depressed. The client was aware of self, time, others and events. The client denied illusions, delusions, and hallucinations. He also denied suicidal attempts, plans, or ideas. His speech was of normal rate and volume.
A: The client is demonstrating some positive response to the treatment.
P: A decision to ensure that the client continues with the current treatment approach was made because of the improvement in symptoms. The client was scheduled for a follow-up visit after one month.
Alcohol Use Disorder
Name: P.A
Age: 50 years
Diagnosis: Alcohol Use Disorder
S: P.A is a 50-year-old client who came to the unit for his third follow-up visit. The client was diagnosed with alcohol use disorder four months ago and has been on pharmacological treatment, group psychotherapy and participating in Alcohol Anonymous group. The client was diagnosed with the disorder after he presented with a number of symptoms or complaints to the department. The complaints included the persistent intake of larger amounts of alcohol for a long period. The client had also reported that his binge use of alcohol had persisted over a long time. The client also complained of unsuccessful interventions to stop or control binge abuse of alcohol. He reported that most of the strategies that he has adopted to overcome the addiction have been unsuccessful. There was also the complaint that the client egaged in activities that enabled him to obtain alcohol. This included selling his properties to get money for purchasing alcohol. Alcohol addiction was noted to have caused a significant decline in the social and occupational productivity of the client. The other symptoms that the client had included unsatisfied craving for alcohol and use of alcohol despite the interpersonal and social problems associated with alcohol.
O: The client was poorly dressed for the occasion. His orientation to self, others, time and events were intact. The client reported that he participation in group psychotherapy and alcohol anonymous group was effective in helping him learn of diversion strategies for alcohol cravings. He denied illusions, delusions, and hallucinations. He also denied suicidal thoughts, attempts and plans.
A: The client is responding well to the adopted treatments. It is expected that his coping skills will improve with time.
P: The client was advised to continue with the current treatment approaches and participation in Alcohol Anonymous group.
Major Depression
Name: T.C.
Age: 44 years
Diagnosis: Major Depression
S: T.C is a 44-year-old female who came to the unit for her follow-up visit for major depression. The client was diagnosed with depression five months ago and has been on treatment. The client had reported a number of complaints. One of them was the persistent feeling of having depressed mood in most of the days throughout the day. The client also reported that her interest in pleasurable things and events had declined significantly over the past few months. The lost in interest in things had also made her self-isolate from others. T.C was also worried that she had gained some weight over the past four months despite feeling depressed. She also reported an increase in her appetite. In some cases, she experienced feelings of being worthless and failure in life. She however denied any history of suicidal thoughts, attempts, and plans. Based on the above symptoms, the client was diagnosed with major depression.
O: The client appeared dressed appropriately for the occasion. Her self-reported mood was flat. Her judgment was intact. She had normal speech in terms of rate and volume. The client denied illusions, delusions and hallucinations. She also denied any history of suicidal thoughts, attempts or plans.
A: The client is experiencing moderate symptoms of depression.
P: The dosage of antidepressants was increased. She was also advised to continue with the group psychotherapy sessions to enable her develop effective coping skills for managing depression. She was scheduled for a follow-up visit after one month.
Sample Answer 2 for PRAC 6645 Wk 1 Assignment 3: Clinical Hour and Patient Logs
Alcohol Use Disorder
Name: B.D
Age: 36 years
Gender: Male
Diagnosis: Alcohol Use Disorder
S: B.D. is a 36-year-old male patient who came to the facility to seek help. He reports a history of chronic alcohol consumption. The patient reports negative impacts such as deteriorating health, work difficulties, and relationship issues. He has continually become alcohol dependence and quit drinking.
O: The patient is unkempt and disheveled with signs of poor self-care. He is alert and oriented. His speech is slurred, and he exhibits impaired coordination. His memory is intact with a coherent though process. However, thought content is preoccupied with drinking thoughts. He denies suicidal thoughts or ideations.
A: According to the DSM-V criteria, the patient’s symptoms indicate alcohol use disorder.
P: The patient needs to start CBT individual therapy sessions to help address the underlying issues leading to the problem.
Binge Eating Disorder
Name: L.S
Age: 16 years
Gender: Female
Diagnosis: Binge Eating Disorder
S: L.S. is a 16-year-old female patient who visited the facility, indicating that she has been advised by friends to seek help. She reports engaging in in periods of binge eating where he eats large quantities of food and even has an urge to eat more even if she is full. She experiences guilt and shame, which makes her uncomfortable.
O: The patient is well-dressed and appropriately groomed. She is also alert and oriented. She appears overweight. The patient’s mood is depressed and anxious. She has a normal speech. Her thought process is coherent but focused on concerns regarding her body size and shape. She has an intact memory. She denies any thoughts of self-harm.
A: The patient’s symptoms are indicative of binge eating disorder
P: The patient should start weekly CBT sessions to help with maladaptive thoughts.
Intermittent explosive disorder (IED)
Name: M.M
Age: 37 years old
Gender: Female
Diagnosis: Intermittent explosive disorder (IED)
S: M.M is a 37-year-old female patient who came to the facility with history frequent loss of temper. She claims to be moody most of the time, especially the time of the year every year. She exhibits other symptoms such as weight gain and trouble with sleep. In addition, she complains of boredom and low concentration levels. She also finds it hard to keep friends.
O: she is well-dressed and groomed. She is also oriented and alert. The patient is irritable and angry. She has an intact memory. She has a pressured speech. She has a coherent thought process. She is delusional and exhibits a threat of harm to herself and others.
A: Regarding the DSM-V criteria, the patient has intermittent explosive disorder.
P: The patient should start individual CBT sessions to help with the symptoms.
Major Depressive Disorder
Name: R.N
Age: 16 years old
Gender: Female
Diagnosis: MDD
S: R.N. is a 16-year-old female patient who came to the facility for an evaluation. She indicates that she had been diagnosed with depression and she used antidepressants to manage them. However, she stopped using the medication for fear of being judged. She exhibits other symptoms such as sleeping difficulties, reduced appetite, crying spells, reduced concentration levels, and reduced interest in activities.
O: The patient is well-dressed and groomed. She is alert and oriented. She speaks fluently, in a normal tone and volume. Her insight is congruent. Her thought process is age-appropriate, with unremarkable judgment. Her memory is intact. She, however, displays a sad mood and seems to be distracted most of the time. She reports a feeling of worthlessness but denies suicidal ideation.
A: Based on the DSM-V criteria the patient has MDD
P: The patient should start group therapy sessions to help with the symptoms.
Obsessive Compulsive Disorder
Name: M.T
Age: 37-years
Gender: Male
Diagnosis: Obsessive compulsive disorder
M.T is a 37-year-old male patient who came to the facility for a psychiatric visit. He indicates that he has been having distressing and intrusive thoughts related to contamination. He dreads germs and contamination making him frequently wash his hands. He reports that such action reduces his anxiety and fear of germs. Such symptoms and behavior have negatively impacted his daily life.
O: The patient is well-dressed and appropriately groomed. He is alert and oriented. He looks restless. He has a normal speech. He also has a coherent thought process and memory. However, his thoughts are preoccupied with contamination and germs. He is easily distracted. He denies delusions or hallucinations.
A: Based on the DSM-V criteria, the patient’s symptoms show obsessive compulsive disorder.
P: The patient needs to start weekly CBT sessions for better coping skills.
Enuresis Disorder
Name: S.N
Age: 9 years old
Gender: Male
Diagnosis: Enuresis Disorder
S: S.N. is a 9-year-old boy who was brought in by her mother to seek help. She indicates that her son has development a habit of bedwetting. She indicates that when the patient went camping, they shared a bed with a friend who noticed that the patient wet the bed at night. Ever since they have been making him and calling him names, he has lost interest in routine activities and doesn’t even want to go to school.
O: The patient is generally healthy, with no signs of any delays in the developmental stages. He is also alert and oriented. He looks anxious and sad. He has a coherent thought process and intact memory. He denies suicidal action
A: The patient wets the bed at night; hence, he has enuresis disorder.
P: The patient should start family therapy sessions to help with the maladaptive thought patterns.
Acute Stress Disorder
Name: D.D
Age: 31-years
Gender: female
Diagnosis: Acute Stress Disorder
D.D is a 31-year old female patient who came to the clinic for a visit. He reports experiencing work pressure and a recent incident of witnessing an accident scene. She reports intense fear, nightmares, flashbacks, and intrusive memories related to the accident. She also reports feeling on the edge for some time now.
O: The patient is well-dressed and groomed. She is also alert and oriented. She finds it difficult to concentrate and she is easily distracted. She exhibits and anxious mood. Her thought process is preoccupied with memories and thoughts of the accident. She denies suicidal thoughts or ideations.
A: The patient’s symptoms are indicative of acute stress disorder.
P: The patient should start trauma-focused CBT to help address the symptoms.
Bipolar Disorder
Name: W.C
Age: 15 years old
Gender: Female
Diagnosis: Bipolar Disorder
S: W.C. is a 15-year-old female patient who came to the facility accompanied by her father. The father indicates that their daughter has been having mood fluctuations. However she has been missing her doses due to forgetfulness. She also reports that in most cases, she doesn’t feel like taking the medication since they do little to make her better. Her mood fluctuations have intensified in the past week
O: The patient walked in well-groomed in age-appropriate clothes. The patient maintained eye contact during the interview with appropriate facial expressions. Her thought process is coherent and logical. She denies delusion, hallucinations, and suicidal ideation. She confirms being forgetful, but her long-term memory is intact.
A: The patient’s symptoms are indicative of bipolar disorder
P: The patient should start group therapy sessions to help with the symptoms.
General Anxiety Disorder (GAD)
Name: O.M
Age: 52 years old
Gender: Female
Diagnosis: General Anxiety Disorder (GAD)
S: O.M. is a 52-year-old female patient who visited the clinic for a psychiatric assessment. She presents with signs of anxiety, accompanied by headache, decreased appetite, and diarrhea 2 to 3 times every week. She reports anxiety about her retirement, which she feels she is not prepared for, and about her husband, who wants a divorce.
O: She is well-dressed and appropriately groomed. She is alert and well-oriented in person, place, and time. She actively participate in the interview. She looks anxious and sad. She displays a constricted effect with good insight and judgment. Her memory is intact, with an unremarkable thought process. Mild impairment was observed in her functional status.
A: Based on the DSM-V diagnostic criteria, the patient has generalized anxiety disorder
P: The patient should start weekly individual CBT sessions to help deal with the symptoms.
Intellectual Development Disorder
Name: C.V
Age: 10-years
Gender: female
Diagnosis: Intellectual development disorder
S: C.V. is a 10-year-old female patient who was brought to the facility by her parents. They indicate that their daughter has exhibited developmental delays and adaptive functioning challenges. She has exhibited various delays in motor skills and language. She also finds it hard to carry out self-care activities.
O: The patient is well-dressed and groomed. She is also alert and oriented. She has a positive and stable mood. She has a concrete speech lacking complexity. She also exhibits limited insight. She exhibits limited ability to express thoughts and ideas verbally. She denies delusions or hallucinations
A: The patient’s symptoms are indicative of intellectual development disorder.
P: The patient needs to start family therapy sessions to help address behavioral challenges.
Delusional disorder
Name: F.A
Age: 36 years
Gender: Female
Diagnosis: Delusional disorder
F.A. is a 36-year-old female patient who came to the facility accompanied by her younger brother. He indicates that the patient has been showing disturbing symptoms. She has been reporting seeing non-existent people, places, and events. She recently claimed that some people have been spying on them and want to harm them. Her brother denies seeing such people.
O: She is well dressed. She is also alert and oriented. She looks anxious and demonstrates signs of hypervigilance. She is anxious and fearful. Her memory is intact. She also has a clear speech. Her thought content is preoccupied with delusional beliefs people who want to harm her. She denies suicidal thoughts.
A: According to DSM-V criteria, the patient has delusional disorder.
P: The patient should commence weekly CBT sessions to help with the symptoms.
Separation Anxiety Disorder (SAD)
Name: T.B
Age: 9 years old
Gender: Male
Diagnosis: separation anxiety disorder
S: T.B. is 9-year-old boy who was brought to the facility by his parents for a checkup. They report that he has expressed worry and anxiety all the time about silly things, such as what will happen if the parents fail to pick him up from school. He tends to be stubborn most of the time, throwing objects around the house and easily getting irritated. He finds it difficult to sleep at night due to frequent nightmares. When at school, he consistently asks for permission to go home, complaining of stomach aches or headaches.
O: He is well-groomed and oriented. He is also oriented in person, place, and time. He looks sad and displays clingy behavior. He has a clear speech. Well-organized thought process. He exhibits intact memory with an appropriate thought process. Denies potential harm to self or others.
A: Based on the DSM-V criteria, the patient has a separation anxiety disorder
P: The patient should commence weekly sessions of family therapy to help deal with the symptoms.