PRAC 6645 Wk 1 Assignment 3: Clinical Hour and Patient Logs
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
PRAC 6645 Wk 1 Assignment 3 Clinical Hour and Patient Logs
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
PRAC 6645 Wk 1 Assignment 3 Clinical Hour and Patient Logs
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.