PRAC 6655 WEEK 7 Assignment 1 : Clinical Hour and Patient Logs
Clinical Logs
Major Depression
Name: E.V
Age: 29 years
Diagnosis: Major Depression
S: E.V. is a 29-year-old client that came to the unit for her eighth follow-up visit for major depression. She was diagnosed with the disorder nine months ago and has been on treatment. She recalled that the diagnosis was reached after she presented to the unit with complaints that included feeling sad most of theworthless and excessive guilty most of the time. There was also a decline in appetite, insomnia, lack of interest, and being socially withdrawn. The symptoms could not be attributed to any other cause
such as medication use, medical condition, or substance abuse. The symptoms had affected significantly her ability to perform optimally in her academic and social roles. As a result, she was diagnosed with major depression and has been undergoing treatment in the facility.
O: The patient appeared dressed appropriately for the occasion. She was oriented to self, place, time, and events. Her judgment was intact. She denied any suicidal thoughts, attempts, or plans as well as illusions, delusions, and hallucinations. Her mood was normal.
A: The client has responded well to the treatments. She had developed effective coping skills for depressive symptoms. She also reports no side effects associated with medications.
P: Psychotherapy sessions were terminated with consent obtained from the client. She was advised to continue with antidepressant therapy. She was scheduled for a follow-up visit after three months.
Major Depression
Name: K.G
Age: 33 years
Diagnosis: Major Depression
S: K.G is a 33-year-old female who came to the unit for the first time for assessment. She came with complaints that
included the persistent feeling of having a depressed mood most of the days throughout the day. She also reported that her interest in pleasurable things had declined significantly over the past few months. K.Galso reported that she has gained some weight over the past four months, increased appetite, and feelings of being worthless. 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 a 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 requires treatments to help manage depressive symptoms.
P: The client was started on antidepressants. She was also enrolled in group psychotherapy sessions to enable her to develop effective coping skills for managing depression. She was scheduled for a follow-up visit after one month.
Major Depression
Name: J.E
Age: 43 years
Diagnosis: Major Depression
S: J.E is a 43-year-old client that came to the unit for his fifth follow-up visit, after being diagnosed with depression. The diagnosis was reached after he came with complaints that included depressed mood in most of the days for every day. He was also socially isolated as he lacked interest in things and pleasure. He reported that the depressed mood had made it difficult for him to engage in his occupational roles. The additional symptoms the client raised included difficulties in decision making, insomnia, and increased irritability. 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. He reported that his mood has improved with the adopted treatments. The client was oriented to self, others, time, and events. She denied illusions, delusions, and hallucinations. He denied suicidal thoughts and attempts. He also denied current suicidal plans.
A: The symptoms of depression have improved.
P: The client was advised to continue with the current treatment. Hewas also advised to come for a follow-up visit after four weeks.
Major Depression
Name: R.A
Age: 55 years
Diagnosis: Major Depression
S: R.A is a 55-year-old female who came to the clinic today for her follow-up visit for depression. She has been on antidepressants and group psychotherapy treatments. The diagnosis was reached after she presented to the unit with complaints that included sadness almost every day. She also complained of feeling intense guilt alongside changes in her sleeping habits. She noted that her quality and quantity of sleep had declined significantly, as she was struggling to fall asleep and maintain it. She had also lost interest in the social and occupational roles that she used to engage in before the diagnosis. The above symptoms had led to her being diagnosed with major depression and initiated on antidepressants and group psychotherapy treatments.
O: The patient appeared appropriately dressed for the clinical visit. She was oriented to self, place, time, and events. The rate and volume of speech of the patient were normal. The self-reported mood of the client was normal. The client denied illusions, delusions, and hallucinations. She also denied a recent history of suicidal thoughts, attempts, and plans.
A: The client has demonstrated an effective response to the adopted treatments.
P: The client was advised to continue with antidepressant treatments. Psychotherapy sessions were terminated, as treatment goals had been achieved. The client was scheduled for a follow-up visit after one month.
Insomnia
Name: M.O
Age: 33 years
Diagnosis: Insomnia
S: M.O is a 33-year-old male who came to the unit for his first visit. He came with complaints of persistent lack of quality sleep for the last five months. M.O also raised symptoms that accompanied the lack of sleep that included being dissatisfied with the quality and quantity of sleep and awakenings at night and finding it hard to fall asleep again. The disturbances in sleep were reported to have significant impairment in the client’s social, educational, occupational, and behavioral areas of functioning. A further history taken from the client showed that the insomnia was not due to any condition, medication,or alcohol or substance abuse. As a result, he was diagnosed with insomnia and initiated on psychotherapy.
O: The client appeared appropriately dressed for the clinical visit. He was oriented to self, place, time, and events. He yawned frequently during the assessment due to the lack of sleep the previous night. His judgment was intact with the absence of illusions, delusions, and hallucinations. He denied a history of suicidal thoughts, attempts, and plans.
A: The client has moderate symptoms of insomnia.
P: The client was initiated on individual psychotherapy sessions to help him develop effective skills for enhancing the quality and quantity of sleep. Hewas scheduled for a follow-up visit after four weeks.
Delusional Disorder
Name: P.A
Age: 35 years
Diagnosis: Delusional Disorder
S: P.A is a 35-year-old female client that came to the unit for her second follow-up visit today after being diagnosed with delusional disorder. The diagnosis was reached after the client came initially to the unit with complaints of feeling that someone is planning to kill her. The feelings had persisted for more than a year. She felt that people planned to kill her due to her position in society. Further history taken from the client showed that the client knew that the feelings were maybe untrue. 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 denied recent delusions. She denied any history of suicidal thoughts, plans, and attempts. Her speech was normal in terms of rate and volume.
A: The client has improved in symptoms following the treatment.
P: The client was advised to continue with the current treatment. She was scheduled for a follow-up visit after four weeks.
Substance Abuse Disorder
Name: M.W
Age: 43 years
Diagnosis: Substance Abuse Disorder
S: M.W. is a 43-year-old male that came today to the clinic for his follow-up visit after being diagnosed with substance abuse disorder. He has been on pharmacological treatment and group psychotherapy. He was diagnosed with the disorder after he came to the unit with complaints of binge alcohol consumption that was worsening daily. He had to increase the amount of alcohol consumed to get his desired level of intoxication. He also sold his property to get money for alcohol. Alcohol abuse had affected his family, as he was worried that it would break should he not find a solution.Alcohol abuse was also affecting his social and occupational functioning. As a result, he was diagnosed with substance abuse disorder and initiated on treatment.
O: The patient appeared appropriately dressed for the occasion. He appeared slightly underweight for his age. His orientation to self, place, time, and events were intact. He denied altered thought processes, as evidenced by the absence of illusions, delusions, and hallucinations. He also denied suicidal thoughts, plans, and attempts. He demonstrated mild tremors during the assessment.
A: The client demonstrates improvement in symptoms. He has been actively participating in group psychotherapy sessions.
P: The client was initiated on Alcohol Anonymous group. He was also advised to continue with the current treatments. He was scheduled for a follow-up visit after four weeks.
Schizophrenia
Name: L.Y
Age: 30 years
Diagnosis: Schizophrenia
S: L.Y is a 30-year-old client who came to the unit for his regular follow-up visits after being diagnosed with schizophrenia three months ago. He was diagnosed with the disorder after he presented to the unit with symptoms that included false belief in his self-identity. The client believed that he was a pastor at a local church. However, L.Y. was a truck driver, hence, altered self-identity. The client also had disorganized speech during his first visit to the unit. His ability to express his emotions was significantly diminished. The symptoms were not associated with any medical condition, medication, or substance abuse. Therefore, he was diagnosed with schizophrenia and initiated on treatment.
O: The client has dressed appropriately for the occasion. His orientation to self, place, time, and events were intact. The client’s self-report mood was normal. The speech volume and rateare normal. His judgment is 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, as evidenced by symptom improvement.
P: The client was advised to continue with the current due to the moderate improvement in symptoms of schizophrenia. The client was booked for a follow-up visit after one month.
Bipolar Disorder
Name: G.E
Age: 28 years
Diagnosis: Bipolar Disorder
S: G.E is a 28-year-old client that came to the unit for his second follow-up visit after being diagnosed with bipolar disorder five months ago. The diagnosis was reached after she came with complaints that included an expansive mood where the patient felt that she was in control of everything. She was also easily irritable and found it difficult to concentrate on tasks. She also engaged in goal-directed activities and impulsive behaviors. The symptoms alternated with those of depression such as insomnia, depressed mood, and changes in appetite. The symptoms could not be attributed to any cause such as medical condition, medication, or substance abuse. As a result, she was diagnosed with bipolar disorder and has been on treatment in the unit.
O: The client was dressed appropriately for the occasion. She was oriented to self, time, space, and others. Her judgment was intact. The speech was of normal rate and volume. She denied illusions, delusions, and hallucinations. She also denied suicidal thoughts, attempts, and plans.
A: The client is responding well to treatment.
P: The client was advised to continue with the current treatments. She was scheduled for a follow-up visit after four weeks.
Post-Traumatic Stress Disorder
Name: R.A
Age: 26 years
Diagnosis: Post-Traumatic Stress Disorder
S: R.A. is a 26-year-old male client that came to the unit for his first follow-up visits after being diagnosed with post-traumatic stress disorder a month ago. The client was diagnosed after he presented with abnormal symptoms that developed following his traumatic encounter. He came with complaints that included the persistent recurrence of the distressing memories about the traumatic event. He reported flashbacks and psychological distress following his exposure to stimuli that related to the event. As a result, he avoided any stimuli that reminded him about the experience. He also reported additional symptoms that included difficulty in concentration, making decisions and insomnia. The symptoms had affected the client’s ability to engage in his occupational and family roles. Consequently, he was diagnosed with post-traumatic stress disorder and initiated on psychotherapy and antidepressants in the unit.
O: The client was dressed appropriately for the occasion. He was oriented to self, others, time, and events. His judgment was intact. He denied illusions, delusions, and hallucinations. He also denied suicidal thoughts, attempts, and plans.
A: The adopted treatment interventions have been effective in managing the depressive symptoms of post-traumatic stress disorder. There has been an improvement in symptoms compared to the last visit.
P: The client was advised to continue with the current treatments. He was scheduled for a follow-up visit after four weeks.