PRAC 6665 WEEK 1 Assignment 1 : Clinical Hour and Patient Logs
Walden University PRAC 6665 WEEK 1 Assignment 1 : Clinical Hour and Patient Logs-Step-By-Step Guide
This guide will demonstrate how to complete the Walden University PRAC 6665 WEEK 1 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 6665 WEEK 1 Assignment 1 : Clinical Hour and Patient Logs
Whether one passes or fails an academic assignment such as the Walden University PRAC 6665 WEEK 1 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 6665 WEEK 1 Assignment 1 : Clinical Hour and Patient Logs
The introduction for the Walden University PRAC 6665 WEEK 1 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 6665 WEEK 1 Assignment 1 : Clinical Hour and Patient Logs
After the introduction, move into the main part of the PRAC 6665 WEEK 1 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 6665 WEEK 1 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 6665 WEEK 1 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.
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Sample Answer for PRAC 6665 WEEK 1 Assignment 1 : Clinical Hour and Patient Logs
Clinical Logs
Major Depression
Age: 40 years
Diagnosis: Major Depression
S: C.Y is a 40-year-old client that came to the unit for her third follow-up visit, after she was diagnosed with depression four months ago. The client was diagnosed after she experienced symptoms that included depressed mood in most of the days for every day. She was also socially isolated as he lacked interest in things and pleasure. She reported that the depressed mood had made it difficult for her to engage in her occupational roles. The client also reported that her ability to make decisions was also significantly affected. He level of irritability was also high. 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 her mood has been improving with the adopted treatments. 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 advise
d to come for a follow-up visit after four weeks.
Major Depression
Name: R.T
Age: 40 years
Diagnosis: Major Depression
S: R.T is a 40-year-old male who came to the clinic today for his follow-up visit after being diagnosed with major depressive disorder three months ago. The client has been on antidepressants and group psychotherapy treatments.
R.T was diagnosed with major depressive disorder after he came to the clinic with complaints that included the feelings of sadness almost every day. The client also felt intense guilt that made him socially isolated. There was also the change in the sleeping habits of the patient. Accordingly, he noted the increasing difficulties he was experiencing to fall asleep and maintain sleep. The client also reported lack of energy, and suicidal ideations and attempts. There were also the complaints of lack of interest in the social and occupational roles that the patient used to engage in before the diagnosis. Based on the above symptoms, the client was diagnosed with depression and initiated on antidepressants and group psychotherapy.
O: The patient appeared appropriately dressed for the occasion. He was oriented to self, place, time and events. The rate and volume of speech of the patient was normal. The self-reported mood of the client was normal. The client denied illusions, delusions and hallucinations. He also denied recent history of suicidal thoughts, attempts, and plans.
A: The client is responding well to the treatment. The improvement in symptoms is in accordance with the developed treatment objectives. The client is also tolerating the adopted treatment interventions.
P: The decision that the patient continues with the current treatment was made. This was based on the improvement in the symptoms of depression.
Major Depression
Name: D.K
Age: 37 years
Diagnosis: Major Depression
S: D.K is a 37-year-old client that came to the clinic today for the sixth follow-up visit after being diagnosed with major depression seven months ago. He has been on antidepressants and group psychotherapy treatments. D.Kwas diagnosed with depression after she presented with complaints of feeling sad most of the days almost all the days, feeling worthless and guilty most of the times. There was also the complaint of decline in appetite, as she died not want any type of food. Her interest in pleasure also declined significantly. The client also reported suicidal thoughts without attempts or plans. The symptoms had affected significantly her ability to perform as expected in her occupational roles. The symptoms could not be attributed to other causes such as medication use, medical conditions or substance abuse. She was therefore 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. Her mood has improved. She also tolerates the adopted treatments as expected.
P: Psychotherapy sessions were terminated with consent obtained from the client. She was advised to continue with antidepressant therapy. She was scheduled for follow-up visit after two months.
Major Depression
Name: K.A
Age: 28 years
Diagnosis: Major Depression
S: K.A is a 28-year-old male client who came to the unit for her first follow-up visit after being diagnosed with major depression a month ago. The client was brought due to his abnormal behaviors for the last six months. Some of the abnormal behaviors that had been reported during the previous visit to the clinic included losing interest and pleasure. The mood of the client was reported to have been always depressed in most of the days. The client also appeared socially withdrawn, as he did not want to interact with people. As a result, he stayed indoors for most of the times. The client also reported that his mood was severely depressed in most of the days with feelings of worthlessness. When asked about his sleeping and dietary habits, he reported that he rarely slept and had elevated appetite. He was also concerned that his ability to make decisions had worsened significantly over the past, as he found it difficult to concentrate.The client also reported suicidal thought without an attempt or plan. Based on the above data, the client was diagnosed with major depression and initiated on treatment.
O: The client appeared moderately groomed for the clinical visit. His mood was moderately depressed. His insight was normal. His speech was of normal rate and volume. His orientation to self, others, time, and events were intact. The client denied suicidal thoughts plans or attempts since the last visit to the clinic.
A: The client reports moderately improvement in symptoms of major depression. He is also tolerating the adopted treatment interventions.
P: The dosage of antidepressants was increased to achieve optimum therapeutic effect on symptom management. The client was advised to continue with the group psychotherapy sessions. He was scheduled for the next follow-up visit after four weeks.
Generalized Anxiety Disorder
Name: R.T
Age: 22 years
Diagnosis: Generalized Anxiety Disorder
S: R.T is a 22-year-old female client that that came to the clinic for her fourth follow-up visit for generalized anxiety disorder. She was diagnosed with the disorder after she presented to the clinic with complaints of excessive fear and anxiety that was beyond her control. The client also reported that the fear she had was related to her academic performance in the medical school. She was worried that she was likely to fail leading to her losing her scholarship for the program.Symptoms that included palpitations, chest tightness, sweating, and tremors accompanied the feelings of excessive fear. The excessive fear and anxiety had affected significantly the ability of the client to perform optimally in her academic and social roles. The symptoms could not be attributed to any cause such as medications, medical condition, or substance abuse. As a result, she was diagnosed with generalized anxiety disorder and initiated on treatment.
O: The client appeared appropriately dressed for the occasion. Her orientation to self, others, time and events were intact. The insight of the client was intact. She denied illusions, delusions, and hallucinations. She also denied suicidal thoughts, attempts, and plans.
A: The client reported that she no longer experiences excessive fear and anxiety. She also reported effectiveness of the psychotherapeutic strategies for managing her problem. The treatment outcomes have been achieved.
P: The participation of the client in group psychotherapy sessions was terminated with her consent. The sessions were terminated because the desired treatment outcomes had been achieved.
Panic Disorder
Name: C.P
Age: 24 years
Diagnosis: Panic Disorder
S: C.P is a 24-year-old male who came to the clinic for a follow-up visit for treatment due to panic disorder. He was diagnosed with the disorder five months ago and has been on treatment. The diagnosis of panic disorder was reached after the client presented with symptoms that included feelings of excessive fear of not performing as expected in his institution. The panic disorder was associated with a number of symptoms. They included palpitations, sweating, trembling, and feeling chocked. There were also the complaints of chest pain, feelings of chocking, dizziness, and feelings of unreality. The symptoms had affected significantly the functioning of the client. As a result, he was diagnosed with panic disorder and initiated on group psychotherapy.
O: The client appeared appropriately dressed for the occasion. He was oriented to self, space and time. The thought content of the client was normal. He denied illusions, hallucinations, and delusions. The client also denied suicidal thoughts, plans, and attempts.
A: The desired treatment outcomes have been achieved.The client reports effective coping with the distressing symptoms of panic disorder.
P: The psychotherapy sessions were terminated, as the treatment outcomes had been achieved. The client was scheduled for a follow-up visit after two months to assess his coping with the disorder.
Delusional Disorder
Name: D.E
Age: 34 years
Diagnosis: Delusional Disorder
S: D.E is a 34-year-old female client that came to the unit as a referral by her family physician for psychiatric assessment. She came with complaints of feeling that someone is planning to kill. She noted that she has had the feelings for the past one year and she often feels insecure of her safety. The client also reported that someone wanted to kill her because of her position in the society. She felt that someone targets her due to her immense achievements and social connections she has with the most powerful people in the community. 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 persecutory delusions 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.
Post-Traumatic Stress Disorder
Name: G.L
Age: 32
Diagnosis: Post-traumatic stress disorder
S: G.L is a 32-year-old female that came to the unit today for her first follow-up visit after being diagnosed with post-traumatic stress disorder. G.L was diagnosed with the disorder following her involvement in a road accident. According to her, she has been experiencing distressing memories about the accident. She has also been experiencing flashbacks and nightmares about the accident. She often engages in activities that divert her attention from the incident. She also reported to have been avoiding any situations that share similarities with the traumatic experience. The stressful memories and avoidance of situations associated with the accident had affected significantly her ability to perform optimally in her place of work. It also affected her ability to make decisions. Based on the above, G.L was diagnosed with post-traumatic stress disorder and initiated on antidepressants and group psychotherapy sessions.
O: The client appeared dressed appropriately for the occasion. She was oriented to self, others, time, and events. Her speech was of normal rate, content and volume. She maintained normal eye contact during the assessment. She denied illusions, delusions, and hallucinations. She also denied suicidal thoughts, plans, and attempts.
A: The client appears to responding well to treatment. She denies any side effects of the antidepressants. She is positive towards attending group psychotherapy sessions.
P: The client was advised to continue with the current treatments. She was scheduled for a follow-up visit after four weeks.
Substance Abuse Disorder
Name: L.O
Age: 45 years
Diagnosis: Substance abuse disorder
S: L.O is a 45 year-old male that came today to the clinic for his fifth follow-up visit after being diagnosed with substance abuse disorder. L.O has been on pharmacological treatment and group psychotherapy to help him overcome addiction. He reported that he was diagnosed with substance abuse disorder after he came to the unit with complaints of binge consumption of alcohol. He noted that his alcohol consumption habits were worsening on a daily basis. He often had to increase the amount of alcohol consumed to get his desired level of intoxication. He also noted that he engaged in practices such as selling family properties and stealing to get money for purchasing alcohol. L.O also reported that he had enrolled in Alcohol Anonymous group last year with the intention of stopping alcohol consumption. However, he was unsuccessful due to the effects of withdrawal symptoms. He came to the unit for assistance after he found that his binge consumption of alcohol was almost breaking his family. It 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 process, 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 when compared to the last visit. He has been actively participating in the group psychotherapy sessions.
P:The patient continues to demonstrate improvement in symptoms. He also tolerates the prescribed medications. 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.
Insomnia
Name: E.L
Age: 38 years
Diagnosis: Insomnia
S: E.L is a 38-year-old male that came to the clinic for the third visit after being diagnosed with insomnia. E.L has been on psychotherapy treatment. He recalled that he was diagnosed with insomnia after he presented to the unit with complaints of chronic lack of sleep. He noted that his quality and quantity of sleep started deteriorating six months prior to the visit to the hospital. He reported that he remained awake throughout most of the nights. He also experienced awakening in some days, which made it difficult for him to fall asleep thereafter. He had tried using sleep enhancing medications but they were not effective. The lack of sleep had affected his productivity in workplace since he often fell asleep during the afternoon hours. Because of the above problems, he came to the unit for assessment where he was diagnosed with insomnia and initiated on individual psychotherapy.
O: The patient appeared dressed appropriately for the occasion. He was oriented to self, others, time, and events. His thought content was intact. His speech was normal in terms of rate and volume. He denied illusions, delusions, and hallucinations. He also denied suicidal thoughts, plans, and attempts. He did not demonstrate any abnormal behaviors such as poor eye contact, yawning, and tremors during the assessment.
A: The psychotherapy treatment appears to be effective. The patient reports a significant improvement in his quality of sleep. He also reports enhanced engagement in occupational activities unlike in the past.
P: The client was advised to continue with the psychotherapy treatment, as it was effective. He was scheduled for a follow-up visit after four weeks.
Sample Answer 2 for PRAC 6665 WEEK 1 Assignment 1 : Clinical Hour and Patient Logs
Obsessive-Compulsive Disorder
Name: J.N
Age: 28-years
Gender: Female
Diagnosis: Obsessive-Compulsive Disorder
J.N. is a 28-year-old female patient who came to the clinic seeking an assessment. She reports intrusive and distressing obsessions related to contamination fears. She also displays recurrent thoughts on contaminants and dirt, which makes her wash her hands many times a day. She fears touching surfaces and does not want to go to crowded places. These symptoms have negatively impacted his her life.
O: The patient is well-dressed and looks her age. She is also alert and oriented. She is in an anxious mood. Her thoughts are preoccupied with fears of contamination. She rarely concentrates. Her thought process is coherent, though focused on the obsessions.
A: According to DSM-V criteria, these symptoms show obsessive-compulsive disorder.
P: The patient needs to start weekly CBT sessions to help manage contamination-associated obsessions and compulsions.
Oppositional Defiant Disorder
Name: S.C
Age: 10 years
Gender: Female
Diagnosis: Oppositional Defiant Disorder
S.C. is a 10-year-old female patient who was brought to the facility by her parents. They report that the patient has been exhibiting unpleasant symptoms that have negatively impacted her relationship with the family. The mother reports that the patient has been having oppositional behavior at school and home. She engages in frequent arguments, defiance, and refusing to comply with rules. She also throws tantrums when scolded.
O: The patient is well-dressed and groomed. She is also alert and oriented. She is sometimes cooperative but also demonstrates oppositional behavior during the assessment. She has fluent and normal speech. She looks irritable. Her thought process is coherent. She has an intact memory. She denies delusions and hallucinations.
A: The patient’s symptoms point to ODD.
P: The patient should start weekly sessions of cognitive behavioral therapy to help address maladaptive thoughts and behavior.
Anorexia Nervosa
Name: K.H
Age: 16 years
Gender: Female
Diagnosis: Anorexia Nervosa
K.H. is a 16-year-old female patient who came to the clinic for a psychiatric assessment. She reports experiencing a substantial decrease in food consumption in the last few months, which has led to weight loss. She has been avoiding food for fear of gaining more weight and being obese. She also reports being dissatisfied with her body size and image. She indicates that she hates being obese.
O: The patient is well-dressed and groomed. She is also alert and oriented. She exhibits signs of physical deterioration and appears emaciated. She finds it hard concentrating. She has a depressed mood. She has a coherent thought process, but her thoughts are preoccupied with body image, weight, and food. The patient denies suicidal thoughts or ideation.
A: The patient’s symptoms are indicative of anorexia nervosa
P: The patient should start weekly CBT sessions to improve coping skills and deal with distorted thought patterns,
Postpartum depression
Name: M.N
Age: 22 years
Gender: Female
Diagnosis: Postpartum depression
M.N. is a 22-year-old female patient who visited the facility after a referral by her primary physician. She reports giving birth to her first child a few weeks prior. She has exhibited symptoms such as changes in sleep patterns, sleep complications, reduced energy, and sadness. She indicates that she has been overwhelmed by childcare duties, and she expresses thoughts of inadequacy as a mother, as well as worries that she may not make a good mother.
O: she is well-dressed and well-groomed. She is also alert and oriented. However, she looks fatigued. She looks sad. She also struggles to concentrate and looks teary. The patient’s memory is intact. His thought process is intact. She denies suicidal thoughts or thoughts to harm her baby
A: The patient’s depressive symptoms are due to recently giving birth, indicating postpartum depression
P: The patient should start sessions of cognitive-behavioral therapy to deal with the symptoms.
Generalized Anxiety Disorder
Name: C.V
Age: 14 years
Gender: Male
Diagnosis: Generalized Anxiety Disorder
C.V. is a 14-year-old male patient who visited the clinic for an initial evaluation. He has been having excessive worry and anxiety for the past months. The patient has been having problems with his friends and his school performance has been declining, which makes him worried. He reports feeling tense, restless, and on the edge most of the time and has found it hard to control his thoughts.
O: The patient is well-dressed and groomed. He is however, restless and tensed. He also fidgets a lot. He exhibits rapid and pressured speech. He has a coherent thought process and intact memory. The patient denies delusions or hallucinations.
A: The patient’s symptoms point to anxiety disorder.
P: The patient should start CBT sessions to identify and challenge maladaptive thought patterns
Schizoaffective Disorder
Name: E.R
Age: 50 years
Gender: Female
Diagnosis: Schizoaffective Disorder
E.R. is a 50-year-old female patient who came to the clinic for a psychiatric visit. She reports a history of fluctuating mood symptoms, including periods of psychosis, mania, and depression. Other symptoms reported include disorganized thinking, paranoid ideation, and auditory hallucinations, which have been persistent for some time.
O: The patient looks disheveled and poor hygiene is evident. She is also agitated and restless. Her speech is rapid and tangential. The thought process is circumstantial and tangential. The thoughts are preoccupied with themes of grandiosity and persecution. The patient has mild attention and concentration impairments.
A: The patient’s symptoms are indicative of schizoaffective disorder.
P: The patient should start sessions of CBT to help address psychotic symptoms and develop coping skills.
Autism Spectrum disorder
Name: P.P
Age: 11-years
Gender: male
Diagnosis: Autism spectrum disorder
P.P. is an 11-year-old male patient who came to the clinic accompanied by his parents for a follow-up appointment. The patient reports that the patient has been having persistent symptoms such as sensory sensitivities, repetitive behaviors, and challenges with social communication. He exhibits difficulties with transition as well as increased rigidity in routines.
O: The patient is well-dressed and groomed. He is also alert but not oriented. Repetitive behavior, such as repetitive movements, is visible. His speech is echolalic at times, and he tends to repeat phrases. He has intact cognitive functioning and intact memory. No suicidal ideations.
A: The patient’s symptoms show autism spectrum disorder.
P: The patient is to commence CBT sessions to help develop social skills
Insomnia
Name: B.M
Age: 51 years
Gender: male
Diagnosis: Insomnia
B.M. is a 51-year-old male patient who came to the clinic for an assessment. The patient reports problems falling asleep and maintaining sleep. He attributes this problem to increased work-related anxiety and stress. He experiences frequent awakenings during the night as well as early morning awakenings. He experiences other symptoms, such as difficulty concentrating, irritability, and fatigue.
O: The patient is well-dressed and groomed. He is also alert and oriented. He looks tired and exhibits restlessness and anxiety. He has clear speech, a coherent thought process, and an intact memory. He denies suicidal thoughts, actions, or ideation
A: The patient’s symptoms are an indication of insomnia disorder
P: The patient will start CBT focused on restructuring negative thoughts and using strategies that can help him improve sleep efficiency.
Enuresis Disorder
Name: D.D
Age: 10 years old
Gender: Male
Diagnosis: Enuresis Disorder
D.D. is a 10-year-old male patient who came to the facility for a psychiatric visit accompanied by his mother. The mother reports that the patient’s development stages and milestones are intact. However, he has developed a habit of bedwetting at night. As such, he has to put on pull-ups at night, something that the boy hates. He reports embarrassment and sadness due to this condition.
O: The patient is well-dressed and groomed. He is also alert and oriented. His mood is sad. He looks uncomfortable talking about sleep. He has a fluent speech. His thought process and memory are both intact. He denies suicidal thoughts or thoughts of self-harm.
A: The patient’s symptoms are indicative of enuresis disorder
P: The patient needs to start a family therapy session to help identify the underlying factors and equip the patient with coping strategies.
Panic Attack Disorder
Name: T.D
Age: 32 years old
Gender: Male
Diagnosis: Panic Attack Disorder
T.D. is a 32-year-old male patient who visited the facility for a psychiatric check. He has experienced chest pain episodes for some weeks and thinks that it may lead to a heart attack as it had happened to one of his friends. He also expresses sadness, depression, and confusion. He also reports other symptoms, such as pressure sensations, choking, shortness of breath, and anxiety.
O: The patient is appropriately dressed and well-groomed. He is also alert and oriented. He appears anxious and in a sad mood. He exhibits a pressured speech. He has a coherent thought process but is occupied with thoughts of the uncomfortable symptoms. He has an intact memory. The patient denies suicidal thoughts.
A: The patient’s symptoms indicate a panic attack, which leads to chest pain.
P: The patient needs to commence individual psychotherapy sessions to help with the condition.
Nightmare Disorder
Name: K.V
Age: 9 years old
Gender: Male
Diagnosis: Nightmare Disorder
K.V. is a 9-year-old male patient who was brought to the facility with reports sleep complications. The sleep disturbance has been associated with frequent nightmares which has also led to significant emotional distress. The patient’s episodes of nightmare have become more frequent and disturbing. He fears being in the dark alone or sleeping alone.
O: The patient is appropriately dressed and well-groomed. He is alert and oriented. He is fatigued, sleepy, and tired. His speech was clear, and he had a coherent thought process. The patient’s short-term and long-term memory is intact. He denies delusions or hallucinations. He also denies suicidal thoughts.
A: The patient’s symptoms indicate nightmare disorder.
P: The patient is to commence weekly sessions of individual cognitive behavioral therapy to help address the thoughts.
Major Depressive Disorder
Name: T.C
Age: 41 years
Gender: Male
Diagnosis: Major Depressive Disorder
T.C. is a 41-year-old male patient who presents to the facility for an assessment. He reports various symptoms, such as feelings of worthlessness, anhedonia, persistent low mood, and reduced interest in previously enjoyable activities. He also reports recurrent suicidal thoughts, disrupted sleep patterns, and changes in appetite. He has been experiencing these symptoms for the last half a year.
O: The patient looks disheveled and has poor grooming habits. He is also tearful and withdrawn. He is in a depressed mood. His speech is slow, monotonous, and low volume. His thought process is coherent, with intact memory. He exhibits mild impairment in concentration and attention. He reports suicidal thoughts but no action so far.
A: The patient’s symptoms are indicative of major depressive disorder
P: The patient is to start weekly sessions of CBT to help him deal with the symptoms.