PRAC 6665 WEEK 4 10 CLINICAL/PATIENT LOG IN
PRAC 6665 WEEK 4 10 CLINICAL/PATIENT LOG IN
Generalized Anxiety Disorder
Name: D.D
Age: 33 years
Diagnosis: Generalized anxiety disorder
S: D.D is a 33-year old female client that came to the unit for a fourth follow-up visit after being diagnosed with generalized anxiety disorder five months ago. The diagnosis was reached after she came with complaints that included excessive worry and anxiety about unknown outcomes in her family and workplace. The feelings of excessive fear and worry were beyond her control. The accompanying symptoms that the client reported included chest pain, shortness of breath, tremors, and sweating. The symptoms could not be attributedto causes such as medication use, substance abuse, and medical condition. As a result, she was diagnosed with generalized anxiety disorder and initiated group psychotherapy.
O: The client appeared well-groomed for the occasion. She was oriented to self, others, time, and events. She was alert during the assessment. She denied illusions, delusions, and hallucinations. She also denied suicidal thoughts, attempts, and plans.
A: The psychotherapy treatment has been effective. The client reports sustained improvement in symptoms. She has also identified effective coping mechanisms.
PRAC 6665 WEEK 4 10 CLINICAL PATIENT LOG IN
P: The client was advised to continue with the current treatment. Should the client report sustained symptom improvement during the next visit, a decision to terminate the treatment will be made.
Panic Disorder
Name: J.J
Age: 25 years old
Diagnosis: Panic Disorder
S: J.J. is a 25-year-old client that came for his fourth visit to the unit after being diagnosed with panic disorder three months ago. The diagnosis was reached after the client presented with symptoms that included experiencing unexpected panic attacks with no trigger. He also reported rapid onset of extreme fear with accompanying symptoms such as sweating, palpitations, trembling, and breathlessness. He expressed fear of further attacks and engaged in avoidance behaviors. A further assessment demonstrated that the symptoms could not be attributed to causes such as medication use, medical condition, or substance abuse. As a result, he was diagnosed with panic disorder and initiated on psychotherapy sessions.
O: The client appeared well-groomed for the occasion. His orientation to self, others, events, and time were intact.
PRAC 6665 WEEK 4 10 CLINICALPATIENT LOG IN
His mood was normal. Thought content and process were intact. He denied illusions, delusions, and hallucinations. Healso denied suicidal thoughts, plans, and attempts.
A:The desired sustained improvements in symptoms of panic disorder have been achieved. The client reports consistent use of coping strategies in managing distressing symptoms of the disorder.
P: The client’s participation in psychotherapy sessions was terminated. The treatment outcomes had been achieved. He was informed to visit the unit should he experience symptom recurrence.
Obsessive-Compulsive Disorder
Name: X.T
Age: 28 years
Diagnosis: Obsessive-compulsive disorder
S: X.T is a 28-year-old female who came to the clinic for her second follow-up visit after being diagnosed with obsessive-compulsive disorder. The diagnosis was reached after she presented with complaints that included frequent experiences of persistent and recurrent intrusive and unwanted urges. The symptoms were associated with considerable anxiety and distress. She reported difficultiesinsuppressing the unwanted thoughts and urges using diversion behaviors to neutralize them. The compulsive behaviors included frequent hand washing and checking, which are time-consuming. The client noted that the symptoms had affected her social and occupational functioning. The symptoms could not be attributed to other causes such as medication, medication, substance abuse, or medical condition. Therefore, she was diagnosed with obsessive-compulsive disorder and initiated on psychotherapy.
O: The client appeared well-groomed for the occasion. The orientation of the client to self, others, events, and time were intact. The mood of the client was normal. Thought content and process were intact. She denied illusions, delusions, and hallucinations. She also denied suicidal thoughts, plans, and attempts. Her speech was of normal rate and volume.
A: There has been improvement in the symptoms of obsessive-compulsive disorder.
P: The client was advised to continue with psychotherapy sessions.She was scheduled fora follow-up after one month.
Binge Eating Disorder
Name: R.T
Age: 20 years
Diagnosis: Binge eating disorder
S: R.T is a 2o-year old female client that came to the unit for her fifth follow-up visit. She was diagnosed with binge eating disorder six months ago and has been on psychotherapy. The diagnosis was reached after she presented with complaints that included abnormal eating habits. She reported eating a large amount of abnormal food for her age. The client reported being unable to control her eating habits. As a result, she was worried that it might harmher health. The eating habits had also affected her self-esteem, as she was embarrassed to eat in the presence of others. Based on the above, R.Twas diagnosed with binge eating disorder and initiated on individual psychotherapy.
O: R.T appeared appropriately dressed for the occasion. She was oriented to self, place, time, and events. She denied any history of illusions, delusions, or hallucinations. Her self-identity was improved. She denied suicidal thoughts, attempts, and plans.
A: Psychotherapy sessions have been effective. The desired treatment objectives have been achieved. The client reports that she now has control over her abnormal eating habits.
P: The individual psychotherapy sessions were terminated with the client’s consent. She was scheduled for a follow-up visit after two months.
Post-Traumatic Stress Disorder
Name: A.B
Age: 28 years
Diagnosis: Post-traumatic stress disorder
S: A.B is a 28-year-old client that came to the unit for her first follow-up visit after being diagnosed with post-traumatic stress disorder two months ago. The diagnosis was reached after she started experiencing abnormal symptoms following her involvement in a road accident. She had raised complaints that included the persistent recurrence of the distressing memories about the accident. She also reported flashbacks and intense distress following her exposure to stimuli related to the event. As a result, she demonstrated avoidance behaviors towards any stimuli related to the traumatic event. A.B. was worried that the symptoms had affected her ability to engage in occupational and family roles. As a result, she was diagnosed with post-traumatic stress disorder and has been on treatment in the unit.
O: The client was appeared dressed appropriately for the occasion. She was oriented to self, others, time, and events. Her judgment was intact. She denied illusions, delusions, and hallucinations. She also denied suicidal thoughts, attempts, and plans.
A: The adopted treatment interventions have effectively managed the depressive symptoms of post-traumatic stress disorder. The client reports improved tolerability to the treatment.
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: K.K
Age: 50 years
Diagnosis: Substance abuse disorder
S: K.K. is a 50-year-old male that came today to the clinic for his fifth follow-up visit after being diagnosed with substance abuse disorder. The diagnosis was reached after he came to the unit with complaints of binge alcohol consumption. The client reported that his alcohol consumption habits were worsening daily. He increased the amount of alcohol consumed regularly to get his desired level of intoxication. He also engaged in selling family properties and stealing to get money for purchasing alcohol. The client had enrolled in an Alcohol Anonymous group to overcome his addiction problem. However, he was unsuccessful due to the effects of withdrawal symptoms. Alcohol abuse had also affected his social and occupational functioning. As a result, he came to the unit for assistance, where 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 an altered thought process. He also denied illusions, delusions, and hallucinations. The client denied suicidal thoughts, plans, and attempts. He demonstrated mild tremors during the assessment.
A: There have been moderate improvements in symptoms compared to the last visits.
The client also tolerates the prescribed medications.
P: The client was advised to continue with the current treatments. He was also initiated on Alcohol Anonymous group. He was scheduled for a follow-up visit after four weeks.
Insomnia
Name: M.S
Age: 32 years
Diagnosis: Insomnia
S: M.S. is a 32-year-old male that came to the clinic for his firth visit for insomnia. The diagnosis of insomnia was reachedafter he presented to the unit with complaints of poor quality and quantity of sleep. He reported a chronic lack of sleep for six months before the visit to the hospital. He also reported other complaints that included remaining awakened throughout most nights and some awakening, making it difficult for him to fall asleep after that. The sleep problem had affected his productivity in the workplace since he often fell asleep during the afternoon hours. The symptoms could be not be attributed to medication use, medical condition, or substance abuse. As a result, 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.
A: The psychotherapy treatment has been effective. The desired treatment objectives have been achieved.
P: The client’s participation in psychotherapy sessions was terminated. The treatment goals had been achieved.
Major Depression
Name: J.O
Age: 43
Diagnosis: Major Depression
S: J.O is a 43-year-old client that came to the psychiatric department for her follow-up visit for major depression. She was diagnosed with the disorder three months ago after presenting with complaints that included persistent feelings of guilt and worthlessness. She also reported having a severely depressed mood for most of the days. She also complained of the lack of energy to engage in her activities of daily living and professional work. She also had difficulties concentrating and making decisions and insomnia for the last two months before the first hospital visit. She could not attribute the symptoms to a medical condition, medicines, or substance abuse. As a result, she was diagnosed with major depression and initiated on treatment.
O: The client was dressed appropriately for the occasion. Her orientation to self, others, time, and events were intact. Her self-reported was normal. Her speech was normal in terms of rate and volume. She denied illusions, delusions, and hallucinations. She also denied suicidal thoughts, attempts, and plans.
A: The client is responding well to the treatment. The symptoms of major depression have improved.
P: The client was advised to continue with current treatments. She was scheduled for a follow-up visit after four weeks.
Major Depression
Name: T.R
Age: 38 years old
Diagnosis: Major depression
S: T.R is a 38-year-old female client that came to the unit for her seventh follow-up visit for major depression. She was diagnosed with the disorder eight months ago and has been on treatment. The diagnosis was reached after she presented with complaints that included feelings of sadness most of the days almost all the days, worthlessness, and guilt most of the time. There were also complaints of a decline in her appetite and becoming withdrawn. Her interest in pleasure also declined significantly. The symptoms had significantly affected her ability to perform optimally in her social roles. A further assessment demonstrated that the symptoms could not be attributed to other causes such as medication use, medical conditions, or substance abuse. Therefore, she was diagnosed with major depression and 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, illusions, delusions,or hallucinations. Her mood self-reported mood was “normal.”
A: The client has responded well to the treatments. Her mood has improved as per the developed treatment plan.
P: Psychotherapy sessions were terminated with consent from the client. She was advised to continue with antidepressant therapy. She was scheduled for a follow-up visit after two months.
Schizophrenia
Name: O.J
Age: 36 years
Diagnosis: Schizophrenia
S: O.J. is a 36-year-old male client that came to the unit for his third follow-up visit. He was diagnosed with schizophrenia four months ago. The diagnosis was reached after he raised complaints that included seeing imaginary things and hearing voices. The symptoms had adversely affected his level of social and occupational functioning. A further assessment revealed that the symptoms had persisted for more than six months. The symptoms could not be attributed to causes such as medication use, substance abuse, and medical conditions. As a result, he was diagnosed with schizophrenia and initiated on treatment.
O: The client appeared well dressed for the occasion. He was oriented to space, time, events, and self. He denied any recent experience of illusions, delusions, and hallucinations. He also denied suicidal thoughts, attempts, and plans. His thought content was future-oriented. His speech was of normal rate and volume.
A: The adopted treatments are effective in managing the symptoms of schizophrenia.
P: The patient was advised to continue with the current treatments. He was scheduled for the next follow-up visit after four weeks.