PRAC 6665 WEEK 6 CLINICAL HOUR AND PATIENT TIME LOG IN
PRAC 6665 WEEK 6 CLINICAL HOUR AND PATIENT TIME LOG IN
Generalized Anxiety Disorder
Name: T.T
Age: 30 years
Diagnosis: Generalized Anxiety Disorder
S: T.T is a 30-year-old female client that that came to the clinic for her follow-up visit for generalized anxiety disorder. The diagnosis was reached after she presented to the clinic with complaints of excessive fear and anxiety beyond her control. She also reported accompanying symptoms that included palpitations, sweating, and tremors accompanied the feelings of excessive fear. The excessive fear and anxiety had affected significantly her ability to perform optimally in her academic and social roles. The symptoms could not be attributed to any cause such as medications, medical conditions, 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. 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. Cogni
PRAC 6665 WEEK 6 CLINICAL HOUR AND PATIENT TIME LOG IN
tive-behavioral treatment has been effective in symptom improvement.
P: The client was advised to continue with psychotherapy sessions. The treatment will be terminated if the clients report further improvements during the next visit. She was scheduled for a follow-up visit after four weeks.
Persecutory Delusion
Name: A.M
Age: 25 years
Diagnosis: Persecutory Delusion
S: A.M. is a 25-year-old client that came to the unit for follow-up after being diagnosed with persecutory delusion.
PRAC 6665 WEEK 6 CLINICAL HOUR AND PATIENT TIME LOG IN
The diagnosis was reached after the client came with complaints that included the persistent feeling that someone wanted to kill her. The feelings made her suspicious of anybody around her. She also avoided unfamiliar places since she felt that someone was targeting to kill her. The feelings of being haunted had affected significantly her life since she was socially withdrawn. As a result, she was diagnosed with persecutory delusion and initiated on psychotherapy session.
O: The client appeared appropriately dressed for the occasion. Her orientation to space, time, others, and events was intact. She denied recent illusions, delusions, and hallucinations. She also denied any experience of suicidal thoughts, plans, or attempts. Her thought process was future-oriented.
A: Psychotherapy sessions are effective in symptom improvement. The client had developed effective coping skills for the disorder.
P: The client was advised to continue with the psychotherapy sessions. She was scheduled for a follow-up visit after four weeks.
Post-Traumatic Stress Disorder
Name: A.T
Age: 28 years
Diagnosis: Post-traumatic stress disorder
S: A.T. is a 28-year-old client that came to the unit for her regular follow-up visits after she was diagnosed with post-traumatic stress disorder six months ago. The diagnosis was reached after she raised complaints that developed following her involvement in a road accident. She had raised complaints that included frequent recurrence of the distressing memories about the accident. She also reported flashbacks and intense distress following her exposure to stimuli that related to the event. As a result, she avoided any stimuli that related to the traumatic event. The symptoms had a negative effect on the ability of the client to engage in her occupational and family roles. Therefore, she was diagnosed with post-traumatic stress disorder and has been on treatment in the unit.
O: The client was 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 been effective in managing the depressive symptoms of post-traumatic stress disorder.
P: The client was advised to continue with the current treatments. She was scheduled for a follow-up visit after four weeks.
Major Depression
Name: S.S
Age: 33 years
Diagnosis: Major Depression
S: S.S. is a 33-year-old client that came to the unit today for his follow-up visit after being diagnosed with major depression. The diagnosis was reached after he came to the unit with complaints that included persistent feelings of depressed mood and lack of pleasure and interest. He also reported difficulties in concentrating on his social and occupational roles. The additional symptoms included feelings of hopelessness, insomnia, and suicidal thoughts. The symptoms had affected significantly his ability to perform in his social and occupational roles. A further assessment had revealed that the symptoms were not due to a medical condition, medication, or substance use. As a result, he was diagnosed with major depression and initiated on antidepressants and psychotherapy sessions.
O: The client appeared well-groomed for the session. He was alert during the assessment. He reported that his mood had improved significantly following the adopted treatments. He denied illusions, delusions, and hallucinations. His speech rate and volume were intact. He denied any recent experience of suicidal thoughts, attempts, and intentions.
A: The client is responding well to the treatment.
P: The client was advised to continue with the treatments. He was scheduled for a follow-up visit after four weeks.
Major Depression
Name: S.T
Age: 33 years
Diagnosis: Major Depression
S: S.T. is a 33-year-old client that came to the unit for the third follow-up visit after being diagnosed with major depression. The diagnosis was reached after the client raised complaints that included feelings of hopelessness, suicidal thoughts,and depressed mood on most days. The client also reported insomnia, lack of energy, and difficulties in decision-making. The symptoms were not attributable to any medical condition, medication, or substance abuse. They had also affected significantly the client’s ability to perform optimally in his social and occupational roles. As a result, he was diagnosed with major depression and initiated on treatment.
O:The patient appeared dressed appropriately for the occasion. His speech was normal in terms of rate with normal volume. His self-reported mood was improved. The client denied illusions, delusions, and hallucinations. He maintained normal eye contact during the assessment. His thought content was future-oriented. He denied recent suicidal thoughts, plans, or attempts.
A: The symptoms of major depression have improved, translating to treatment effectiveness.
P: The client was advised to continue with the current treatment. He was scheduled for a follow-up visit after four weeks.
Bipolar Disorder
Name: T.R
Age: 40 years
Diagnosis: Bipolar Disorder
S: T.R is a 40-year-old client that came to the unit for her follow-up after she was diagnosed with bipolar disorder. The diagnosis was reached after she came to the unit with complaints of cycling elevated and depressed mood episodes. The symptoms of elevated mood included participating in goal-oriented activities and delusions. The symptoms alternated with those of depressed moods, such as insomnia, feelings of guilt, depressed mood, and lack of energy. The alternation of symptoms lasted for a month. The symptoms had significantly affected the client’s ability to engage in her daily routines. Further assessment ruled out drug use, medical problem, or substance and alcohol abuse as the cause of the problem. As a result, she was diagnosed with bipolar disorder and initiated on treatment.
O: The client appeared appropriately dressed for the occasion. She was oriented to self, place, time, and events. Her judgment was intact. She denied any recent experience of delusions, hallucinations, illusions, suicidal thoughts, plans, and attempts.
A: The adopted treatments are effective. There is an evident improvement in symptoms and tolerance to treatment.
P: The client was advised to continue with the treatments. She was booked for a follow-up visit after four weeks.
Dysthymia
Name: X.T
Age: 43 years
Diagnosis: Dysthymia
S: X.T is a 43-year-old male that came to the unit for his follow-up visit after being diagnosed with dysthymia. The diagnosis was reached after he presented to the unit with complaints that included depressed mood almost everyday, loss of pleasure, weight gain, and insomnia. The client also reported restlessness, loss of energy, and hopelessness. However, the symptoms were less severe than those of major depression were. Based on the above, the client was diagnosed with dysthymia and prescribed antidepressants.
O: The client appeared appropriately dressed for the occasion. His self-reported mood was ‘improved.’ The client’s thoughts were future-oriented. The client’s speech was normal in rate and tone. He denied illusions, delusions, and hallucinations. He also denied suicidal thoughts, attempts, and plans.
A: The treatment is effective in treating the depressive symptoms of dysthymia.
P: The client was advised to continue with the prescribed antidepressants. He was scheduled for a follow-up visit after four weeks.
Panic Disorder
Name: R.A
Age: 34 years
Diagnosis: Panic Disorder
S: R.A is a 34-year-old female that came to the unit for her third follow-up visit after being diagnosed with panic disorder. The diagnosis was reached after she came to the unit with complaintsthat included intense fear of feelings of impending doom. She also raised additional symptoms that included feelings of being choked, sweating, chest pains, nausea, and fear of dying. She also avoided unknown places due to fear of harm to her. The experiences of panic attacks had been experienced for the last two months and had affected significantly her quality of life. Therefore, she was diagnosed with a panic attack and started on group psychotherapy.
O: The client appeared neatly dressed. She was oriented to self, place, time, and events. She reported that her sense of mood had improved since the last visit. Her judgment was intact. Her speech was normal. She denied any history of illusions, delusions, hallucinations, and suicidal thoughts, plans, or attempts.
A: The client is responding well to the treatment.
P: The client was advised to continue with group psychotherapy sessions. She was booked for a follow-up visit after one month.
Insomnia
Name: E.R
Age: 25 years
Diagnosis: Insomnia
S: E.R is a 25-year-old male who came to the clinic for his fifth follow-up visit for insomnia. The diagnosis was reached after he presented to the unit with complaints of difficulties falling asleep. He had also reported finding it hard to maintain sleep. The accompanying symptoms noted during his initial visit included daytime sleeping, reduced energy levels, and productivity in his workplace. The sleep problems had affected his ability to perform optimally in his workplace. A further assessment had revealed that the problem could not be attributed to any medical condition, medication, or substance abuse. As a result, hewas diagnosed with insomnia and initiated on group psychotherapy.
O: The client appeared appropriately dressed for the occasion. His orientation to self, place, time, and events were intact. The self-reported mood of the client was normal. The judgment of the client was intact. He denied any history of delusions, hallucinations, or illusions. He also denied any history of suicidal thoughts, attempts, and plans.
A: The client reported improvements in sleep quality and quantity. Group psychotherapy sessions have been effective in symptom improvement.
P: The client was scheduled for a follow-up visit after four weeks. He was advised to continue with the group psychotherapy sessions. A decision to terminate the treatment will be made should the client report continuous symptom improvement.
Schizophrenia
Name: H.L
Age: 33 years
Diagnosis: Schizophrenia
S: H.L is a 33-year-old female client that came to the unit for her third follow-up visit after being diagnosed with schizophrenia two months ago. The diagnosis was reached after she presented to the unit with complaints that included seeing things and hearing voices. The persistent experience of the symptoms had affected significantly her quality of life and ability to engage optimally in social and occupational roles. A further assessment had revealed that the symptoms could not be attributed to causes such as medication use, substance abuse, and medical conditions. As a result, she was diagnosed with schizophrenia and initiated on treatment.
O: The client appeared well-groomed for the occasion. She was oriented to space, time, events, and self. She denied any recent experience of illusions, delusions, and hallucinations. She also denied suicidal thoughts, attempts, and plans. Her thought content was future-oriented.
A: The adopted treatments are effective in managing the symptoms of schizophrenia.
P: The patient was advised to continue with the current treatments. Shewas scheduled for the next follow-up visit after four weeks.