PRAC 6645 WEEK 7 Clinical Hour and Patient Logs

Sample Answer

Panic Attack Disorder

Name: C.A
Age: 40 years old
Gender: Male
Diagnosis: Panic Attack Disorder

C.A is a forty-year-old male patient who visited the facility for a psychiatric check. He reports episodes of chest pain which has been existing for weeks. As such, he expresses fear of heart attack. He also expresses sadness, depression, and confusion. Other symptoms experienced by the patient include 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 has a sad mood. His speech is pressure. 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.

Binge Eating Disorder

Name: H.C
Age: 15 years old
Gender: Female
Diagnosis: Binge Eating Disorder

H.C. is a fifteen-year-old female patient who visited the clinic seeking psychiatric help. She reports that she is embarrassed with her eating behavior as she eats large amounts of food. She consumes large meals in one sitting and sometimes has the urge to eat even if she is full. She has failed to regulate her behavior even after trying hard. She indicates that the habit may one day make her obese.

• O: The patient is appropriately dressed and well-groomed. She is also alert and oriented. She looks depressed and sad. The indicates that she has low self-esteem as she is always embarrassed. She has a coherent thought process. Her short and long-term memory is intact. She denies suicidal thoughts or ideation.
• A: The patient has developed a habit of eating large meals. Hence, the diagnosis is a binge eating disorder.
• P: The patient needs to have a change in thought patterns. Therefore, she should start family therapy sessions to help understand the family dynamics and get appropriate education and psychoeducation.

Intermittent explosive disorder (IED)

Name: B.T
Age: 38 years old
Gender: Female
Diagnosis: Intermittent explosive disorder (IED)

B.T. is a thirty-eight-year-old female patient who came to the clinic with reports of frequent loss of temper. She also indicates that she has noticed that she has become moody at a particular time every year for some time now. She exhibits other symptoms such as complications keeping friends, sleeping complications, and getting bored more frequently.

• O: The patient is appropriately dressed and well-groomed. She is also alert and oriented in person, place, and time. She is irritable and looks sad. She exhibits a pressured speech. She denies suicidal thoughts or ideas. However, she is positive for delusion. She confirms thoughts of harm to self and others.
• A: The symptoms are indicative of intermittent explosive disorder.
• P: The patients should commence weekly sessions of individual CBT for better thought patterns.

Attention Deficit Hyperactivity Disorder

Name: G.D
Age: 9 years old
Gender: Female
Diagnosis: Attention Deficit Hyperactivity Disorder

G.D. is a 9-year-old female patient who was accompanied to the facility by her parents. They report that she has been exhibiting symptoms that have been a worry to the family. She easily gets distracted, makes mistakes and finds it hard to concentrate. She also gets it difficult to follow instructions and complete her assignments. She has also been disruptive and forget a lot.

• O: The patient is appropriately dressed and groomed. She is also alert and oriented. She looks restless, walks around, and fidgets a lot. She has a coherent thought process and a clear speech. Here memory is also intact. She denies delusions and hallucinations. She also denies suicidal ideations.
• A: Based on the DSM-V criteria, the patient’s symptoms are indicative of ADHD.
• P: The patient needs to start family therapy sessions to help her with the symptoms and thought patterns.

Nightmare Disorder

Name: D.V
Age: 9 years old
Gender: Male
Diagnosis: Nightmare Disorder

D.V. is a 9-year-old male patient who was brought to the facility with reports of undesirable symptoms. He has been experiencing recurring nightmares, which significantly affect his sleep, making him emotionally distressed. The patient’s episodes of nightmare have become more frequent and disturbing.

• O: The patient is appropriately dressed and well-groomed. He is alert and oriented. He is fatigued, sleepy, and tired. His speech is clear and he has 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 symptoms point to nightmare disorder.
• P: There is a need to commence weekly sessions of individual cognitive behavioral therapy.

Bipolar disorder

Name: F.R
Age: 38 years old
Gender: Male
Diagnosis: Bipolar disorder

T.R is a thirty-eight-year-old male patient who came to the clinic seeking psychiatric help. The patient reports mood swings which have worried him for months. He indicates that he sometime experiences periods of intense and low energy. Other symptoms include such as fatigue, hopelessness, sadness, and elation. The patient also reports experiencing other problems, such as complications with concentration, racing thoughts, impulsive behavior, and sleep complications.

• O: The patient is well-groomed and appropriately dressed. He is also alert and oriented. He has a sad mood and he is disturbed by his current symptoms. He finds it difficult to concentrate. He talks more than usual and he has a pressure speech. The thought process is incoherent. He has an intact memory. He denies suicidal thoughts.
• A: The patient’s symptoms show that he has bipolar disorder.
• P: The patient needs to start weekly psychotherapy, especially group therapy sessions to help with get peer support, develop coping strategies and prevent relapses.

Generalized Anxiety Disorder

Name: M.M
Age: 45 years old
Gender: Male
Diagnosis: Generalized Anxiety Disorder

M.M. is a 45 -45-year-old male patient who came to the clinic for a psychiatric evaluation after experiencing excessive anxiety, fear, and worries regarding his family and daily life. The worries have no particular trigger. Other symptoms experienced include muscle tension, sleep problems, irritability, and challenges with concentration. Consequently his daily life and social functioning have been impacted negatively.

• O: The patient is appropriately dressed and well-groomed. He is also alert and oriented. He is bothered by his symptoms. he has pressured speech. He also finds it hard to concentrate. His memory is intact. The thought process is also coherent. Denies any suicidal thoughts or actions.
• A: The patient has been experiencing anxiety symptoms for sometimes. The diagnosis based on the symptoms is generalized anxiety disorder.
• P: The patient needs to start weekly group therapy sessions to help him develop coping strategies and skills.

Post-Traumatic Stress Disorder

Name: M.G
Age: 12 years old
Gender: Male
Diagnosis: Post-Traumatic Stress Disorder

M.G. is a 12-year-old male patient who came to the facility with reports of worrying symptoms after he was involved a recent accident. The patient escaped with no major injuries and was discharged after being treated in the ER. He reports flashbacks, nightmares, and intrusive thoughts regarding the incident. He experiences intense fear and avoidance behaviors. He also has concentration problems.

• O: The patient is well-dressed and groomed. He is also alert and oriented. He is anxious and worried. He struggles to maintain eye contact and finds it hard to concentrate. The patient shows symptoms of irritability. He has an intact memory. The patient has hallucinations. He denies suicidal thoughts or ideations.
• A: the symptoms started following a traumatic experience. Therefore, the diagnosis is PTSD.
• P: The patient needs to start weekly sessions of trauma-focused family therapy session to help with the symptoms, help family members understand the patient better, improve communication skills and understand the triggers.

Premenstrual Dysphoric Disorder

Name: N.T
Age: 20 years old
Gender: Female
Diagnosis: Premenstrual Dysphoric Disorder

N.T is a 20-year-old female patient who came to the clinic for a psychiatric visit. She indicates that she has been having recurring severe mood disturbances and physical discomfort days prior her menstrual periods. She indicates that she experiences symptoms such as hopelessness, feelings of sadness, intense mood swings, and irritability. She also reports other symptoms, such as worry, restlessness, and racing thoughts. She also experiences physical symptoms during such times including breast tenderness, bloating, and fatigue.

• O: The patient is well-groomed and appropriately dressed. She is also alert and oriented. She is in a sad mood and worried about her symptoms. Her long-term and short term memory are intact. She has a coherent thought process.. The patient denies suicidal ideations or ideation.
• A: The patient symptoms point to premenstrual dysphoric disorder.
• P: The patient should start sessions of group therapy sessions to help with the symptoms and share experiences with peers.

Insomnia

Name: S.U
Age: 43 years old
Gender: Female
Diagnosis: Insomnia

S.U is a 43-year-old female patient who visited the facility with a complaint of lack of sleep for the past few months. She gets is hard to fall asleep and maintain sleep. She usually wakes up from sleep at night and often fails to fall a sleep again. Therefore, her social functioning is greatly impacted. She reports that she strongly believes that she can get help from the facility. This lack of sleep is not connected with any substance use or abuse.

• O: The patient is well-dressed. She is also oriented to self, space, and time. She looked tired and fatigued, due to lack of enough sleep at night. The short-term or long-term memory is intact. She has a coherent thought process. She denied suicidal thoughts or actions.
• A: According to DSM-5 criteria, this patient was diagnosed with insomnia
• P: The patient should start sessions of family therapy session for insomnia to help with the thought patterns, improve sleeping conditions and address sleep deterrents.

Schizophrenia Spectrum and Other Psychotic Disorders

Name: Z.N
Age: 55 years old
Gender: Female
Diagnosis: Schizophrenia Spectrum and Other Psychotic Disorders

Z.N. is a 55-year old female patient who came to the facility accompanied by her partner. The patient claims that there are people who usually watch her outside the house with the intention of causing harm to them. She also hears voices at night. The partner confesses that she has never seen such people nor heard strange voices.

• O: The patient is appropriately dressed. She is also alert and oriented. She is delusive and reports seeing a bird in the room. He finds it hard to maintain eye contact and continually gazes in the room. She is positive for hallucinations and delusions. She has a disorganized thought process. She denies suicidal thoughts or behaviors
• A: based on the DSM-5 criteria, the patient’s symptoms are indicative of schizophrenia spectrum and other psychotic disorders.
• P: The patient should start weekly individual CBT sessions to help the patient identify and challenge the distorted beliefs and thought patterns.

Enuresis Disorder

Name: R.C
Age: 10 years old
Gender: Male
Diagnosis: Enuresis Disorder

R.C. is a 10-year-old male patient who came to the facility for a psychiatric visit. The parents indicate that the boy has all his development stages and milestones intact. He has been bedwetting for sometime. As such, he has to put on pull-ups at night, which he doesn’t like. He usually feels embarrassed due to his behavior.

• 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 point to nocturnal enuresis disorder
• P: The patient needs to start family therapy session to help identify the underlying factors and equip the patient with coping strategies.