PRAC 6635 WEEK 4 Clinical Hour and Patient Logs

Sample Answer

1. Schizophrenia

S L.K. is a 22-year-old female who presented with auditory hallucinations. She reports she has had these symptoms for the last nine months. She also reports people are wanting to kill her by poisoning her. She has had bizarre thoughts and constantly creates new words. Additionally, she has abnormal behavior, exhibits anhedonia, and is socially withdrawn. She reports she no longer feels the need to wake up and go to her classes and work.

• O: Patient is alert, disoriented, agitated, and poorly groomed. She shows apathy and a flat affect. She has an incoherent thought process, uses neologisms and word salad, and has persecutory delusions. Auditory hallucinations, concrete thinking, and gaps in memory are present, and she lacks insight.
• A: Neurocognitive disorder noted with the presence of hallucinations and delusions.
• P: initiate cognitive-behavioral therapy, interpersonal, occupational, and family therapy.

2. Depression

S A.W. is a 30-year-old male who reports he has had a relapse of a constantly low depressed mood for the last month. He reports a significant appetite increase and has gained over 15 pounds. Additionally, he reports feeling fatigued most of the day and sleeps more than 12 hours. He also says he is experiencing anhedonia, feels worthless and is unable to go to work.

• O: Patient is alert, oriented, and well-groomed. He has a depressed mood, coherent thought, good judgement and insight. There are no hallucinations or delusions.
• A: The patient has a relapse of depressive episodes and is concerned about how the symptoms are impacting his life.
• P: Intensify cognitive-behavioral therapy, interpersonal and occupational therapy.

3. Bipolar Mood Disorder

S P.L. is a 26-year-old male who presents with excessive talking, sings out loudly, and often changes the subject topic. He reports that God has chosen him to restore people’s faith and save them from the sins they have committed. He reports sleeping for two hours and feels the need to move around different places to preach. He has been involved in destructive personal property and furniture during this period and has not reported to work.

• O: Patient is alert, oriented, inappropriately groomed, and anxious. He has an elated and expansive mood with a grandiose delusion. He has pressure of speech, flight of ideas, and circumstantiality. He has good judgment, partial insight, and no hallucinations.
• A: Manic episode characterized by pressure of speech, flight of ideas, and grandiose delusion.
• P: Initiate cognitive-behavioral therapy, family and occupational therapy.

4. Alcohol Use Disorder

S G.L. is a 32-year-old female in a halfway house after a successful detox. She reportsthat she started taking alcohol seven years ago, and during that period, she has increased the amount she takes and is unable to control her intake. She reports wanting to cut down but is unable to due to intense cravings and withdrawal symptoms such as shivering and vomiting. She says that she continued taking alcohol despite losing her job as well as children’s custody. She states she needs to recover to at least see her children and get a source of income.

• O: Patient was alert, oriented, relaxed, and well-groomed. The patient had coherent thoughts and no hallucinations or delusions. The patient has good judgment and insight.
• A: There was marked improvement after treatment, and the patient denies having any alcohol cravings.
• P: Continue with motivational-enhanced, cognitive-behavioral, and family and occupational therapy.

5. Illness Anxiety Disorder

S B.W. is a 42-year-old female who presented, fearing she might have breast cancer after experiencing mild pain around her breast. She reports that in the last 11 years, she has been on high alert about her health after her mother, aunt, and sister succumbed to breast cancer. She reports performing a breast examination daily and visits two or more hospitals when she feels or sees anything abnormal on her breast. She says she has spent a lot of money on consultations and tests. She reports she fears having the disease as she is going to die.

• O: Patient is alert, oriented, agitated, and well-groomed. She is irritable but has a coherent thought process. Hallucinations and delusions are absent.
• A: The patient is in constant worry of breast cancer and is aware of the breast cancer symptoms.
• P: Initiate mindfulness-based cognitive therapy, group therapies, and acceptance and commitment therapy

6. Delirium

S P.Y. is a 48-year-old female who is on her second day after an abdominal surgery and woke up confused and disoriented. She has a poor memory of recent events, difficulty talking and recalling words, says incomprehensible words and does not understand when spoken to. In addition, she is easily distracted, withdrawn, inattentive, irritable, and restless.

• O: Patient is confused, disoriented, and agitated. She has incoherent thoughts, poor recent memory and judgment, and is irritable but has no hallucinations or delusions.
• A: Confusion, disorientation, and memory loss have been noted in this patient after her surgery.
• P: Initiate cognitive-stimulation and reminiscence therapy

7. Adjustment Disorder

S R.K. is a 19-year-old male who presented with excessive sadness and stress two weeks after joining college. He reports this is the first time he has been away from family and friends since he was born. He reports feeling hopeless, anxious, withdrawn, and irritable. Additionally, he says he no longer enjoys things he used to enjoy and has difficulty sleeping, doing daily activities, and concentrating. He says he feels like quitting school to go back home.

• O: Patient is alert, oriented, well-groomed, and anxious. He is irritable and depressed but has a coherent thought process and no hallucinations or delusions.
• A: The patient has difficulty adjusting to his new environment, resulting in sadness and anxiety.
• P: Initiate cognitive-behavioral therapy, interpersonal therapy, and problem-solving therapy.

8. Disruptive Mood Dysregulation Disorder

S S.L. is a 7-year-old male brought to the clinic by his mother after he threw a glass towards her after being reprimanded. The mother says that she noticed the son having severe temper outbursts since he was four years old that are more intense and last longer for the situation, which are inappropriate for his age. She reports that the son is angry most days. His symptoms have affected his school as he is often irritable and has engaged in verbal and violent outbursts.

• O: The child is alert, easily distracted, fidgety, and irritable. He is anxious and appears disturbed by the new environment. He has several anger outbursts characterized by tantrums.
• A: Severe anger outbursts and irritability with failure to cope in different environments.
• P: Cognitive behavioral therapy, Dialectical behavior therapy for children, and Parent, family and social training.

9. Generalized Anxiety Disorder

S K.P. is a 28-year-old female who reports experiencing excessive worry about her upcoming wedding. She reports she has been fearing that she might be stood up during her wedding despite several reassurances from her boyfriend. Additionally, she fears several things might go wrong on that day, such as the weather, the décor, catering, the dance, and the priest. She adds that she feels she might not be able to meet her boyfriend’s expectations of her as a wife. She reports that the thoughts have made it difficult for her to sleep and concentrate on her daily activities, worsening her anxiety,

• O: Patient is alert, oriented, and anxious. She is irritable but with coherent thought, intact memory, and judgement.
• A: The patient is experiencing generalized anxiety coupled with insomnia.
• P: Initiate cognitive-behavioral therapy.

10. Insomnia

S P.T. is a 25-year-old female who reports that she has been having trouble sleeping at night, resulting in chronic fatigue. She reports having these symptoms for the last three months and denies taking a lot of caffeine. She reports she often sleeps late at night after having difficulties sleeping, wakes up three to four hours later, and has difficulties going back to sleep later. As a result, she feels fatigued, anxious, and irritable, has difficulties concentrating, and constantly worries about her sleep pattern.

• O: Patient is alert, oriented, and anxious. She has a coherent thought process and lacks hallucinations and delusions.
• A: The patient has insomnia, causing her to be in severe anxiety.
• P: Initiate cognitive-behavioral therapy and sleep therapy.

11. Autism

S R.L. is a four-year-old girl who was brought to the clinic when the mother noticed he does not respond to her name when called and no longer speaks as he used to before. She reports she has noticed her daughter has progressively become withdrawn as she plays alone, does not engage in imitative play, and lacks eye contact and facial expression. Additionally, she reports the daughter cannot start a conversation or keep one going, keeps repeating words and phrases, fails to understand simple directions, and has recently had specific food preferences. She reports that the daughter has been engaging in harmful behavior such as head banging, shows repetitive movements, and is often irritated when her normal routine is interrupted.

• O: The child is alert and agitated and shows mutism and blunted affect. She is hyper-vigilant and has repetitive movements. She only interacts with the mother.
• A: The child is experiencing challenges in communication and social interactions.
• P: Initiate cognitive-behavioral therapy and family therapy.

12. Separation Anxiety Disorder

S F.H. is a nine-year-old female who wasbrought to the clinic by her father after he noticed she regularly has excessive distress whenever he is about to leave or leaves for a work trip. He reports that the daughter had often told him not to leave as she feared he would die, just like the mother did when she was away on a work trip. Additionally, he reports that when he is gone, the daughter has trouble sleeping, has constant nightmares, and fails to go to school despite having a nanny around.

• O: The child is alert, oriented, and relaxed. She has a coherent thought process and exhibits a trance when asked about her mother.
• A: Severe distress when separation is anticipated or when it occurs.
• P: Initiate cognitive-behavioral therapy and family therapy.