PRAC 6635 WEEK 5 Clinical Hour and Patient Logs

Sample Answer

1. Bipolar mood disorder

S O.G. is a 24-year-old who presented with unusually excessive loud talking accompanied by rapidly changing topics. He reports having the symptoms for the last two weeks. He says he has been sleeping for less than three hours and feels an excessive need to be on the move. He reports having broken several household utensils and other people’s property. He says that in the last two weeks, he has been gambling more than he is used to.

• O: Patient is alert, disoriented, agitated, and inappropriately groomed. He has flight of ideas, pressure of speech, circumstantiality, and an elevated and expansive mood. His memory is intact, with partial insight.
• A: The patient is experiencing a manic episode accompanied by insomnia and impulsivity.
• P: Initiate cognitive-behavioral therapy and interpersonal therapy.

2. Schizophrenia

S A.J. is a 32-year-old female who presented with a recurrence of auditory and visual hallucinations that have lasted more than a month. However, she reports antipsychotic medication noncompliance as they made her gain weight. She reports that she has been feeling very important in the last month as she can directly communicate with God. She also reports having abnormal thoughts and disorganized behavior. She reports she has been experiencing anhedonia, is socially withdrawn, and lacks the willpower to go to work.

• O: Patient is alert, disoriented, agitated, and inappropriately groomed. She is irritable with a blunted affect. She has incoherent thought, poverty of speech, perseverance, hallucinations, and grandiose delusions. She has poor memory, judgment, and insight.
• A: The patient has a recurrence of psychotic symptoms due to medication noncompliance.
• P: Reinforce cognitive-behavioral therapy, interpersonal therapy, and occupational therapy.

3. Brief Psychotic Episode

S L.P. is a 17-year-old femalewho presented to the clinic with auditory and visual hallucinations. She reports having the symptoms for the last 17 days. She reports feeling that her teacher is in love with her. Additionally, she has been having disorganized speech and thought and abnormal behavior. She reports having a six-month history of cannabis use.

• O: Patient is alert, disoriented, agitated, and poorly groomed. She is irritable and with a blunted affect. She has incoherent thought, perseverance, poverty of speech, erotomanic delusions, and hallucinations. She has gaps in her memory and poor memory and judgment.
• A: Psychotic episode with hallucinations and delusions due to cannabis use
• P: Initiate cognitive-behavioral therapy and interpersonal therapy.

4. Depression

S L.N. is a 34-year-old male who presented with a sad and depressed mood for the last two months after separating from his wife. He reports sleeping most of the day, has a reduced appetite, and has lost about 10 pounds. He reports having unusual excessive fatigue, has anhedonia, and has trouble concentrating and making decisions. Additionally, he has noticed he cannot remember some crucial details and has failed to report to his work during this period. He reports feeling guilty after the separation but has not had any suicidal ideations.

• O: Patient is alert, oriented, relaxed, and well-groomed. He has a depressed mood, coherent thoughts with some thought block, and no delusions or hallucinations. He has gaps in his memory but with good judgment and insight.
• A: The patient feels guilty after separating from his wife and is in a constant low mood.
• P: Initiate cognitive behavioral and interpersonal, family, and occupational therapy.

5. Dementia

S I.P. is a 72-year-old male who is brought to the clinic by his wife after she noticed he has been having worsening memory loss for the last year. She reports that the husband has had a 15-year history of hypertension. She reports that he has been experiencing problems communicating, finding words, and recalling people and town names during this period. She reports he has been struggling with planning, performing complex tasks, and solving previously easy problems. She reports he has been getting lost easily and confuses the rooms in their own home. She reports she has noticed he has been getting confused, does not know the time and dates, is anxious, and is easily paranoid.

• O: Patient is alert, well-groomed, agitated, and disoriented. He has an irritable mood and incoherent thoughts with derailment but no hallucinations or delusions. He has short-term and long-term memory loss and poor judgment.
• A: Neurocognitive disorder with amnesia noted.
• P: Initiate cognitive-stimulation therapy and reminiscence therapy.

6. Illness Anxiety Disorder

S S.K. is a 45-year-old female who came in for a consultation for fear of having diabetes. She reports having gestational diabetes in her last pregnancy with a positive family history of diabetes. She reports that she fears having diabetes as her mother is currently on dialysis due to diabetic renal complications. She reports that since her last pregnancy five years ago, she self-tests daily, has visited the hospital monthly and fails to get adequate reassurance from the doctors and a normal blood sugar test. She reports on several occasions, she has used non-prescribed insulin for self-reassurance.

• O: Patient is alert, oriented, anxious, and well-groomed. She has a coherent thought process, good judgment and insight, but with no hallucinations and delusions.
• A: The patient is constantly worried about getting diabetes and needs reassurance.
• P: Initiate mindfulness-based cognitive therapy and acceptance and commitment therapy

7. Substance-Use Disorder

S P.N. is a 32-year-old male who is currently on detox following heroin use. He reports that he has been using heroin for the last six years, and during this period, he has increased the amount he takes gradually. He reports that the increased use is due to excessive cravings and tolerance. He reports that he has been needing the drug to allow him to get enough energy to perform an activity. Additionally, he reports that the use has made him lose friends and relationships, fail to concentrate on his work and steal to maintain a constant supply. He reports he has had withdrawal symptoms whenever he tries to stop using the drug, making him fail to stop using. He feels he needs the treatment to get his life together and maintain a constant income.

• O: Patient is alert, oriented, relaxed, and well-groomed. He has a coherent thought process and no hallucinations or delusions. Her memory and judgment are intact.
• A: There has been marked improvement after initiation of treatment, and the patient is willing to be on treatment.
• P: Initiate cognitive-behavioral, family, group, interpersonal and occupational therapy.

8. Generalized Anxiety Disorder

S B.K. is a 26-year-old female who presented with increased restlessness and persistent worrying over her upcoming engineering examinations. She is an excellent student and fears that she may fail in her final examinations. She reports that recently, she has been overthinking plans and creating solutions if she fails. Additionally, she has been anxious about whether she is ready to become an engineer and cannot set the worry aside. She reports she has been having difficulties concentrating and sleeping, further worsening her anxiety.

• O: Patient is alert, oriented, relaxed, and well-groomed. She is anxious, has coherent thoughts, no hallucinations or delusions, and has an intact memory.
• A: The patient is experiencing generalized anxiety coupled with insomnia and difficulty concentrating.
• P: Initiate cognitive-behavioral therapy and interpersonal therapy.

9. Separation Anxiety Disorder

S G.K. is a nine-year-old male who the mother brought in after she noticed he has been having excessive distress whenever she wants to leave the house to go to work. She reports that the son has been having these symptoms ever since she was admitted to the hospital after having a work-related accident. She reports that the son always has nightmares about separation, and he fears that something terrible will happen to the mother while at work. She reports that he has difficulty sleeping whenever she is not at home and is always restless at school.

• O: Patient is alert, oriented, and restless. He has coherent thoughts, is hyper-vigilant, and is irritable whenever the mother shifts her posture.
• A: Severe distress when separation is anticipated or when it occurs.
• P: Initiate cognitive-behavioral therapy and family and reassurance therapy.

10. Post-Traumatic Stress Disorder

S T.M. is a 22-year-old male who witnessed a gang shooting two months ago while he was walking home at night. He reports that since the incident, he has been having recurrent memories, flashbacks, and nightmares about the event. He reports he is often agitated whenever he walks along the same street at night and often uses another longer route to get home. He reports that recently, he is easily startled, hyper-vigilant, and has had trouble sleeping and concentrating.

• O: Patient is alert, oriented, hyper-vigilant, and well-groomed. He has a coherent thought process and intact memory but no hallucinations or delusions.
• A: The patient is hyper-vigilant and exhibits trance whenever the topic arises.
• P: Initiate trauma-focused cognitive behavioral therapy, cognitive processing therapy, and imaginal exposure.

11. Autism

S Z.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 has speech regression. Additionally, she reports the daughter cannot initiate a conversation as she previously would and keeps repeating the exact words, often misusing them. She reports she has noticed her daughter has progressively become withdrawn, lacks eye contact and facial expression, and fails to express emotion. She reports that he seems not to understand simple directions, shows hand flapping, is clumsy, and has recently had specific food preferences.

• O: Patient is alert, shows mutism, and is hyper-vigilant. She does not demonstrate eye contact and has a flat affect. She does not respond when spoken to and is unable to coordinate activities.
• A: The child is experiencing difficulties in communication and social interaction.
• P: Initiate cognitive-behavioral therapy and social and family therapy.

12. Attention-Deficit Hyperactive Disorder

S O.L. is a five-year-old male who was brought by his mother after she noticed constant inattention and impulsivity. She reports that the son has had trouble remaining focused on tasks, has difficulty following simple instructions, appears not to listen when spoken to, and has trouble organizing his tasks. She reports that the son often fidgets while seated, is constantly distracted, often makes sudden and unanticipated runs, speaks a lot, and cannot wait for his turn.

• O: The child is alert, agitated, and fidgets on the seat. He keeps running up and down the room, fails to complete a task, and interrupts the mother repetitively during the whole session.
• A: The child exhibits hyperactivity, distractibility, and a reduced attention span.
• P: Initiate family and social psychotherapy and cognitive-behavioral therapy.