PRAC 6635 WEEK 6 Clinical Hour and Patient Logs

Sample Answer

1. Major Depression

S P.L is a 43-year-old male who presented to the hospital with a history of depressed mood characterized by sadness and hopelessness for the last two months with suicidal ideations. He also reports an increased appetite and gaining over 30 pounds. Additionally, he reported feeling fatigued and sleeping a lot during most days. He also says that he has been experiencing anhedonia and has trouble concentrating and making decisions.

• O: He is well-kept and relaxed. He reports of a sad mood. He has a coherent thought process but has suicidal ideations. His memory is intact, and no hallucinations or delusions were noted. He is well-oriented and has good judgment and insight.
• A: The client recognizes he needs help to alleviate his symptoms.
• P: Zoloft 50 mg oral OD.

2. Bipolar Mood Disorder

S P.K is a 37-year-old female who presented to the hospital with an unusual increased talking accompanied by racing thoughts. She was agitated, easily distracted, and had a grandiose delusion. During the period of the episodes, she has been sleeping for less than three hours and has been engaging in destructive and high-risk behavior.

• O: The client was alert and oriented. She was inappropriately dressed in the weather and was easily distracted during the interview. She reports having an elated and expansive mood. Additionally, she has a flight of ideas, pressure of speech, and a grandiose delusion. He has no hallucinations, and his memory is intact.
• A: Manic symptoms noted with easy distractibility. Flight of ideas, pressure of speech, and grandiose delusions were noted.
• P: Lithium 1000 mg PO TDS.

3. Schizophrenia

S S.L. is a 45-year-old male who presented with auditory and visual hallucinations, persecutory delusions, disorganized thought, and abnormal motor behavior. He has had the above symptoms for the last eight months before this visit. He also has bizarre behaviors and talks incompressible words. In addition, he cannot function normally and has lost interest in daily activities.

• O: He is poorly groomed and is agitated with minimal eye contact. He has an apathetic mood with a flat affect. He has looseness of association, perseveration, neologisms, and poverty of speech. Auditory and visual hallucinations and persecutory delusions were present. He has gaps in his memory with concrete thinking.
• A: Neurocognitive disorder noted.
• P: Risperidone 2 mg PO OD.

4. Brief Psychotic Disorder

S S.P is a 36-year-old woman who presented with auditory and visual hallucinations that had only been there for the last 12 days. She has also had a delusional memory with abnormal thoughts and bizarre behavior. This is her first episode, but she reports having used cannabis for the last six months.

• O: She is inappropriately dressed, distracted, and anxious. She is alert but disoriented. She has an irritable mood and a labile affect. She is experiencing looseness of association, incoherent thoughts, and circumstantiality. She also has auditory and visual hallucinations and a delusional memory.
• A: The client is experiencing delusional memory with bizarre behavior.
• P: Risperidone 2 mg PO OD.

5. Alcohol-Use Disorder

S B.N is a 45-year-old male on his 10th day at the rehabilitation center for detox. He presented with a five-year history of alcohol use. He reported that during this period, he had increased the amount of alcohol intake due to an increased tolerance and craving. Additionally, he has been spending a lot of time drinking, making him fail in his significant obligations at work and home. He reports wanting to cut down on how much he drinks and has been unsuccessful due to withdrawal symptoms such as hallucinations and seizures.

• O: The client is alert and relaxed and maintains rapport during the session. He has a coherent thought and is hopeful about the future. He has no hallucinations or delusions, and his memory is intact, with sound judgment.
• A: The patient is improving and is determined to ensure he recovers.
• P: Naltrexone start at 25 mg/day for 7 days, and then increase to target 50 mg/day.

6. Post-Partum Depression

S C.P is a 24-year-old female who presented with a depressed mood a month after delivering a premature infant. She reports she has been crying a lot, withdrawing from family and friends, and losing interest and pleasure in activities she used to enjoy. In addition, she has lost her appetite, is experiencing insomnia, and is unable to make decisions. She is also experiencing guilt and feels incapable of taking care of her child.

• O: She is alert, inappropriately groomed, and disoriented. She reports a depressed mood and grief. Her thought process is coherent, with no hallucinations or delusions. She has lost her short-term memory.
• A: Insomnia, anhedonia, with difficulty coping with the present stressor of caring for a premature child.
• P: Zoloft 50 mg oral OD.

7. Dementia

S Z.P. is a 79-year-old female who was brought in by her son, who reports she has been experiencing gradual memory loss and visual hallucinations. He also says he has noted that she has been experiencing problems communicating, performing complex tasks, problem-solving, and planning. He also reports she has been getting lost while going home and to the grocery stores recently with additional confusion, disorientation, and paranoia.

• O: She is alert, agitated, and disoriented. The client has visual hallucinations, incoherent thoughts, and memory gaps.
• A: Neurocognitive disorder noted.
• P: Aricept 5 mg PO every bedtime.

8. Anorexia-Nervosa

S P.W is a 16-year-old who was admitted after being found unconscious at home with symptoms of malnutrition. The patient reports she does not want to gain weight after being bullied at school. She reports that she has severely restricted food intake through dieting or fasting, denying hunger, making excuses to avoid eating, eating foods low in fat and calories, and lying about how much she has eaten. She also reports self-induced vomiting to get rid of food, using laxatives, and exercising excessively. She also reports being in a low mood due to constant bullying at school

• O: She is alert, oriented, adequately groomed, and anxious. She reports a low mood but a coherent thought process. She has insight and good judgment. Weight 108 pounds, height 5’6, and BMI 17.45.
• A: Her nutritional status improved, but she is still anxious about the weight gain.
• P: Vitamin and Calcium supplements.

9. Attention-Deficit Hyperactive Disorder

S V.L is a 6-year-old boy brought by the mother, complaining that the son has a pattern of failing to pay attention at school and home. The mother reports that she has noticed the son is having trouble staying focused on tasks or play, appears not to listen when spoken to directly, has difficulty following instructions, and fails to finish schoolwork or chores. The mother reports that the behavior has interrupted his learning as he is easily distracted, uncooperative, avoids doing homework, and quickly forgets schoolwork.

• O: the child is alert, anxious, and distracted. He is unable to maintain eye contact and maintain a constant sitting position. He also fails to respond when called and abandons an activity before completion. Deficits in memory and concentration were also present.
• A: Hyperactivity, distractibility, reduced attention span, and memory deficits.
• P: Methylphenidate 10 mg PO OD.

10. Post-Traumatic Stress Disorder

S L.D is a 16-year-old female who is in recovery after being sexually assaulted by a gang two months ago. She reports she has been experiencing nightmares and flashbacks of the incident and avoids talking about it. She reports she feels like she is persistently re-experiencing the traumatic event and has dissociation with intense sadness and guilt. In addition, she has had problems with sleep and concentration and is irritable and hypervigilant.

• O: She is alert, oriented, and hyper-vigilant of her environment. She reports being in a constant low mood and irritable. Her speech is normal, but exhibits trance when the topic of the incident is brought up. Her memory and thought process are intact.
• A: hypervigilance and avoids talking about the sexual assault incident.
• P: Imipramine 75 mg PO once daily.

11. Disruptive Mood Dysregulation Disorder

S W.D. is a 5-year-old boy whose mother reports he has been having severe and frequent tantrums. The mother reports that the son is sad, irritable, and angry almost daily and has an abnormal reaction to a nuisance. She states that the son has been having these symptoms ever since he was two, and they have been worsening progressively. In addition, she reports that the symptoms have affected his daycare and school, as he cannot function in both environments

• O: The child is alert, easily distracted, and irritable. He has several anger outbursts characterized by tantrums. He is fidgety and aware of his environment.
• A: Severe anger outbursts and irritability with failure to cope in different environments.
• P: Methylphenidate 10 mg PO OD.

12. Autism

S S.V is a 4-year-old girl whose mother reports she fails to respond to name, reduced eye contact, and has a regression of language skills. The mother also reports she cannot start a conversation, keep one going, or only start one to make requests or label items. The child speaks in an abnormal tone and rhythm, often repeats words and phrases, and does not understand simple questions. The mother also reports she has repetitive movements, such as hand flapping, and performs activities that may cause harm and is disturbed when routine is affected.

• O: The child is alert and hyper-vigilant. She expresses mutism and has a blunted affect with repetitive abnormal movements. There is minimal interaction with the rest of the people.
• A: Communication and social interaction challenges are present.
• P: Prozac 10 mg orally OD.