PRAC 6635 WEEK 8 Clinical Hour and Patient Logs

Sample Answer

1. Major Depression

S C.M. is a 24-year-old female who presented with a depressed mood, suicidal ideations and felt unworthy. Additionally, she reports she has not been eating and has lost about 10 pounds. She reports she has been experiencing insomnia despite feeling fatigued the whole day. She reports that the symptoms have affected her studies as she has lost interest and cannot concentrate in class as she previously could.

• O: Patient is alert, oriented, and well-groomed. She reports a low mood. She has a coherent thought process but with suicidal ideations. There are no hallucinations and delusions, but with good judgement and insight.
• A: The patient is concerned that the symptoms are affecting her studies, and she needs help to mitigate the effects.
• P: Zoloft 50 mg oral OD.

2. Schizophrenia

S D.L is a 32-year-old female who was presented with visual and auditory hallucinations. She reports she has been experiencing the symptoms for the last nine months. Additionally, she had erotomania delusions as she felt that the current mayor loved her. She also had bizarre behaviour and would create new words. She can no longer do any of her normal previous activities and experiences anhedonia.

• O: Patient is alert but disoriented, agitated, inappropriately groomed, and cannot maintain eye contact. She is irritable and has a blunted affect. Visual and auditory hallucinations and erotomania delusions were present. She has an incoherent thought process, looseness of association, perseveration, word salad and neologisms. There are gaps in her memory.
• A: Neurocognitive disorder was noted
• P: Risperidone 2 mg PO OD.

3. Bipolar I

S F.P is a 40-year-old male who presented with unusual excessive talking and racing thoughts. The symptoms had been presented for the last two weeks and were accompanied by an increased need to move around and destructive behavior. He reports that he had been sleeping for around four hours.

• O: Patient was alert and oriented but inappropriately groomed. He was agitated, easily distracted, and had an expansive mood. He had a flight of ideas, circumstantiality, and pressure of speech. Hallucinations and delusions were absent. Memory and judgement were intact.
• A: Manic symptoms were present, accompanied by pressure of speech, flight of ideas, and easy distractibility.
• P: Lithium 1000 mg PO TDS.

4. Dementia

S S.W. is a 83-year-old male who came to the hospital complaining of increased forgetfulness over the last six months. He reports he can no longer remember the names of people or towns he used to know and often gets lost when driving or walking towards home and his store. Additionally, he reports he is often confused about what time of the day it is and often has visual hallucinations. He also reports he has been having difficulties planning day-to-day activities and performing tasks he could previously do. He reports that the symptoms have made him more paranoid and anxious.

• O: Patient is alert and well-groomed but disoriented. He is anxious with incoherent thoughts and has gaps in his memory.
• A: Neurocognitive disorder noted.
• P: Aricept 10 mg PO every bedtime.

5. Insomnia

S B.G is a 50-year-old male who reports he has been having difficulty falling asleep at night for the last two months. He reports he stays awake almost throughout the night and denies sleeping during the day, being stressed, and taking drinks with caffeine. He reports he wakes up too early and does not feel well-rested after a night’s sleep. Additionally, he reports having daytime tiredness, making it difficult to pay attention and remember. He says that the symptoms have made him more irritable and anxious, with an increased propensity to errors.

• O: The patient is alert, anxious and well-groomed. He is irritable and has a coherent thought process. His memory and judgement are intact.
• A: The patient has insomnia and worries about his sleep pattern.
• P: Fluoxetine 10 mg PO OD.

6. Post-traumatic Stress Disorder

S S.L. is an 18-year-old female who was previously involved in a road traffic accident where most of her classmates passed away two months ago. She reports that she has been experiencing recurrent memories, flashbacks, and nightmares of the traumatic event. She reports she can no longer watch the news and avoids going close to her previous school to avoid relieving the incident. Additionally, she feels detached from family and friends, experiences anhedonia, and has difficulty experiencing positive emotions.

• O: Patient is alert, oriented, and well-groomed. She says she is in a depressed mood. Her speech is normal and shows a trance when the topic of the accident is brought up. Her thought process and memory are intact.
• A: The patient is in grief due to the loss of her friends and has difficulties coping.
• P: Fluoxetine 20 mg PO once daily.

7. Post-Partum Depression

S S.J is a 16-year-old female who presented with a constant low mood six weeks after delivering her daughter. She reports she has been crying too much since she delivered, lost her appetite, and has been experiencing insomnia. Additionally, she reports that she is unable to bond with the baby and feels she is not capable of being a good mother. She reports she feels ashamed for being pregnant while still a teenager, has had several panic attacks, and can no longer make decisions regarding herself and her daughter.

• O: Patient was alert, oriented, and well-groomed. She says she is in a depressed mood and has gaps in her memory. Her thought process is intact, and she has no hallucinations or delusions.
• A: The patient is anxious about her and her daughter and feels hopeless and ashamed. Anhedonia and insomnia are present
• P: Zoloft 50 mg oral OD.

8. Brief Psychotic Episode

S W.P is a 36-year-old who presented to the clinic with visual and auditory hallucinations present for one week. She reports she feels that her neighbors want to kill her for no apparent reason. She also had abnormal thoughts and behavior and would use incomprehensible words. She reports being on morphine pain medication.

• O: Patient is alert, agitated, disoriented, and inappropriately groomed. She is irritable and has a blunted affect. She has an incoherent thought process, persecutory delusions, and hallucinations.
• A: The patient is experiencing hallucinations and delusions, which may be a result of the use of morphine.
• P: Risperidone 2 mg PO OD.

9. Generalized Anxiety Disorder

S G.R. is a 17-year-old female who reports experiencing excessive worry about her upcoming examinations. She reports she has been performing above average, making her overthink plans and solutions if she fails. She reports she has been feeling on edge, unable to let go of the worry, and has difficulty concentrating in school. Additionally, she feels uncertain about whether she will pass her examinations. She reports that her constant worry makes her feel fatigued, nervous, and irritable, and she has problems with sleep.

• O: Patient is alert, oriented, and anxious. She is irritable but with coherent thought, intact memory, and judgment.
• A: The patient is experiencing generalized anxiety coupled with insomnia.
• P: Lorazepam 4mg oral twice daily.

10. Autistic Spectrum Disorder

S G.G is a 5-year-old boy who was brought to the clinic when the mother noticed he does not respond to his name and has a regression in his speech. She reports she has noticed her son has progressively become withdrawn, plays alone, and lacks eye contact and facial expression. Additionally, she reports the son cannot start a conversation or keep one going, keeps repeating words, and fails to understand simple directions. She reports that the son has become clumsy, shows repetitive movements, and is often irritated when his normal routine is interrupted.

• O: The child is alert and agitated and shows mutism and blunted affect. He is hyper-vigilant and has repetitive movements. He only interacts with the mother.
• A: The child is experiencing challenges in communication and social interactions.
• P: Prozac 10 mg orally OD.

11. Anorexia Nervosa

S E.R. is a 16-year-old female who was brought to the clinic by her mother after she noted she has excessively lost weight and currently has swelling on her hands and feet. The patient reports she has felt the need to lose weight in order to look like her classmates. She reports she has been skipping meals, refuses to eat, denies hunger, spits food after chewing, lies about how much she has eaten, induces herself to vomit food, and uses enema and laxatives. Additionally, she says she only eats food low in fat and calories to avoid getting fat.

• O: She is alert, oriented, adequately groomed, and anxious. She is apathetic and has a flat affect. She has coherent thought and judgement but lacks insight. Weight 80 pounds, height 5’2, and BMI 14.65.
• A: Her nutritional status improved, edema is yet to resolve, and she is still anxious about the weight gain.
• P: Vitamin and Calcium supplements.

12. Attention-Deficit Hyperactive Disorder

S P.O is a 4-year-old girl who was brought to the clinic after the mother noticed she had difficulty concentrating on one activity. She says she first noticed the symptoms when the daughter was two years old, and the symptoms have been worsening. She reports that the daughter can no longer stay seated in a class, frequently fidgets and squirms in a seat, and talks too much. She says she is always on a constant need to move even when the situation is inappropriate and interrupts others while they are playing or talking.

• O: The child is alert, agitated, and fidgets on the seat. He keeps on running up and down the room and interrupts the mother during the whole session repetitively.
• A: Hyperactivity, distractibility, and a reduced attention span.
• P: Methylphenidate 10 mg PO OD.