PRAC 6635 Week 9 Clinical Hour and Patient Logs

Sample Answer

1. Major Depressive Disorder

S A.K is a 38-year-old female who presented with a depressed mood and suicidal ideations. She reports having had the symptoms for a month. Additionally, she reports she has not been experiencing loss of appetite, has lost about 10 pounds, and currently feels unworthy. She reports she has been experiencing insomnia despite feeling fatigued the whole day. She reports that the symptoms have affected her business as she has lost interest and cannot make decisions regarding her business 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 judgment and insight.
• A: The patient is depressed and concerned that the symptoms are affecting her business, and she is ready to accept help.
• P: Paroxetine 30mg oral once daily.

2. Bipolar I Disorder

S S.P. is a 46-year-old male who presents with excessive talking, sings out loudly, and often changes the subject topic. He reports that he has had the symptoms for two weeks after failing to take his medication for a month. He reports sleeping for two hours and feels the need to move around different places. He has been involved in destructive personal property and furniture and has not reported to work during this period.

• O: Patient is alert, oriented, inappropriately groomed, and anxious. He has an elated and expansive mood, pressure of speech, flight of ideas, and circumstantiality. He has good judgment, partial insight, and no hallucinations or delusions.
• A: Manic episode characterized by pressure of speech and flight of ideas.
• P: Lithium 1200mg oral, twice daily.

3. Schizophrenia

S W.H. is a 34-year-old female who presented with visual and auditory hallucinations for the last year. She reports she feels that her current boyfriend has been unfaithful on various occasions. Additionally, she has abnormal thoughts, disorganized speech, and bizarre behavior. She reports experiencing anhedonia, making her socially withdrawn and lose friends, and he lacks the initiative to attend to her daily commitments.

• O: Patient is alert, disoriented, improperly groomed, and agitated. She has apathy, flat affect, incoherent thoughts, circumstantiality, jealous delusions, and visual and auditory hallucinations. He has memory gaps, poor judgment, and lacks insight.
• A: Neurocognitive disorder noted with the presence of hallucinations and delusions.
• P: Risperidone 4mg twice daily.

4. Dementia

S F.D is a 79-year-old male who was presented to the hospital complaining of increased forgetfulness over the last year. He reports a family history of Alzheimer’s. 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 the time of the day and has 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 with memory loss.
• P: Administer Aricept 10mg per day, oral at bedtime.

5. Brief Psychotic Disorder

S C.T. is a 42-year-old female who presented with visual and auditory hallucinations present for the last nine days. She reports she feels that her husband wants to kill her to gain full custody of their children. 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: Initiate risperidone 4mg orally twice daily.

6. Postpartum Depression

S S.P is a 22-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 gave birth, lost her appetite, and has been experiencing insomnia. Additionally, she reports that she cannot bond with the baby and feels incapable of being a good mother, which makes her anxious. She reports she feels unable to care for her daughter alone as her husband died while she was pregnant.

• 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 experiencing postpartum depression and anxiety. Anhedonia and insomnia are also present.
• P: Administer paroxetine 30mg orally once daily.

7. Alcohol Use Disorder

S A.W is a 32-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 lose multiple jobs and has various failed relationships. 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: Administer naltrexone 50mg orally once daily.

8. Autistic Spectrum Disorder

S Z.L is a five-year-old girl brought to the clinic when the mother noticed she does not respond to her name when called, no longer speaks as she used to, and has repeated movements. She reports that her daughter has progressively become withdrawn, plays alone, and lacks eye contact and facial expression. Additionally, she reports the daughter cannot start a conversation, keeps repeating words and phrases, and needs help understanding simple instructions. She reports that the daughter has been engaging in harmful behavior, such as head banging, and is often irritated when her routine is interrupted.

• O: The child is alert and agitated, showing 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: Administer Prozac 20mg per day orally, twice daily.

9. Post-Traumatic Stress Disorder

S G.L is a 20-year-old female who recently witnessed her roommate being sexually assaulted and murdered by a stranger two months ago while in their room. She reports she has been experiencing memories, 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, hyper-vigilant, and can no longer live within the campus

• 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 she exhibits a 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: Administer paroxetine 20mg per day orally once daily.

10. Generalized Anxiety Disorder

S S.D. is a 17-year-old male who reports experiencing excessive worry about his upcoming examinations. He reports that despite performing above average, he has been overthinking future plans and solutions if he fails. He reports feeling on edge and having difficulty concentrating in school. Additionally, he feels uncertain about whether he will pass his examinations and join medical school, causing him to have constant worry, fatigue, anxiety, and insomnia.

• 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: Administer paroxetine 30mg orally once daily.

11. Attention-Deficit Hyperactive Disorder

S V.L is a five-year-old boy brought to the clinic by the mother, complaining that the son has a pattern of decreasing attention at school and home. The mother reports that she has noticed the son has trouble staying focused on tasks or plays and cannot complete his schoolwork and chores. She reports he appears not to listen when spoken to and has difficulty following instructions. The mother reports that the behavior has interrupted his learning as he is easily distracted, uncooperative, and avoids doing 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.
• A: Hyperactivity, distractibility, reduced attention span, and memory deficits.
• P: Administer methylphenidate 20mg once daily in the morning.

12. Anorexia Nervosa

S A.P is a 15-year-old female who was admitted after she started experiencing bilateral pedal edema for four days. The mother reports she has lost a lot of weight over the last three months. The patient reports wanting to lose weight after constant bullying at school. She adds that she has severely restricted food intake through dieting, 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 100 pounds, height 5’6, and BMI 16.15.
• A: Edema has resolved, but she is still anxious about the weight gain.
• P: Administer glucose, fluid, and electrolytes with calcium and vitamin supplementation.