PRAC 6645 WEEK 10 Clinical Hour and Patient Logs

Sample Answer

Substance Use Disorder

Name: T.M
Age: 16 years old
Gender: Female
Diagnosis: Substance Use Disorder

S T.M. is a 16-year-old female patient who was brought to the facility with reports of heroin addiction. She has used heroin for almost two years. She confirms low self-esteem, low self-worth, depression, hopelessness, helplessness, and poor insight. She experienced sexual trauma, which made her start taking the substances to counter the effects.

• O: The patient is well-groomed in age-appropriate clothes. She is well-oriented in person, place, and time. She has a sad facial expression. She finds it hard to maintain eye contact. Her thought process is intact.. She displays poor insight. She, however, denies hallucination or suicidal ideation.
• A: Based on the symptoms, the patient has substance use disorder.
• P: The patient is to start group therapy sessions to help her deal with the problem

Separation Anxiety Disorder (SAD)

Name: G.G
Age: 8 years old
Gender: Male
Diagnosis: Separation anxiety disorder

S G.G. is an 8-year-old boy who presented to the psychiatric unit with his mother for psychiatric evaluation. The patient’s mother claims that he has always been anxious and worried all the time about silly things, such as whether she is going to die or will not pick him up from school. He tends to be stubborn most of the time, throwing objects around the house, which even puts him in danger when in school. He finds it difficult to sleep at night due to frequent nightmares. When at school, he consistently asks for permission to go home, complaining of stomach aches or headaches.

• O: He is well-groomed and oriented. He is also oriented in person, place, and time. The patient is cooperative and answers questions appropriately while maintaining eye contact. He has a clear speech. Well-organized thought process. He exhibits intact memory with an appropriate thought process. Denies potential harm to self or others. Denies suicidal ideations or hallucinations.
• A: Based on the DSM-V criteria, the patient has a separation anxiety disorder
• P: The patient should commence weekly sessions of family therapy to help deal with the symptoms.

Intermittent explosive disorder (IED)

Name: J.H
Age: 41 years old
Gender: Female
Diagnosis: Intermittent explosive disorder (IED)

S J.H is a 41-year-old female patient who reports to the clinic complaining of losing her temper. She claims to be moody most of the time, especially this time of the year, every year. She has been having sleeping problems and gained weight recently. She reports lower concentration and also talks about being bored most of the time. Therefore, she finds it hard to keep friends.

• O: she is well-dressed and groomed. She is also oriented and alert. She looks sad, angry, and irritable. She has a coherent thought process. She is delusional and exhibits a threat of harm to herself and others. She has fluent but pressured speech.
• A: Regarding the DSM-V criteria, the patient has intermittent explosive disorder.
• P: The patient should start individual CBT sessions.

General Anxiety Disorder (GAD)

Name: B.Z
Age: 49 years old
Gender: Female
Diagnosis: General Anxiety Disorder (GAD)

S B.Z is a 49-year-old female patient who presented to the clinic for psychiatric evaluation. She presents with signs of anxiety, accompanied by headache, decreased appetite, and diarrhea 2 to 3 times every week. She reports being anxious about many life events and about her children who live in another town.

• O: She is well-dressed and appropriately groomed. She is alert and well-oriented in person, place, and time. She actively participate in the interview. She is looks sad. Her mood is dysphoric. She displays a constricted effect with good insight and judgment. Her memory is intact, with an unremarkable thought process. Her functional status is, however, mildly impaired.
• A: Based on the DSM-V diagnostic criteria, the patient has generalized anxiety disorder
• P: The patient should start weekly individual CBT sessions to help deal with the symptoms.

Binge Eating Disorder

Name: M.M
Age: 15 years old
Gender: Female
Diagnosis: Binge Eating Disorder

S M.M is a 15-year-old female who came to the facility with a history of binge eating disorder. The patient confirms previous therapeutic approaches while still in junior high school following a traumatic incidence of sexual abuse. She remembers mentioning her eating disorder to the psychiatrist who ignored the claim, focusing only on her traumatic experience. She is embarrassed by this condition and she has consistently increased her weight, which worries her

• O: The patient is appropriately dressed and well-groomed. She is also alert and oriented. However, she looks sad. She also expressed low self-esteem. She denies suicidal thoughts and ideations.
• A: The patient’s symptoms point to Binge Eating Disorder.
• P: The patient should commence sessions of family therapy to help her deal with the symptoms.

Autism Spectrum Disorder (ASD)

Name: D.S
Age: 12 years old
Gender: Male
Diagnosis: Autism Spectrum Disorder

S D.S is a 12-year-old male patient who was referred to the psychiatric unit with a history of autism, anxiety, and depression. The patient has been receiving mental treatment for these disorders ever since his third grade. The patient’s parents report that he experiences outbursts, anger, and feeling of being rejected by someone. They also report other symptoms, such as social phobias, excessive worry, and OCD-like behaviors.

• O: The patient is well-dressed and groomed. He is well-oriented in terms of time, person, and place. His insight is intact. His speech was normal, and he displayed appropriate behavior during the interview. His judgment is appropriate for his age. He exhibits mild psychomotor agitation. He also displayed a euthymic mood. Both his short-term and long-term memories are appropriate. His concentration is good with an appropriate thought process.
• A: The patient symptoms and history are an indication of Autism Spectrum Disorder.
• P: The patient is to commence individual CBT to help in managing the symptoms.

Major Depressive Disorder

Name: N.K
Age: 17 years old
Gender: Female
Diagnosis: MDD

S N.K. is a 17-year-old female patient who came to the facility for an evaluation. She reports a history of depression during her early adolescence, which she used antidepressant medication to manage. She, however, stopped using her medication when she joined college, as she was afraid of her friends judging her. She reports sleeping difficulties, reduced appetite, crying spells, reduced concentration levels, reduced interest, social phobia, and low energy levels.

• O: The patient is well-dressed and groomed. She is well-oriented in place, person, and time. She speaks fluently, in a normal tone and volume. Her insight is congruent. Her thought process is age-appropriate, with unremarkable judgment. Both her long-term and short-term memory are intact. She, however, displays a sad mood and seems to be distracted most of the time. She reports a feeling of worthlessness but denies suicidal ideation. Denies nightmares, hallucinations, or delusions.
• A: Based on the DSM-V criteria the patient has MDD
• P: The patient should start group therapy sessions to share the experiences with peers and develop better management strategies.

Enuresis Disorder

Name: R.W
Age: 10 years old
Gender: Male
Diagnosis: Enuresis Disorder

S R.W. is a 10-year-old boy who was brought in by her mother for bedwetting at night. She reports that one day, when the patient went camping, they shared a bed with a friend who noticed that the patient wet the bed at night. Ever since they have been making him and calling him names, he has lost interest in routine activities and doesn’t even want to go to school. The patient calms down to having problems sleeping at night.

• O: The patient is generally healthy, with no signs of any delays in the developmental stages. He is also alert and oriented. He looks sad. He has a coherent thought process and intact memory. He denies suicidal action or mind
• A: The patient wets the bed at night; hence, he has enuresis disorder.
• P: The patient should start family therapy sessions.

Insomnia

Name: J.D
Age: 38 years old
Gender: Male
Diagnosis: Insomnia

S J.D. is a 38-year-old male patient who came into the psychiatric unit for follow-up. He was diagnosed with insomnia some months before the present visit. The main reason behind his insomnia diagnosis is the persistent inability to fall and stay asleep. This has been greatly affecting his school work, as he cannot concentrate for long hours and seems to daydream most of the time

• O: The client appeared well-oriented in time, place, and person. He displays intact judgment. He, however, has a reduced concentration span and looks sleepy. He tries to maintain eye contact. His short- and long-term memories are intact. Denies delusion, hallucination, and illusions. He, however, confirms that he has been depressed lately, given that his lack of sleep is affecting his job.
• A: The patient’s symptoms point to insomnia
• P: The patient is to start individual sleep-focused CBT

Narcissistic Personality Disorder

Name: K.L
Age: 31 years old
Gender: Female
Diagnosis: Narcissistic Personality Disorder

S K.L. is a 31-year-old female patient who was recommended to seek psychiatric evaluation from her workplace. She claims that some male colleagues is in love with her because she is a powerful and beautiful woman. She however denies any incidences of sexual harassment or inappropriate behavior displayed by her male colleagues

• O: She is well-dressed and appropriately groomed. The patient’s orientation in time, place, and person is impressive. She is very cooperative and communicates in a clear tone, with appropriate speech volume. She maintains eye contact. Her memory is intact. She, however, displays a compromised thought process with a delusional perspective of things. Displays tactile and hallucinations. Denies suicidal thoughts.
• A: The patient meets the DSM-V diagnostic criteria for Narcissistic Personality Disorder
• P: The patient should start individual therapy sessions.

Bipolar Disorder

Name: A.A
Age: 17 years old
Gender: Female
Diagnosis: Bipolar Disorder

S A.A. is a 17-year-old female patient who came to the psychiatric clinic accompanied by both her parents, with a history of mood fluctuation. She reports that she has been missing her doses due to forgetfulness. She also reports that the drugs have failed to manage her symptoms. Her mood fluctuations have intensified, hence the need to seek psychiatric help.

• O: The patient walked in well-groomed in age-appropriate clothes. The patient maintained eye contact during the interview with appropriate facial expressions. Her thought process is coherent and logical. She denies delusion, hallucinations, and suicidal ideation. She confirms being forgetful, but her long-term memory is intact. Her insight is absent. The patient displays a limited ability to identify the consequences of her actions. Denies suicidal ideation, or a history of suicidal attempts.
• A: according to the DSM-V the patient has bipolar disorder
• P: The patient should start group therapy sessions to help with the symptoms.

Posttraumatic Stress Disorder (PTSD)

Name: W.S
Age: 14 years old
Gender: Male
Diagnosis: PTSD

S W.S. is a 14-year-old male patient who presented to the clinic for psychiatric evaluation for PTSD. He claims to have taken off after hearing the sound of a fireworks blast. He complains of being unable to sleep as a result of nightmares. He also reports anxiety symptoms, tightened stomach muscles, and nausea.

• O: The patient appears neat and well-kept. He is quite restless and frightened. He stammers with a tremulous speech. His thought process is logical, with no evidence of delusions or hallucinations. He also denies suicidal ideology. Remote and recent memory is good.
• A: The symptoms point to PTSD
• P: The patient should start family therapy sessions.