PRAC 6645 WEEK 4 Clinical Hour and Patient Logs

Paper Instructions

Patient Log

Throughout this course, you will also keep a log of patient encounters using Meditrek. You must record at least 80 patients by the end of this practicum. You must record at least 80 patients by the end of this practicum. You must see at least 5 pediatric/adolescent patients and 5 adult/older adult patients.

The patient log must include the following:

  • Date
  • Course
  • Clinical Faculty
  • Approved Preceptor
  • Patient Number
  • Client Information
  • Visit Information
  • Practice Management
  • Diagnosis

Student Notes

Students must include a brief summary/synopsis of the patient visit—this does not need to be a SOAP note; however, the note needs to be sufficient to remember your patient encounter

By Day 7 of Week 4

Record your clinical hours and patient encounters in Meditrek.

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Generalized Anxiety Disorder

Name: S.C
Age: 11-years
Gender: Female
Diagnosis: Generalized Anxiety Disorder

S.C. is an 11-year-old female patient who visited the facility for a psychiatric evaluation. The patient has been having excessive and persistent worries regarding various everyday concerns such as their family’s well-being, her relationship with her friend, and school attendance. She feels restless, on the edge, and complications controlling her worries. She also experiences struggles with sleep, headaches, and muscle tension. These symptoms have persisted for months, hence negatively impacting her school work.

  • O: The patient is appropriately dressed and well-groomed. She is also alert and oriented. She fidgets and looks restless. The patient has a cognitive distortion due to excessive worry. Her memory is intact. She denies hallucinations, delusions, or suicidal thoughts.
  • A: According to the DSM-V criteria, the patient’s symptoms point to generalized anxiety disorder.
  • P: The patient needs to start sessions of cognitive behavioral therapy to help her with cognitive distortions and excessive worries.

Schizophrenia

Name: B.D
Age: 62 years old
Gender: Male
Diagnosis: Schizophrenia

B.D. is a 62-year-old male patient who came to the facility accompanied by his partner for a psychiatric visit. The patient had been diagnosed with schizophrenia and has current reports of increased auditory hallucinations and paranoid ideation. The partner reports that her husband has been hearing non-existent voices encouraging him to kill himself. Other symptoms include problems with concentration, anxiety, and significant changes in appetite, mood, and sleep patterns.

  • O: The patient is poorly groomed and has bad hygiene. He also displays psychomotor agitation. He has suicidal thoughts, delusions, and hallucinations. His memory and thought process are both impaired. He displays significant difficulty in concentrating.
  • A: The symptoms point to schizophrenia.
  • P: The patient should start psychotherapy sessions. For instance, individual and group therapy should be used to help him develop better coping skills.

Nightmare Disorder

Name: R.A
Age: 8 years old
Gender: Female
Diagnosis: Nightmare Disorder

R.A. is an 8-year-old female patient who was brought to the clinic by her mother. The mother reports that her daughter has, in the last few weeks, been experiencing disturbing nightmares. They have become as frequent as three times in a week. The patient sometimes wakes up in the middle of the night screaming that some scary animal wants to hurt her. She fears sleeping alone and has changed sleep patterns.

  • O: The patient is appropriately groomed and well-dressed. She is also alert and oriented. Her mood is sad, and she becomes anxious when she hears about bedtime and sleep topics. Her thought process is coherent, and she displays intact memory. The patient denies suicidal thoughts or ideations.
  • A: The symptoms displayed by the patient show nightmare disorder.
  • P: It is important for the patient to start CBT sessions once a week for better outcomes.

Panic Attack Disorder

Name: N.V
Age: 33 years old
Gender: Female
Diagnosis: Panic Attack Disorder

N.V is a 33-year-old female patient who came to the facility with reports of frequent episodes of intense fear as well as discomfort. She experiences symptoms such as fear of losing control, dizziness, breath shortness, chest pain, and palpitations. These symptoms come at any time and do not have any triggers. She, therefore, avoids situations or activities that may trigger anxiety.

  • O: The patient is well-dressed and groomed. She is alert and oriented. She has an anxious and apprehensive mood. She finds it difficult to concentrate. Her thought process is coherent but preoccupied with panic attacks.
  • A: the patient’s subjective and objective information is consistent with panic attack disorder.
  • P: The patient should start CBT sessions to help her address her cognitive distortions and manage anxiety.

Adjustment Disorder

Name: P.R
Age: 10-years
Gender: Male
Diagnosis: Adjustment disorder

P.R. is a ten-year-old male patient who was brought to the facility by his parents. The parents report worrying symptoms. They indicate that their son recently moved to a new school, which has made the boy exhibit increased irritability, cry more, and experience social withdrawal. He is also slow to engage in social activities and expresses loneliness and feelings of sadness. He indicates that he misses his friends from the previous school.

  • O: The patient is well-dressed and groomed. He is also alert and oriented. He avoids eye contact, and he is hesitant in verbal communication. He is in a sad mood and looks tearful. His thought process is coherent. He has intact short and long-term memory. He finds it difficult to concentrate. He denies suicidal thoughts or ideation.
  • A: The patient recently moved to a new school, so the symptoms are indicative of adjustment disorder.
  • P: The patient needs to start family therapy to help him deal with the symptoms and adjust to his new school.

Narcissistic Personality Disorder

Name: J.M
Age: 34-years
Gender: Male
Diagnosis: Narcissistic Personality Disorder.

J.M. is a 34-year-old male patient who came to the facility with his partner. The wife reports that her husband has been experiencing interpersonal complications and a self-perceived need for validation and admiration. He also displays symptoms such as being preoccupied with fantasies of having a unique status, beauty, brilliance, and unlimited success. The patient also lacks empathy and has a sense of entitlement.

  • O: The patient is well-groomed and has a fashionable suit, emphasizing a concern for his appearance. He is alert and oriented. He has assertive behavior and interrupts assessment to focus on his successes. He is in a euthymic mood and also exhibits impatience. He displays signs of grandiosity. He has a coherent thought process and intact memory. He denies suicidal thoughts or ideations.
  • A: The patient’s symptoms are indicative of Narcissistic personality disorder.
  • P: The patient needs to start cognitive-behavioral therapy sessions to help him challenge and modify his maladaptive thought patterns connected with entitlement and grandiosity.

Autism Spectrum disorder

Name: F.B
Age: 12-years
Gender: Female
Diagnosis: Autism spectrum disorder

F.B. is a 12-year-old female patient who came to the facility accompanied by her mother. The mother indicated that they had come for her follow-up concerning her developmental and behavioral progress. While the patient has made some progress, there are still challenges, especially at school, where she finds it difficult to communicate with others and socially interact. She has also experienced occasional meltdowns and enhanced sensitivity to sensory stimuli.

  • O: The patient is well-dressed and groomed. She is also alert and oriented. She engages in reduced eye contact and exhibits repetitive motor movements. She has a neutral mood but sometimes looks frustrated at attempts at social interaction. She has a coherent thought process with intact cognition. The patient denies hallucinations, delusions, or suicidal thoughts.
  • A: The patient’s diagnosis is autism spectrum disorder
  • P: The patient is to continue with the weekly psychotherapy sessions to help her cope better.

Post-traumatic stress disorder

Name: J.N
Age: 26-years
Gender: Female
Diagnosis: Post-traumatic stress disorder

J.N. is a 26-year-old female patient who came to the facility with distressing symptoms weeks after witnessing an accident involving multiple vehicles. She experiences nightmares and intrusive and recurrent distressing memories related to the accident. She also displays other symptoms, such as avoiding traveling on the road and a sense of detachment.

  • O: The patient is well-dressed and appropriately groomed. She is also alert and oriented. However, she appears anxious. She displays emotional lability, hypervigilance, and irritability. Her thought process is focused on worries and distressing memories regarding the accident. She finds it difficult to concentrate. She denies suicidal thoughts or ideations
  • A: The patient’s symptoms appeared after she experienced an accident; therefore, she has PTSD.
  • P: The patient should start weekly sessions of cognitive processing therapy to help her address negative beliefs and thought processes.

Binge Eating Disorder

Name: G.C
Age: 15-years
Gender: Male
Diagnosis: Binge Eating Disorder

G.C. is a 15-year-old male patient who came to the facility for a psychiatric visit. He reports that he has increasingly experienced periods where he consumes large amounts of food and feels a lack of control during such periods. Such episodes usually lead to feelings of shame, guilt, and distress. The need to eat large meals is triggered by boredom and stress, and he engages in them even when he is not physically angry. He fears that he will soon be obese if the trend continues.

  • O: The patient is well-dressed and groomed. He is also alert and oriented. He looks distressed when talking about his binge-eating behavior. He finds it hard to maintain eye contact and fidgets a lot. The patient’s thought process is goal-directed. He has intact cognition and short and long-term memory. He denies suicidal thoughts or ideation.
  • A: The patient’s symptoms point to binge eating disorder
  • P: The patient should start weekly sessions of CBT to help him address the emotional triggers that lead to the disorder, challenge negative beliefs, and enhance coping skills.

Obsessive-Compulsive Disorder

Name: M.J
Age: 37-years
Gender: Female
Diagnosis: Obsessive-Compulsive Disorder

M.J. is a 37-year-old female patient who visited the facility to seek psychiatric help due to unwanted symptoms. She indicates that she has been having distressing and intrusive obsessions centered around fears of contamination. She exhibits recurrent thoughts about dirt and germs, making her wash her hands several times a day and avoid public places for fear of contamination. This behavior has impacted her relationships and well-being.

  • O: The patient is well-dressed and groomed. She is also alert and oriented in person, space, and time. She looks anxious and preoccupied with contamination fears and thoughts. His thought process is focused on obsession. She has impaired concentration
  • A: The patient’s symptoms and obsessions mean that she has obsessive-compulsive disorder.
  • P: The patient needs to start CBT sessions to help her deal with contamination-related compulsions and obsessions.

Attention-Deficit/Hyperactivity Disorder (ADHD)

Name: D.K
Age: 9-years
Gender: male
Diagnosis: ADHD

D.K is a 9-year-old male patient who was brought to the facility by his mother, who indicates that he is worried about the symptoms his son is exhibiting. The patient has been displaying various symptoms, such as distractibility, forgetfulness, frequent careless mistakes, forgetfulness, and difficulty completing tasks. He also hates following instructions, finds it hard to remain calm and seated at one point, and engages in impulsive verbal responses.

  • O: The patient is well-dressed and groomed. He is also alert and oriented. He is in a euthymic mood. He fidgets a lot and finds it hard to remain calm. He, therefore, walks up and down the room. He finds it hard to concentrate. He has a coherent thought process and intact memory.
  • A: According to the DSM-V diagnostic criteria, the patient’s symptoms point to ADHD.
  • P: The patient needs to start Family therapy sessions to help him deal with the symptoms.

Social Anxiety Disorder

Name: F.T
Age: 41-years
Gender: Female
Diagnosis: Social Anxiety Disorder

F.T. is a 41-year-old female patient who visited the clinic for psychiatric help. She has increasingly exhibited symptoms such as substantial avoidance behavior and distress when with unfamiliar people or when she has to engage in public speaking. She fears embarrassment, scrutiny, and negative evaluation by others. She exhibits various symptoms, such as a racing heart, trembling, and sweating whenever she has to engage in social interactions.

  • O: She is smartly dressed and well-groomed. She is also alert and oriented. However, she is anxious and shows signs of discomfort. She avoids eye contact and fidgets. She has a goal-directed thought process. She is concerned about social interactions. Her memory is intact. She denies suicidal thoughts or ideations.
  • A: The patient’s symptoms are indicative of social anxiety disorder.
  • P: The patient needs to start CBT sessions to help with irrational fears and negative thought patterns.

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