PRAC 6645 WEEK 5 Clinical Hour and Patient Logs

Sample Answer

Internet Gaming Disorder

Name: G.D
Age: 37 years
Gender: Male
Diagnosis: Internet Gaming Disorder

G.D is a 37-year-old male patient who presents to the clinic to seek psychiatric help. He indicates that he is worried about his internet gaming habits. He has been spending an increasing amount of time playing online games, which has consequently disrupted his daily life. He has also neglected his family roles and responsibilities which makes him stressed and anxious. He reports being frustrated and feeling guilty since he is not able to control his gaming behavior.

• O: The patient is well-dressed and groomed. He is also alert and oriented. He looks disheveled and fatigue. He frequently checks his phone for gaming notifications during the session. He has a coherent speech. His thought process is coherent. Denies any suicidal thoughts or actions.
• A: The patient’s symptoms point to internet gaming disorder.
• P: The patient needs to start weekly sessions of cognitive behavioral therapy to help him address the underlying issues and modify the maladaptive gaming-related behaviors.

Conduct Disorder

Name: F.J
Age: 10 years
Gender: Male
Diagnosis: Conduct Disorder

F.J is a 10-year-old male patient who was brought to the facility by his mother. The mother reports that the patient has been showing worrying behavior both at home and in school. Over the past six months, he has continually experienced episodes of defiance, aggression, and rule-breaking. He gets offended when corrected.

• O: The patient is appropriately dressed and well-groomed. He is also alert and oriented. The patient interrupts, show restlessness and finds it difficult to stay seated during the session. He is in irritable mood and is easily frustrated. He has coherent speech and intact memory
• A: The patient’s symptoms indicate conduct disorder.
• P: The patient should start sessions of cognitive behavioral therapy to help him identify and modify his maladaptive thought patterns and acquire coping skills.

Borderline Personality Disorder

Name: S.A
Age: 28 years
Gender: female
Diagnosis: Borderline personality disorder

S.A is a 28-year-old female patient who came to the facility for a psychiatric visit. She reports various symptoms such as self-harming behaviors, unstable and intense relationships and history of mood swings. The patient reports experiences of frequent sense of emptiness, being overwhelmed by shifting and intense emotions, and struggles with unstable self-image. She engages in interpersonal conflict which leaves her feeling abandoned.

• O: The patient is appropriately dressed and groomed. She is also alert and oriented. She displays rapid mood shifts. She has coherent speech. Expresses hopelessness and frustration about her relationships. She has an intact memory and a coherent thought process. She denies suicidal thoughts or ideation.
• A: according to the DSM-V criteria, the patient’s symptoms indicate borderline personality disorder.
• P: The patient should start weekly sessions of Dialectical behavior therapy to improve emotional regulation.

Social Anxiety Disorder

Name: R.E
Age: 14 years
Gender: Male
Diagnosis: Social Anxiety Disorder

R.E is a 14-year old male patient who came to the facility accompanied by his parents. The patient confesses to experiencing substantial distress in social situations, such as when participating in sporting activities while in school. The patient indicates fear of negative evaluation; hence, he avoids social interactions. He also experiences other physical symptoms such as nausea and trembling when exposed to social stimuli. He indicates that he wants to improve his ability to engage with peers.

• O: The patient is well-dressed and groomed. He is also alert and oriented. He fidgets a lot and gives brief and hesitant responses. He has a clear speech. He has a coherent thought process and intact memory. He expresses fear and anxiety when thinking about upcoming social events. He denies suicidal thoughts or ideation.
• A: The patient’s symptoms point to social anxiety disorder.
• P: The patient is to commence weekly sessions of cognitive behavioral therapy to help him address negative thought patterns.

Antisocial Personality Disorder

Name: H.D
Age: 32 years
Gender: female
Diagnosis: Antisocial personality disorder

H.D is a 32-year-old female patient who was brought to the facility by her partner who indicated that he thinks she can get help from the facility. The patient is has history of problems remaining in employment and problems with interpersonal relationships. She also has several cases of fraud, theft, and legal issues, which have led to arrests. The patient doesn’t express remorse for her action. She is also deceitful and manipulative. The partner also describes the patient as displaying impulsivity and a lack of consideration for others’ well-being.

• O: The patient is appropriately dressed and presents with a self-assured demeanor. She is alert and oriented. She has a clear and persuasive speech. She has a coherent thought process and intact memory. She denies suicidal actions or thoughts. However, she exhibits minimal empathy for others.
• A: According to the DSM-V criteria, the patient’s symptoms are indicative of antisocial personality disorder.
• P: The patient should start dialectical behavior therapy to help address the maladaptive behavior and thinking patterns.

Persistent Depressive Disorder

Name: N.C
Age: 41 years
Gender: Male
Diagnosis: Persistent Depressive Disorder

N.C is a 41-year-old male patient who visited the facility to seek psychiatric help. The patient reports persistent feelings of hopelessness and low mood. He also indicates that he has been having depressive symptoms consistently for the last two year. Some of the symptoms include thoughts of worthlessness, low energy, disrupted sleep patterns, and difficulty finding pleasure in activities he loved.

• O: The patient is well-dressed and groomed. He is alert and oriented. He looks fatigued and struggles to maintain eye contact. He displays a sad mood. He has a slow speech and finds it difficult to concentrate. He denies history of hypomania or mania. He also denies suicidal thoughts or ideation.
• A: The patient’s symptoms are consistent with persistent depressive disorder
• P: The patients should start sessions of psychodynamic therapy to help address the negative thought patterns and develop coping strategies.

Attention-Deficit/Hyperactivity Disorder

Name: R.B
Age: 8 years
Gender: female
Diagnosis: Attention-Deficit Hyperactivity Disorder.

R.B. is an 8-year-old female patient who came to the facility accompanied by her parents. They report that their daughter has been experiencing problems with paying attention. Other symptoms include hyperactivity and impulsivity. Consequently, she finds it difficult to maintain focus in his activities, completing home work and school performance. These symptoms have been observed for six months.

• O: The patient is well-dressed and groomed. She is also alert and oriented. She fidgets, finds it difficult to stay seated, and is restless. She has clear speech but tends to shift topics rapidly and interrupts. She also finds it hard to follow instructions. She has a coherent thought process and intact memory. She denies suicidal thoughts or ideation.
• A: The patient’s symptoms are indicative of ADHD.
• P: The patient should commence weekly sessions of cognitive behavioral therapy to help improve emotional regulation and develop coping strategies.

Avoidant Personality Disorder

Name: A.D
Age: 19 years
Gender: Male
Diagnosis: Avoidant Personality Disorder

A.D. is a 19-year-old male patient who came to the clinic for a psychiatric visit. The patient presents with history of social interaction avoidance, fear of criticism and social anxiety. He indicates that he is usually uncomfortable in social situations, doesn’t want to be criticized, and has a desire to be liked. He also has a strong tendency to avoid social activities. He indicates that he feels frustrated and distressed about the potential effects of his avoidant behaviors on his daily functioning.

• O: The patient is well-dressed and groomed. He is also alert and oriented. He expresses a constricted affect and sad mood. He has a clear speech but expresses self-doubt in his speech. He has a coherent thought process and intact memory. The patient denies suicidal thoughts or ideation.
• A: The patient’s symptoms are consistent with avoidant personality disorder.
• P: The patient should start psychodynamic therapy to help him acquire coping strategies, improve self-esteem, and deal with negative thought patterns.

Bulimia Nervosa

Name: K.T
Age: 14 years
Gender: Female
Diagnosis: Bulimia Nervosa

K.T. is a 14-year old female patient who came to the facility accompanied by her foster mother. The mother expressed concern about the patient’s eating habits. Even though the patient is preoccupied with her body weight and fears gaining weight, she engages in episodes of binge eating. She therefore has to induce vomiting to compensate for the behavior. Even though her body weight is within the normal range, she expresses a desire to lose more weight. She reports that her eating habits and behavior have brought her shame and guilt.

• O: The patient is well-dressed and groomed. She is also alert and oriented. Her weight is within the normal ranges, but the mother indicates that she has experienced fluctuations in the last few months. She avoids eye contact when talking about her eating habits. She has a fluent speech. She has a coherent thought process and intact memory. She denies suicidal thoughts or ideations.
• A: The patient’s symptoms point to bulimia nervosa.
• P: The patient needs to start dialectical behavior therapy to help her address the distortions in the thoughts connected to eating and body image.

Schizoaffective Disorder

Name: N.H
Age: 52 years
Gender: Female
Diagnosis: Schizoaffective disorder

N.H. is a 52-year-old female patient who was brought the facility by her husband and daughter due to mental health concerns. The patient has been exhibiting symptoms such as paranoid thoughts and auditory hallucinations. She also experiences periods of difficulty concentrating, disrupted sleep, and low moods. She also expresses feelings of worthlessness, hopelessness, and racing thoughts.

• O: The patient is well-dressed and groomed. She looks disheveled and shows psychomotor agitation. She participates in a conversation with signs of emotional distress and auditory hallucinations. She has clear speech but, in most cases, stops to respond to internal stimuli. She denies suicidal ideations or thoughts.
• A: The patient’s symptoms show schizoaffective disorder.
• P: The patient should start sessions of individual therapy to help with the psychotic and mood symptoms.

Post-Traumatic Stress Disorder

Name: N.J
Age: 13 years old
Gender: Male
Diagnosis: Post-traumatic stress disorder (PTSD)

N.J. is a 13-year-old male patient who visited the facility for a psychiatric assessment accompanied by his mother. He complains of frequent and unpleasant nightmares following a recent car accident that left his mother injured. He has also exhibited symptoms such as irritability, agitation, emotional detachment, social isolation, hostility, anxiety, and sleep difficulties.

• O: The patient is well-dressed and groomed. He is also alert and oriented but shows symptoms of distraction. The patient had an intact thought process and short and long term memory. He fidgets during the exams. He is positive for suicidal thoughts and nightmares. He denies hallucinations.
• A: The patient’s symptoms point to PTSD based on the DSM-V criteria.
• P: The patient should start weekly cognitive behavioral therapy to help with the symptoms.

Insomnia

Name: L.H
Age: 55 years old
Gender: Male
Diagnosis: Insomnia

L.H is a 55-year-old male patient who came to the facility for an assessment after reports with sleep difficulties. He finds it hard to fall asleep. The patient is also easily distracted from sleep. He is therefore, fatigued during the day and unable to complete tasks effectively. He has been using sleeping pills to help him fall asleep but he doesn’t want them anymore.

• O: He is appropriately dressed and groomed. He is also alert and oriented. He looks fatigued and sleepy, pointing to a lack of sleep the previous night. He finds it hard to concentrate. He has a coherent thought process and intact memory. He denies suicidal thoughts or ideations.
• A: the patient’ symptoms show insomnia
• P: The patient is not willing to take sleeping pills anymore. Therefore, he needs to start sleep-focused CBT sessions.