PRAC 6645 WEEK 8 Clinical Hour and Patient Logs

Sample Answer

Oppositional Defiant Disorder

Name: M.J
Age: 10 years old
Gender: Male
Diagnosis: Oppositional Defiant Disorder

M.J is a ten-year-old male patient who was brought to the facility by his mother. The mother reported that the patient has been having a behavioral change, both at home and school. He continually finds it hard to follow the rules, defies instructions, and engages in frequent arguments. These symptoms have persisted close to six months, causing sadness to the family members.

• O: The patient is appropriately dressed and appears his age. He is also alert and oriented. He maintains eye contact but shows sins of restlessness. He is interruptive and engages in minimal conversation. He has a coherent thought process and intact memory. He has an irritable and defiant mood. His sleep is clear and coherent but goal-directed.
• A: Based on the DSM-5 criteria, the patient has oppositional defiant disorder.
• P: The patient should start family therapy to help understand the dynamics within the family system and offer psychoeducation.

Postpartum Depression

Name: S.C
Age: 22 years old
Gender: Female
Diagnosis: Postpartum depression

S.C. is a twenty-two-year-old female patient who came to the clinic with reports of anxiety, hopelessness, and sadness following the birth of her first child one and a half months ago. She has faced challenges bonding with her new born. She also has other symptoms such as disrupted sleep patterns and appetite changes. She has also lost interest in activities such as reading which she adored before.

• O: The patient has a disheveled appearance. She is alert and oriented. She struggles to make eye contact. She also exhibits restlessness, and psychomotor agitation. Her thought process is ruminative and focuses on feelings of guilt. Her speech is slow and low volume. She reports feelings of inadequacy as a first time mother. Reports suicidal ideation.
• A: Based on the DSM-V criteria, the patient has postpartum depression.
• P: The patient should start group therapy sessions to help her get peer support and normalize the experiences of a first-time mother. In addition, group therapy would help in psychoeducation.

Alcohol Use Disorder

Name: G.W
Age: 33 years old
Gender: Male
Diagnosis: Alcohol use disorder

G.W. is a thirty-three-year-old male patient who reported to the facility to seek help for the struggles he has with alcohol consumption. He has a history of regular alcohol use, which has just been getting worse in the past few years and months. Consequently, he has been having lateness and absenteeism problems at work and family problem. He indicates that he needs help to improve his well-being.

• O: The patient is visibly having poor hygiene and grooming. He is also oriented but looks fatigued. He has an impaired concentration. His thought process is coherent. He exhibits slurred speech and a slow rate of articulation. He has an anxious and dysphoric mood. He denies suicidal thoughts or ideations.
• A: The patient’s symptoms point to alcohol use disorder.
• P: The patient needs to start individual CBT sessions to help him develop coping skills and address the distorted thought patterns.

Separation Anxiety Disorder

Name: H.T
Age: 8 years old
Gender: female
Diagnosis: Separation Anxiety Disorder

H.T. is an eight-year-old female patient who visited the clinic accompanied by her parents. The parents report that their daughter is usually distressed when separation from them is imminent. She expresses excessive worry about harm to her or her parents when separated. She, therefore, expresses reluctance to attend school, which is negatively affecting her learning progress and performance.

• O: The patient is well-dressed and appropriately groomed. She is also alert and oriented. She displays clingy behavior during the assessment. She has a clear speech. She has a fearful and anxious mood. Her though process is coherent, though she expresses worry and harm about separation. She denies delusions or hallucinations. She also denies suicidal thoughts or ideation.
• A: The patients symptoms point to separation anxiety disorder.
• P: The patient should start family therapy sessions to help understand the family interactions, roles, dynamics, and factors that may contribute to the problem.

Insomnia

Name: B.C
Age: 55 years old
Gender: female
Diagnosis: Insomnia

B.C. is a 55-year-old female patient who visited the facility with reports of chronic difficulty falling asleep and maintaining sleep. She quickly gets distracted from her sleep and frequently wakes up at night. She, therefore, struggles to wake up in the morning to attend to her chores. The problem is also negatively affecting her quality of life.

• O: She is well-dressed and groomed. She looks tired and fatigued. She has a sad and anxious mood, especially when talking about sleep. Her thought process is focused on the problem of not getting sufficient sleep. Her short and long term memory is intact. She denies suicidal thoughts or ideations.
• A: The patient’s symptoms are indicative of chronic insomnia since she also estimates her sleep hours at night as around four hours.
• P: The patient needs to start individual cognitive behavioral therapy for insomnia which focuses on cognitive restructuring.

Binge eating disorder

Name: S.R
Age: 15 years old
Gender: male
Diagnosis: binge eating disorder

S.R is a 15-year-old male patient who came to the facility with reports of recurrent episodes of binge eating. He indicates that he experiences a feeling of loss of control during such episodes and he eats large amounts of food within very short durations. Such episodes are usually followed by distress and guilt. He has tried to stop but he has been unable.

• O: The patient is appropriately dressed and groomed. He is also alert and oriented. He expresses shame when discussing the binge eating episodes. His thought process is preoccupied with guilt, weight, and body image connected to binge eating. He has a clear speech. His memory is also intact. Denies thoughts of self-harm or suicidal thoughts.
• A: The patient’s symptoms indicate a binge eating disorder.
• P: The patient should start group therapy sessions to help share experiences with others and get peer support. The sessions can also be important for psychoeducation.

Post-traumatic stress disorder

Name: D.S
Age: 38 years old
Gender: female
Diagnosis: Post-traumatic stress disorder

D.S is a 38-year-old female patient who came to the facility with reports of uncomfortable symptoms following a traumatic experience some months ago. Since then, she has been exhibiting various symptoms such as avoidance of what reminds her of the event, hypervigilance, and frequent nightmares related to the event and distressing memories.

• O: The patient is well-dressed an appropriately groomed. She is also alert and oriented. She displays limited eye contact. She is irritable and finds it hard to concentrate. She has a coherent thought process but is preoccupied with past events. She denies thoughts of self harm.
• A: According to the DSM-V criteria, the patient has PTSD
• P: The patient should start family therapy sessions to help enhance communication and coping skills.

Body Dysmorphic Disorder

Name: A.S
Age: 12 years old
Gender: Female
Diagnosis: Body Dysmorphic Disorder

A.S is a twelve-year-old female patient who was brought to the facility by her mother. The mother indicates that her daughter has been expressing worrying concerns regarding her appearance which has led to distressing behaviors and thoughts. She indicates that her face is not proportional and that her body has many flaws. Therefore, she spends much time in mirrors and tries so many mythical things to fix her perceived imperfections.

• O: She is well-dressed and appropriately groomed. She is alert and oriented. She has a distressed and anxious mood. She frequently covers part of her face when talking. She has a clear speech. She also has a coherent thought process. Her memory is intact. She denies suicidal thoughts, but she admits to hating how she looks.
• A: The patient’s symptoms point to body dysmorphic disorder.
• P: The patient should start group sessions to get peer support, reduce the stigma, and feel less isolated regarding her body image concerns.

Schizoaffective Disorder

Name: P.D
Age: 56 years old
Gender: Male
Diagnosis: Schizoaffective Disorder

P.D is a 56-year-old male patient who visited the facility for a psychiatric checkup. The patient has a history of schizoaffective disorder and currently reports ongoing complications with daily functioning, psychotic symptoms, and mood fluctuations.

• O: The patient is disheveled and is poorly groomed. He also displays psychomotor agitation. He finds it hard to create and maintain eye contact. His mood varies rapidly from expansive and elevated to irritable. The patient has an impaired thought process with racing thoughts evident. He is also positive for hallucinations and grandiose delusions.
• A: The patient’s symptoms and history are indicative schizoaffective disorder.
• P: The patient should start individual cognitive behavioral therapy to help in addressing thought content and improve coping skills and insights.

Enuresis Disorder

Name: C.F
Age: 8 years old
Gender: Male
Diagnosis: Enuresis Disorder

C.F. is an 8-year-old male patient who came to the facility accompanied by his parents. The parents indicate that the boy has all his development stages and milestones intact. He has been bedwetting consistently for weeks. He feels embarrassed as he needs to put on pull-ups at night. He has continually liked playing alone.

• O: The patient is well-dressed and groomed. He is also alert and oriented. His mood is sad.. He has a fluent speech. His thought process and memory are both intact. He denies suicidal thoughts or thoughts of self-harm.
• A: The patient’s symptoms are indicative of enuresis disorder
• P: The patient needs to start family therapy session to help identify the underlying factors and help him develop coping skills.

Avoidant Personality Disorder

Name: M.T
Age: 26 years
Gender: Male
Diagnosis: Avoidant Personality Disorder

M.T. is a twenty-six-year-old male patient who visited the facility for a checkup. He reports a history of social anxiety, fear of criticism, and social interaction avoidance. The patient also indicates that he has a strong desire to be liked, fears criticism and usually feels uncomfortable in social situations. He reports that he needs to improve his social activities and social situations.

• O: The patient is appropriately dressed and well-groomed. The patient is also alert and oriented. The patient’s mood is sad. The patient has a clear and coherent speech. The speech is full of self-doubt. The patient’s short and long term memories are both intact. His thought process is coherent. The patient denies suicidal behavior or actions.
• A: Based on the DSM-V diagnostic criteria, the patient’s symptoms are indicative of avoidant personality disorder.
• P: There is a need for the patient to commence group therapy to help him deal with negative thought patterns and improve his self-esteem.

Attention-Deficit/Hyperactivity Disorder

Name: M.M
Age: 10 years
Gender: female
Diagnosis: Attention-Deficit Hyperactivity Disorder.

M.M is a ten-year-old female patient who was brought to the clinic by her parents. The father reports that the patient has been having complications with paying sufficient attention. She also displays impulsivity and hyperactivity symptoms. She finds it difficult to complete tasks assigned.

• O: The patient is appropriately dressed and well-groomed. She is also alert and oriented. However, she fidgets and is restless. The patient has a clear and coherent speech. However, she rapidly shifts topics and interrupts. She finds it hard to follow instructions. Her thought process is coherent.
• A: Based on the DSM-V criteria, the patient’s symptoms indicate ADHD.
• P: The patient should start weekly individual CBT sessions to help her with her behavior and thought patterns.