PRAC 6645 WEEK 9 Clinical Hour and Patient Logs

Sample Answer

Post-Traumatic Stress Disorder

Name: L.B
Age: 26-years
Gender: male
Diagnosis: Post-traumatic stress disorder (PTSD)

L.B. is a 26-year-old male patient who came to the clinic with reports of repeated nightmares following an accident during a mountain hike that left some of his friends with serious injuries requiring hospitalization. He has since experienced various symptoms, such as insomnia, hostility, social isolation, emotional detachment, irritation, and agitation. The patient believes he can get help from the facility.

• O: The patient is well-dressed and oriented. He appears distracted. His short and long-term memory is still intact. The patient’s thought process is normal. He has had a single attempted suicide. However, he denies hallucinations or delirium.
• A: According to the DSM-V criteria, the patient has PTSD.
• P: The patient needs to commence family therapy sessions to help him deal with the symptoms.

Schizophrenia

Name: A.N
Age: 55-years
Gender: Female
Diagnosis: Schizophrenia

A.N. is a 55-year-old female patient who came to the facility accompanied by her partner. The patient reports to be hearing people talking outside her house and watching her in the last few weeks. She finds it hard to sleep due to the sounds she claims to hear loud noises. The partner is concerned that the patient is deteriorating and needs help.

• O: The patient is appropriately dressed and well-oriented in place, time, and person. The patient exhibited delusion. She finds it hard to make eye contact. The patient confirms having hallucinations and also responding to visual and auditory stimuli. Her speech is abnormal and disjointed. The thought process is also inconsistent and disorganized. The patient denies suicidal thoughts or actions.
• A: The patient’s symptoms point to the presence of schizophrenia
• P: The patient should commence individual CBT sessions to help with the symptoms.

Generalized Anxiety Disorder (GAD)

Name: D.Z
Age: 16-years
Gender: Female
Diagnosis: GAD

D.Z is a 16-year-old white female who has a history of generalized anxiety disorder and came to the facility accompanied by her mother for a follow-up. The mother indicates that the patient has been having suicidal thoughts for almost two weeks and that she has been having periods of crying, sometimes for no apparent reason. She indicates that the medication she has been using is not helpful. Other symptoms include appetite and sleep pattern changes.

• O: The patient appropriately dressed and looks oriented. Her speech was clear and normal. She looks sad and bothered. No hallucinations were noted. The patient has a consistent thought process, and the memory is intact. The patient has suicidal thoughts.
• A: The patient’s symptoms still indicate GAD.
• P: The patient needs to start group therapy sessions to help with symptoms

Alcohol Use Disorder

Name: H.C
Age: 35-years
Gender: male
Diagnosis: Alcohol use disorder

H.C. is a 35-year-old male patient who visited the facility for a follow-up. The patient had been engaging in binge drinking; hence was diagnosed with alcohol disorder and put on therapy. He has since tried to abstain from taking alcohol but still finds himself engaging in binge drinking. He complains about withdrawal symptoms which make him feel unpleasant. His work and social life have consequently been affected negatively.

• O: The patient is well and neatly dressed. He appears alert and oriented. The thought process is coherent. His speech is coherent and talks of his willingness to stop the behavior. The patient has no delusions or hallucinations. He also denies suicidal thoughts or attempts.
• A: The patient’s symptoms and history indicate that he still has alcohol use disorder.
• P: The patient should start group therapy sessions to help him cope better and deal with the symptoms.

Oppositional Defiant Disorder

Name: S.S
Age: 12-years
Gender: Male
Diagnosis: Oppositional Defiant Disorder

S.S. is a twelve-year-old who was brought to the clinic by the week for a clinic follow-up. The mother indicates that they visited the clinic some five weeks ago. Having been diagnosed with oppositional defiant disorder earlier, the mother indicates that the family therapy and the parent-management training programs used have somehow helped as the boy is less defiant. However, he still hates taking instruction from older children and siblings. The mother is still not happy with how her son likes arguing with almost everyone.

• O: The patient looks alert and oriented. He is well-dressed and neat. The boy cooperates during the assessment, keen to follow the process but still questions a lot. The boy looks unsettled as he finds it difficult to sit down. His thought process is coherent, and his memory is intact.
• A: The patient has a recurring oppositional defiant disorder
• P: The patient to continue with family therapy sessions

Panic Attack Disorder

Name: B.N
Age: 43-years
Gender: Male
Diagnosis: Panic attack disorder

B.N. is a 43-year-old man who came to the clinic with reports of frequent chest pains. He is worried that he may one day have a heart attack. He indicates other symptoms, such as anxiety and shortness of breath, which usually accompany the chest pains. He also reports that there are periods when he has had sensations such as squeezing, pressure, and choking.

• O: The patient is appropriately dressed and alert. He cooperates well during the assessment. He has an elevated and cooperative mood; however, the patient appears anxious. The speech is clear though rushed. He has coherent thought process and intact memory. No suicidal thoughts were noted.
• A: the symptoms point to a panic attack disorder
• P: The patient needs to start individual CBT sessions to help deal with the symptoms.

Bipolar Disorder

Name: T.F
Age: 36-years
Gender: Male
Diagnosis: Bipolar disorder

T.F. is a 36-year-old male patient who came to the facility for a follow-up visit. He reports various symptoms, such as elevated mood, which comes with delusions, euphoria, excitement, and over-activity. These symptoms have been alternating with spells of substantial depression. During the spells of depression, the patient experiences complications with decision-making and concentration, sleepiness, and reduced energy levels. The period of depression has been as frequent as once a day, and thereafter, the patient experiences a period of joy.

• O: The patient is appropriately dressed and well-groomed. He is also alert and oriented. He is in a sad mood. He has clear and steady speech. He has a coherent thought process and intact memory. The patient denies suicidal ideation, illusions, hallucinations, or delusions.
• A: The patient’s symptoms are indicative of bipolar disorder.
• P: The patient needs to start sessions of groups therapy to help him with the symptoms.

Attention Deficit Hypersensitivity Disorder (ADHD)

Name: T.L
Age: 9 years old
Gender: Male
Diagnosis: Attention Deficit Hypersensitivity Disorder

T.L. is a 9-year-old male patient who was brought to the facility by his mother for a psychiatric visit. The boy is increasingly making silly mistakes at home and school. He also fails to complete his school and homework sometimes due to forgetfulness and lack of attention. The reports from school indicate that the boy continually loves solitude, doesn’t want to play with other children, daydreams, and has a decline in performance.

• O: The patient is well-dressed and appropriately groomed. The mood is sad, and he indicates that he becomes sad whenever he thinks about school, as he had once been bullied. The patient has been showing symptoms such as failing to follow directions, committing careless mistakes, having a short attention span, and forgetfulness. He has a coherent speech. Denies suicidal thoughts.
• A: Based on the DSM-V criteria, the patient’s symptoms indicate ADHD.
• P: The patient needs to start weekly sessions of family therapy to help fight the symptoms.

Anorexia Nervosa

Name: J.G
Age: 15 years old
Gender: Female
Diagnosis: Anorexia Nervosa

J.G. is a 14-year-old female patient who was brought to the facility by her parents. They report that their daughter has been lacking appetite in the last few weeks. She reports that she has been feeling like not eating since she vomits and have feelings of nausea when she tries to eat. The result has been a notable drop in weight. In addition, the patient has other symptoms, such as dry and pale skin, as well as fatigue.

• O: The patient is well-groomed and dressed. She is also alert and oriented. The patient’s speech is clear, with normal tone and volume. She has a coherent thought process and good judgment and insight. She displays a mildly impaired functional status.
• A: The indicated symptoms point to anorexia nervosa. She is also dehydrated, as noted in her dry and pale skin.
• P: The patient should start individual therapy to help deal with the distorted thinking patterns for better outcomes.

Insomnia

Name: M.S
Age: 56 years old
Gender: Female
Diagnosis: Insomnia

M.S. is a 56-year-old patient who visited the facility with reports of insufficient sleep. The first onset was a few months ago, and she was hoping for improvement, which has so far failed to materialize. She has a problem falling asleep, and she is easily distracted from her sleep. The results have been feelings of low energy levels and tiredness during the day. As such, she has not been able to attend to her home tasks appropriately.

• O: The patient is well-dressed and neat. She is alert and oriented. While she is attentive at the start of the interview, she later loses interest with feelings of tiredness setting in. She has no illusions, delusions, hallucinations, or suicidal thoughts.
• A: The patient’s symptoms are indicative of insomnia
• P: The patient needs to start individual therapy sessions.

Autism Spectrum Disorder

Name: G.G
Age: 11 years old
Gender: male
Diagnosis: Autism Spectrum Disorder

G.G. is an 11-year-old boy who presents to the clinic with his mother after a referral. The boy has a history of depression, anxiety, and autism. He has been under medication since these conditions were diagnosed some years back. The mother reports that her son displays feelings of rejection and outbursts of anger. The patient stopped using prescribed medications.

• O: The patient is well-dressed and groomed. He is also well-oriented. The patient has intact insight and age-appropriate judgment. The patient’s speech is normal, with no pressure noted. Has some notable agitation. He has an appropriate short-term and long-term memory and acceptable thought process. However, the boy shows substantial worry and phobia
• A: The patient has autistic spectrum disorder among children.
• P: The patient needs to start family therapy sessions to help with the symptoms.

Substance Use Disorder

Name: A.R
Age: 22 years old
Gender: male
Diagnosis: Substance use disorder

A.R is a 22-year-old male patient who visited the facility accompanied by his father. The father reported that his son had been addicted to heroin since he had been using heroin daily for the last three years. He once tried rehabilitation but failed. The patient reports symptoms such as poor insight, helplessness, hopelessness, depression, and low self-esteem. The patient started using marijuana in his early days, and transitioned to heroin a few years later.

• O: The patient is appropriately dressed and groomed. He is oriented to time and space. He finds it difficult to initiate and maintain eye contact. He has an intact thought process and appropriately responds to questions. He has poor insight and judgment. The patient denies suicidal thoughts or hallucinations.
• A: The patient’s history and symptoms point to substance use disorder
• P: The patient needs to start group therapy sessions.