PRAC 6665 WEEK 9 Assignment 1: Clinical Hour and Patient Logs

PRAC 6665 WEEK 9 Assignment 1: Clinical Hour and Patient Logs

Clinical Hour and Patient Logs

Major Depression

Name: B.T

Age: 33 years

Diagnosis: Major depression

S: B.T. is a 33-year-old client that came to the unit for her second follow-up visit after she was diagnosed with depression three months ago. The client diagnosis was reached after she presented with complaints that included depressed mood in most of the days for every day. She was also socially isolated as he lacked interest in things and pleasure. She reported that the depressed mood had made it difficult for her to engage in her occupational roles. The client also reported that her ability to make decisions was also significantly affected. His level of irritability was also high. She also reported suicidal ideations without plans or intent. As a result, she was diagnosed with major depression and initiated on treatment.

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O: The client appeared appropriately dressed for the occasion. Her self-reported mood was ‘improved.’ The client was oriented to self, others, time, and events. She denied illusions, delusions, and hallucinations. She denied suicidal thoughts, plans,or attempts. Her speech was normal in terms of rate and volume.

A: The symptoms of depression have improved. The client reports positive experiences with the adopted treatment.

P: The client was advised to continue with the current treatment. She was scheduled for a follow-up visit after four weeks.

  Major Depression     

Name: G.R

Age: 28 years

Diagnosis: Major depression

S: G.R is a 28-year-old client that came to the unit as a referral for psychiatric assessment. She came with complaints of feeling sad most of the days, feeling worthless and guilty most of the time. She also reported a decline in her appetite and being socially withdrawn. Her interest in pleasure also declined significantly. She also reported insomnia, easy irritability, and difficulties in concentrating and making decisions. The symptoms had affected significantly her ability to perform optimally in her academic and social roles. The symptoms could not be attributed to other causes such as medication use, medical conditions, or substance abuse. As a result, she was diagnosed with major depression and initiated on treatment in the facility.

O: The patient appeared poorly dressed for the occasion. She was oriented to self, place, time, and events. Her judgment was intact. She denied any suicidal thoughts, attempts, or plans as well as illusions, delusions, and hallucinations. Her mood was depressed.

A: The client is experiencing moderate symptoms of major depression. She needs treatment to manage her depressive symptoms.

P: The client was initiated on antidepressants for the depressive symptoms. She was scheduled for a follow-up visit after four weeks.

Insomnia

Name: O.T

Age: 38 years

Diagnosis: Insomnia

S: O.T is a 38-year-old male that came to the clinic for his sixth follow-up visit after being diagnosed with insomnia. He has been on psychotherapy treatment. He was diagnosed with insomnia after presenting to the unit with complaints of persistent lack of quality and quantity sleep. He reported that he remained awake throughout most of the nights and experienced awakening which was followed by difficulties in falling asleep. The lack of sleep had affected his productivity in the workplace since he often fell asleep during the afternoon hours. As a result, he came to the unit for assistance where he was diagnosed with insomnia and initiated on individual psychotherapy.

O: The patient appeared dressed appropriately for the occasion. He was oriented to self, others, time, and events. His speech was normal in terms of rate and volume. He denied illusions, delusions, and hallucinations. He also denied suicidal thoughts, plans, and attempts.

A: The psychotherapy treatment has been effective. There is considerable symptom improvement.

P: Psychotherapy sessions were terminated since the desired treatment outcomes had been achieved.The client was scheduled for a follow-up visit after two months.

Post-Traumatic Stress Disorder

Name: M.C

Age: 35 years

Diagnosis: Post-traumatic stress disorder

S: M.C is a 35-year-old female client that came to the unit for psychiatric assessment. She came with complaints of abnormal behaviors following her involvement in a road accident. The client raised complaints that included the persistent recurrence of the distressing memories about the accident. She also reported flashbacks and intense distress following her exposure to stimuli that resembled the accident. She also noted difficulties in getting quality and quantity sleep over the last three months. The symptoms had affected her ability to engage in her occupational and family roles. As a result, she came to the unit for assistance where she was diagnosed with post-traumatic stress disorder and initiated on treatment.

O: The client was dressed appropriately for the occasion. She was oriented to self, others, time, and events. Her judgment was intact. She denied illusions, delusions, and hallucinations. She also denied suicidal thoughts, attempts, and plans. His thought process was future-oriented.

A: The client is experiencing moderate symptoms of post-traumatic stress disorder. She needs assistance in managing the distressing symptoms of the disorder.

P: The client was initiated on antidepressant treatment. She was scheduled for a follow-up visit after four weeks to determine her response to treatment.

Post-Traumatic Stress Disorder

Name: G.L

Age: 33 years

Diagnosis: Post-traumatic stress disorder

S: G.L is a 33-year-old male client that came to the unit today for his fourth follow-up visit for post-traumatic stress disorder. He was diagnosedfive months ago with the disorder and has been undergoing treatment. According to his narrative, he started experiencing abnormal symptoms after being involved in a road accident. The symptoms included flashbacks and nightmares about the accident. He also reported avoidance behaviors, being easily irritated, insomnia, and difficulties in concentration. Therefore, the above symptoms led to his diagnosis of post-traumatic stress disorder and treatment initiation.

O: The client appeared well-groomed for the occasion. His orientation to self, others, environment, and events were intact. His self-reported mood was normal. His level of judgment was intact. He denied suicidal thoughts, plans or attempts, illusions, delusions, and hallucinations.

A: The client is responding positively to the treatment. He is also tolerating the medications well since he reports no side effects.

P: The client was advised to continue with the treatments and scheduled for a follow-up visit after one month

Generalized Anxiety Disorder

Name: L.D

Age: 30 years

Diagnosis: Generalized anxiety disorder

S: L.D is a 30-year-old female that came to the unit for psychiatric assessment. The client came with complaints of excessive, unexplained worry of unknown outcomes. The client noted that she frequently experiences excessive fear of failing in her occupational roles and being perceivedas a failure in society. She noted that symptoms that include fatigue, muscle tension, irritability, and restlessness accompany excessive fear. The frequent episodes of excessive fear and anxiety were affecting her social, occupational, and personal life. The symptoms could not be attributed to causes such as substance abuse, medication, or medical condition. As a result, she was diagnosed with generalized anxiety disorder and initiated on individual psychotherapy.

O: The patient appeared appropriately dressed for the occasion. She appeared tense during the assessment. Her orientation to self, others, time, and events were intact. She denied illusions, delusions, hallucinations, suicidal thoughts, attempts, or plans.

A: The client is experiencing moderate symptoms of generalized anxiety disorder. She should be assisted in developing effective coping strategies against the symptoms.

P: The client was initiated on group psychotherapy sessions. She was assisted in identifying and managing triggers of the distressing symptoms. She was scheduled for a follow-up visit after four weeks.

Substance Abuse Disorder

Name: M.M

Age: 50 years

Diagnosis: Substance abuse disorder

S: M.M. is a 50-year-old male that came to the unit for his seventh follow-up visit. He was diagnosed with substance abuse disorder eight months ago and has been on pharmacological treatment, psychotherapy, and Alcohol Anonymous group. The client was diagnosed with the disorder after he came initially with complaints of excessive alcohol intake. He noted that his alcohol intake was beyond the normal levels. He also reported incidences of trying to quit taking alcohol but was unsuccessful due to the intense cravings for the substance. He also noted an increase in the severity of the withdrawal symptoms in days when he did not take alcohol. Alcohol abuse had made him neglect his social, family, and professional responsibilities. The client was worried that his alcohol abuse habits were getting out of hand and would affect his family. As a result, he came to the unit seeking assistance where he was diagnosed with substance abuse disorder and initiated on treatment.

O: The client appeared appropriately dressed for the occasion. His orientation to self, others, time, and events were intact. He denied illusions, delusions, and hallucinations. He also denied suicidal thoughts, plans, or attempts. He did not demonstrate abnormal behaviors that include tics and tremors during the assessment.

A: The client has developed effective coping strategies for managing cravings for alcohol and withdrawal symptoms. He also tolerates well the prescribed treatments.

P: The client was advised to continue with participation in the Alcohol Anonymous group. Psychotherapy sessions were terminated since treatment outcomes had been achieved. He was advised to continue with the current medications. He was scheduled for a follow-up visit after four weeks

Schizophrenia

Name: E.D

Age: 34 years

Diagnosis: Schizophrenia

S:E.D is a 34-year-old male that came to the unit for his follow-up visit after being diagnosed with schizophrenia two months ago. The client has been on treatment. The diagnosis was reached after being brought to the unit with complaints of speech incoherence and false self-identity. The client believed that he was Jesus Christ and he had been sent to save the world. The client also had diminished emotional expression. The symptoms had persisted for more than five months and worsened in severity over time. The symptoms could not be attributed to other causes, including medical conditions, medication use, or substance abuse. As a result, he was diagnosed with schizophrenia and initiated on treatment.

O: The patient appeared dressed appropriately for the occasion. He appeared to be oriented to self, others, time, and events. He reported that delusions had subsided following the treatment. He denied illusions and hallucinations. He also denied suicidal thoughts, attempts, and plans.

A: There has been a moderate improvement in schizophrenia symptoms. The client tolerates the adopted treatment well.

P: The client was advised to continue with the current treatment. He was initiated in the group psychotherapy sessions to help him identify effective coping skills for schizophrenia symptoms. He was scheduled for a follow-up visit after four weeks.

Bipolar Disorder

Name: Z.M

Age: 30 years

Diagnosis: Bipolar disorder

S: Z.M. is a 30-year-old female that came to the unit for her third follow-up visit for bipolar disorder. She was diagnosed with the disorder four months ago and has been on antidepressants. The client recalled that the diagnosis was reached after she came with complaints that included alternating periods of persistently elevated and expansive mood that predisposed her to engage in goal-directed activities. The symptoms lasted for a week and alternated with those similar to depression. The symptoms included a flight of ideas, being more talkative than usual, being easily distracted, and insomnia. The client also engaged in risky behaviors that included alcohol abuse and unplanned financial spending. The symptoms could not be attributed to any other causes, including medication use, medical condition, or substance abuse. As a result, she was diagnosed with bipolar disorder and initiated on treatment.

O: The client was appropriately dressed for the occasion. She was oriented to self, others, time, and place. She denied illusions, delusions, and hallucinations. She also denied expansive, elevated moods over the recent month. She also denied a history of suicidal thoughts, plans, and attempts.

A: The adopted treatment is effective in symptom management.

P: The client was initiated on group psychotherapy treatment alongside the pharmacological intervention. She was scheduled for a follow-up visit after four weeks.

Attention Deficit Hyperactive Disorder (ADHD)

Name: T.A

Age: 10 years

Diagnosis: Attention Deficit Hyperactive Disorder

S: T.A. is a 10-year-old child that was brought to the unit for his follow-up visit for ADHD. The child was diagnosed with ADHD at the age of seven and has been undergoing treatment in the facility. The parent reported that T.A. was diagnosed with ADHD after he demonstrated abnormal behaviors. They included those related to inattention such as failing to pay attention to details, difficulties in completing activities, not listening when being spoken to, and troubles in organizing tasks. The child also demonstrated hyperactivity and impulsivity symptoms that included fidgeting, failing to engage in leisure activities quietly, difficulties in waiting for their turns, and intruding on others. The teacher also reported similar symptoms, leading to the diagnosis of ADHD. The child has been on treatment since then.

O: The child appeared appropriately dressed for the occasion. His orientation to self, others, time, and events were intact. The child denied any abnormal thought processes, including illusions, delusions, and hallucinations. He did not demonstrate abnormal behaviors such as fidgeting during the assessment. She denied suicidal thoughts, plans, or attempts.

A: The child continues to demonstrate a positive response to the treatment. ADHD symptoms have been effectively managed.

P: The child and parent were advised to continue with the treatment. They were scheduled for a follow-up visit after four months.

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Assignment 1: Clinical Hour and Patient Logs

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Clinical Hour Log
For this course, all practicum activity hours are logged within the Meditrek system. Hours completed must be logged in Meditrek within 48 hours of completion in order to be counted.
You may only log hours with Preceptors that are approved in Meditrek. Students with catalog years before Spring 2018 must complete a minimum of 576 hours of supervised clinical experience (144 hours in each practicum course). Students with catalog years beginning Spring 2018 must complete a minimum of 640 hours of supervised clinical experience (160 hours in each practicum course).

Each log entry must be linked with an individual practicum Learning Objective or a graduate Program Objective. You should track your hours in Meditrek as they are completed.

Your clinical hour log must include the following:

Dates
Course
Clinical Faculty
Preceptor
Total Time (for the day)
Notes/Comments (including the objective to which the log entry is aligned)
Patient Log
Throughout this course, you will also keep a log of patient encounters using Meditrek. You must record at least 80 encounters with patients by the end of this practicum (40 children/adolescents and 40 adult/older adult).

The patient log must include the following:

Date
Course
Clinical Faculty
Preceptor
Patient Number
Client Information
Visit Information
Practice Management
Diagnosis
Treatment Plan and Notes: You 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.