PRAC 6675 WEEK 3 Assignment 1: Clinical Hour and Patient Essay
PRAC 6675 WEEK 3 Assignment 1: Clinical Hour and Patient Essay
Oppositional Defiant Disorder (ODD)
Name: K.D Sex: Male
Age: 9 years
Diagnosis: Oppositional Defiant Disorder
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S: K.D is a 9-year-old AA male patient who was referred for psychotherapy by his PCP for ODD. The boy was diagnosed with ODD after demonstrating a consistent pattern of rejecting adults’ authority. The boy’s mother expressed concerns that he was unmanageable both at home and school. He constantly got into fights and arguments with adults at home and school. His teachers complained that the boy would deliberately annoy them. Besides, he refused to comply with requests and rules at school. The mother reported that the boy was stubborn and often tested adults’ limits. As a result, he had been given several warnings at school, and he is now on the verge of expulsion. The boy gets easily annoyed, loses his temper, and tends to blame others for his mistakes.
O: The boy is neat and appropriately dressed. He stays still in his chair but maintains minimal eye contact. His self-reported mood is ‘okay,’ and his affect is broad. His speech is clear, but he often raises his tone ad volume when asked about his poor behavior and disrespect for adults. The boy denies disrespecting or being rude to adults. He demonstrates a logical and coherent thought process. No delusions, hallucinations, phobias, or obsessions were noted. Short- and long-term memory is intact.
A: Irritable mood, Defiant behavior, Oppositional defiant disorder. ADHD was ruled out.
P: Initiate Family therapy (parental guidance and assessment of family interaction), Parent management training (PMT), Cognitive-behavioral treatment (CBT).
Name: G.P Sex: Male
Age: 9 years
Diagnosis: Conduct Disorder
S: G.P is a 9-year-old AA male patient accompanied by his mother for psychotherapy after a referral from the pediatrician. The patient was diagnosed with Conduct disorder after exhibiting a pattern of cruelty and disrespecting others’ rights. The mother reports that the child had been suspended from school due to several complaints of bullying from his schoolmates. The boy would threaten and intimidate his classmates and often start fights in school. Besides, his classmates reported that he stole their items and lunch and would threaten to beat them if they reported him to the school authority. The mother stated that she had gotten several complaints from the neighbor of the boy assaulting his neighbors’ kids and being aggressive to their pets. He has gotten into fights with kids in the neighborhood and ended up destroying property that the mother was forced to pay. The mother expressed concerns since the boy’s behaviors have persisted since he was 6 years and evolved to a point where he violated rules at home and school. His school performance has drastically declined, and he is usually last in his class.
O: The patient is well-groomed and appropriately dressed. He is calm and maintains eye contact throughout the session. His self-reported mood is nervous, and his affect is appropriate. He has a clear speech with a normal rate and volume. He has a coherent and logical thought process. No delusions, hallucinations, phobias, or obsessions were noted. Short- and long-term memory is intact. Oriented to person, place, and time. Demonstrates good judgment.
A: Violation of Rules; Impaired social interaction; Self-esteem disturbance; Risk for violence.
P: Initiate Play Therapy and Parent management training.
Attention Deficit Hyperactive Disorder
Name: S.L Sex: Female
Diagnosis: Attention Deficit Hyperactive Disorder
S: S.L is a 6-year-old White female s referred for psychotherapy by her PCP due to ADHD. ADHD was diagnosed after the patient constantly exhibited hyperactive, impulsive, and inattention. The girl’s guardian reported that the behavior started about two years ago, but she perceived it as part of child development. S.L has temper tantrums and problems with anger management. The mother mentioned that the behavior has interfered with her learning since he cannot remain still in class. The patient’s teacher reported that it was difficult to contain her in class since she would move around when a class was in session and talk excessively. She was also easily distracted and made impulsive decisions. The PCP had prescribed Methylphenidate 36 mg P.O. OD.
O: The patient is well-groomed and appropriately dressed. She fidgets on the chair and maintains minimal eye contact. She constantly moves around the office and cannot maintain one sitting position. Her self-reported mood is worried, and her affect is elevated. Her speech is clear but loud, and her thought process is coherent. No hallucinations, delusions, phobias, or obsessions were noted. No self-injurious thoughts were noted. She has a short attention span and is easily distracted. Her recent memory is impaired, but her long-term memory is intact. Deficits noted in calculation concentration. Judgment and abstract thought are intact.
A: Hyperactivity and Impulsivity; Impaired attention span; Easy distractibility; Deficits in thinking, memory, calculation, and concentration.
P: Initiate Behavioral psychotherapy and continue treatment with Methylphenidate. Involve the child’s class teacher to make the environment conducive to allow her to focus and maintain attention in class. Begin Behavioral parent training. Introduce the child to a social skills group for children with ADHD.
Name: W.P Sex: Female
Diagnosis: Anorexia nervosa
S: W.P is a 16-year-old female of Indian descent on psychotherapy for Anorexia nervosa. Her PCP referred her for anorexia nervosa since she had a persistent pattern of taking very small portions of food and missing some meals to avoid weight gain. The patient reported being irrationally worried about gaining weight and was concerned that if she increased t eh food portions or had three meals a day, she would gain weight that might get out of control. W.P also reported that she avoids taking fluids since they enlarge her tummy. The client said that when she takes large portions of food, she feels guilty and, in return, induces vomiting to limit food absorption. She stated that weight gain would be a failure since she was constantly criticized for being chubby when she was younger.
O: The client is neat and appropriately dressed client but appears emaciated. Her self-reported mood is anxious, and her affect is broad. Her speech is clear with normal rate and volume. She has a coherent thought process, and no hallucinations, delusions, and suicidal ideations were noted. She is preoccupied with thoughts about weight gain and body shape. Her cognition, judgment, memory, and abstract thought are grossly intact.
Weight- 104 pounds, Height-5’5, BMI-17.3.
A: Anxiety; Profound psychological disturbance about body size and weight. Self-esteem disturbance.
P: Initiate weekly Cognitive-behavioral and cognitive remediation therapies. Consider Insight-oriented Individual therapy and Motivational enhancement therapy in future therapies.
Name: W.B Sex: Male
S: W.B is an 8-year-old African American male client accompanied to the psychiatric clinic by his mother. The mother reported that the child was depressed, and he was frequently feeling sad with an irritable mood. She also stated that the child’s teacher mentioned that he has withdrawn from peers in class and has lost interest in academic and extra-curricular activities, which has affected his grades. Besides, the mother reported that the client has a decreased appetite, leading to noticeable weight loss. The boy also sleeps a lot and often has difficulty waking up to school since he usually complains that he has not had enough sleep. The patient appears fatigued most of the days and has a decreased concentration in school and when doing his homework. The boy attained all developmental landmarks at appropriate ages.
O: The physical exam was unremarkable, and laboratory results were within normal limits.
Pertinent findings on MSE include a sad self-reported mood and affect was blunted. The child did not endorse active suicidal ideation but reported that he often thinks about himself being dead and what it would be like to be dead. He scored 30 on the Children’s Depression Rating Scale, indicating significant depression.
A: Pediatric depression; Sleep disturbance; Appetite disturbance.
P: Initiate psychotherapeutic approaches, including cognitive-behavioral therapy, interpersonal therapy, and Family therapy. The patient was started on Zoloft 25 mg orally daily.
Diagnosis: Bulimia nervosa
E.D is a 24-year-old AA female client referred for psychotherapy by her PCP after being diagnosed with Bulimia nervosa. The client has a history of regularly binge eating, followed by abnormal compensatory behaviors to eliminate the excess food from her body system. The client reported that she consumes large amounts of sugary foods high in fat over a short period and then feels that the eating is out of control. She then induces vomiting and takes laxatives to eliminate the excess calories. This occurs 2-3 times a week, and she has engaged in this behavior in the past five months. She expressed concerns about her body shape and weight and stated that the self-induced vomiting and laxatives are efforts to avoid weight gain.
O: Weight- 165 pounds, Height-5’4 BMI-28.3 The client is well-groomed and appropriately dressed for the weather. She is alert, oriented, and maintains eye contact. Her self-reported mood is anxious, and her affect is appropriate. Her speech is clear with normal rate and volume. She has a logical thought process. No hallucinations, delusions, or suicidal ideations were noted. She is preoccupied with thoughts about her body shape, weight, and personal appearance. Her cognition, judgment, memory, and abstract thought are intact.
A: Anxiety; Self-esteem disturbance; Purging behaviors.
P: Initiate weekly Cognitive-behavioral and cognitive remediation therapies.
Major Depressive Disorder
Name: S.A Sex: Female
Diagnosis: Major depressive disorder
S.A is a 44-year White female who presented with complaints of a depressed mood. She reported that she began experiencing a depressing mood 12 weeks ago, and it has worsened over time. The patient attributes the depressed mood to a lack of finances and loss of support from her ex-husband. She also reported losing interest in activities she previously found pleasurable. She stated that she only finds pleasure in eating since her appetite has increased over time, and she has gained about 9 pounds in the past two months. The client states that she feels hopeless and helpless. She had suicidal ideations and suicidal plans of overdosing, but she did not go through with the plans after a friend caught her in the act and called 911. She had a history of depression at 18 years and Schizoaffective at 25 years. The client is currently on Zoloft.
O: The client is shabby-looking and inappropriately dressed. She is alert, appears bored, and maintains minimal eye contact throughout the session. The client is tearful, and her self-reported mood is sad. Affect is labile. Her speech is low and soft with frequent pauses but is logical. No hallucinations or delusions were exhibited, and her long- and short-term memory is intact. Her judgment is limited.
A: Mood disturbance; Appetite disturbances; Suicidal ideations.
P: Continue with Zoloft therapy and monitor the drug’s side effects. Initiate psychotherapy with weekly CBT sessions. Integrate Mindfulness-based cognitive therapy to lower the risk of relapse of depressive symptoms. Include Problem-solving therapy in psychotherapy sessions.
S: E.T is a 48-year-old A.A female client on psychotherapy to manage Insomnia. She reported having difficulties initiating and maintaining sleep for six months. The Insomnia has worsened over time and has interfered with her daily activities since she feels sleepy and fatigued during the day. She feels sleepy before bedtime but stays awake for almost two hours when she gets to bed, and most of the time, she gets out of bed. She is concerned that Insomnia is affecting her job output. The client stated that she has been taking a glass of vodka to help her sleep, but this has not been effective since she experiences nighttime awakening.
O: The client is well-groomed and dressed appropriately for the function and weather. Her self-reported mood is ‘okay,’ and her affect is appropriate. She appears fatigued during the psychotherapy session. Her speech is clear, and her thought process is logical and goal-directed. No delusions, hallucinations, or suicidal ideations present. She is oriented to person, place, and time. Her memory, judgment, abstract thought, and insight are grossly intact.
A: Insomnia; Mood disturbances; Impaired interpersonal or social functioning.
P: Initiate weekly training on sleep hygiene. The client will be advised to: Have light meals in the evening; Avoid daytime naps and caffeine and alcohol in the evening; Have exercises in the late afternoon or early evening; Try to get up at the same time every day regardless of the time she slept. Include Stimulus control therapy to enable the client to relate the bed with sleep and establish rigid wake and sleep times.
Diagnosis: Panic Disorder
S: G.K is a 253-year-old female who presented with complaints of worsening anxiety attacks. The anxiety attacks began about 12 weeks ago. The attacks occur abruptly and peak within 10-30 seconds. Initially, the acute anxiety occurred with palpitations and sweating about 2-3 times a week. However, the attacks have worsened over time and now occur almost every day. The acute anxiety occurs with nausea, breathlessness, profuse sweating, hot flashes, and trembling. The breathlessness makes her choke, and she has a feeling of impending doom. The client states that she avoids going to public places because she might get an anxiety attack when she is being watched. She stated that the attacks occur anywhere and have no specific environmental conditions that trigger them. Besides, there are no factors that suppress the attacks. Her alcohol intake and smoking have increased to help her calm down. She is currently on Paxil 40mg/day.
O: The client is alert and oriented. She is neat and appropriately dressed for the weather. She maintains eye contact but often fidgets during the interview. Her self-reported mood is nervous, and her affect is congruent. Her speech was clear until she became anxious, sweaty, and unable to talk at one point in the interview for about 10 seconds. She exhibits a logical, linear, and goal-directed thought process. No hallucinations, delusion, or suicidal/ homicidal thoughts were noted. Her long-term and short-term memory are intact. She demonstrates good judgment.
A: Anxiety attacks; Impaired social functioning.
P: Initiate CBT alongside pharmacotherapy with Paxil.
Generalized Anxiety Disorder
Diagnosis: Generalized Anxiety Disorder
S: R.F is a 26-year-old Hispanic female referred for psychotherapy by her PCP due to Generalized Anxiety Disorder. The client expressed excessive worries about her new marketing job in a real estate company. She mentioned that the work is overwhelming, and she is always worried about reaching her targets, which is crucial to be retained in the company. She mentioned that she is unable to control her excessive worries, which leave her restless. The client also reported that restlessness impairs her concentration levels, which is starting to affect her job performance. She also stated that she experiences sleep disturbances and is easily fatigued. The PCP had prescribed Lorazepam 3 mg PO B.D.
O: The client is neat and appropriately dressed for the weather. She is alert and cooperative during the session but maintains minimal eye contact. She occasionally fidgets. Her speech is clear, but volume and rate vary from normal to low. She has a coherent thought process and is preoccupied with thoughts about her job. No obsessions, phobias, delusions, or hallucinations were noted. She is oriented to person, place, and time. Memory, abstract thought, judgment, and insight intact. GAD score-8.
A: Generalized anxiety disorder. Impaired occupational functioning. No complaints about the medication’s side effects.
P: Initiate weekly CBT sessions alongside drug therapy. Include social skills training to help the client establish and maintain relationships and manage herself and the stressors.Assignment 1: Clinical Hour and Patient Logs
Please write for 5 children or Adolescents and 5 adults or older adults
Photo Credit: auremar / Adobe Stock
Assignment 1: Clinical Hour and Patient Logs
Photo Credit: auremar / Adobe Stock
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 to be counted. You may only log hours with Preceptors that are approved in Meditrek.
Students with catalog years before Spring 2018â€¯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). By the end of Week 1, make sure you confirm your preceptor and clinical faculty are set up inâ€¯Meditrek.
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:
â€¢ Clinical Faculty
â€¢ Total Time (for the day)
â€¢ Notes/Comments (including the objective to which the log entry is aligned)
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.
The patient log must include the following:
â€¢ Clinical Faculty
â€¢ Patient Number
â€¢ Client Information
â€¢ Visit Information
â€¢ Practice Management
â€¢ Treatment Plan and Notes â€” Students must include a brief summary/synopsis of the patient visitâ€”this does not need to be a SOAP note; however, the note needs to be sufficient to remember your patient encounter.
By Day 7
Record your clinical hours and patient encounters in Meditrek.
Please complete this assignment for 10 different patientsâ€™ thanks
MY CLINICAL PRACTICUM IS A PRIVATE PRACTICE, MY CLINICAL WORKING HOURS WILL BE Thursday AND FRIDAY 8 AM- 5 PM,
I WILL BE WORKING ALONG WITH MY PRECEPTOR WHO IS A PSYCHIATRIC MENTAL HEALTH NURSE PRACTITIONER.
MY CLINICAL SITE IS A PRIVATE PRACTICE THAT PROVIDES DIRECT CLINICAL SERVICES SUCH AS PSYCHIATRIC EVALUATION, CRISIS INTERVENTION, PSYCHOPHARMACOLOGY TREATMENTS, AND REFERRALS AS NECESSARY TO PATIENTS WITH DIFFERENT PSYCHIATRIC DIAGNOSES.
ON EACH OF MY CLINICAL DAYS I WILL BE SEEING 5 PATIENTS AT MY PRACTICUM PER CLINICAL WHICH MEANS THAT I WILL HAVE TO WRITE 5 DIFFERENT PATIENT NOTES EACH DAY TOTAL 10 PATIENTS FOR THE 2 DAYS