PRAC 6675 WEEK 4 Assignment 1: Clinical Hour and Patient Logs Essay

 PRAC 6675 WEEK 4 Assignment 1: Clinical Hour and Patient Logs Essay

 PRAC 6675 WEEK 4 Assignment 1: Clinical Hour and Patient Logs Essay

Autism Spectrum Disorder

Name: D.M

Age: 6-years

Diagnosis: Autism Spectrum Disorder

S: A.C is a 6-year-old AA male referred for psychotherapy by his pediatrician for Autism Spectrum Disorder (ASD). The boy presented with ASD features of developmental regression, abnormal social interactions, repetitive abnormal reactions to environmental stimuli, stereotyped behavior, and lack of symbolic play. The mother reported that the boy had normal developmental milestones until two years of age, when she noticed deficits in the child’s verbal and nonverbal communication skills. The mother reported that the child has odd responses to auditory stimuli such as loud music and car hooting. He also has a high pain threshold

O: The client is well-groomed and appropriately dressed. He is alert but maintains minimal eye contact. The boy was uncooperative at the beginning of the session but became cooperative with time. Speech abnormalities were noted with the client repeating phrases after the clinician. Language delays were also noted. The patient has no social smile when greeted and has an exaggerated stimulus to touch. He has abnormal motor movements with an odd walk. Symbolic play and Protodeclarative pointing were absent. The child has self-injurious behavior, like teeth banging and head punching.

A: Self-injurious behaviors. Deficits in executive function. Difficulties in social interactions.

P: Initiate weekly sessions in auditory integration training, Sensory Integration therapy, and exercise and physical therapy. Incorporate assisted communication into the weekly therapy using letter boards, word boards, and keyboards to assist the child in communication. Connect the child to special education institutions.

Substance Use Disorder

Name: S.L

Age: 17-years

Diagnosis: Substance Use Disorder

S: S.L is a 17-year-old White female on psychotherapy due to Substance-use Disorder. She reports using coke since she was 15 years after she was introduced to it by her friends. She became addicted to heroin after the fourth use. She is forced to increase the dose of the drug every day to get high and cannot stop herself. The client reports that she experiences body aches, severe anxiety, sweating, nausea, vomiting, and muscle cramps when she stops using coke. She has been to rehab twice in the past year but has had a relapse after each program. The client is currently on detoxification and is being administered daily Methadone, which has effectively reduced the cravings for coke.

O: The client is unkempt with long dirty nails and uncombed hair. She is alert but appears anxious and fidgets on the chair. Her self-reported mood is nervous, and her affect is constricted. Her speech is clear with normal volume and rate. She has a coherent and logical thought process with no noted hallucinations, delusions, or phobias. She is oriented to person, place, and time and short-and long-term memory are intact. She has a limited attention span and concentration levels. Abstract thought and judgment are intact. Insight is present.

A: The client is determined to stop cocaine addiction. Cocaine-induced anxiety.

P: Continue with weekly individual therapy sessions focusing on learning skills to enable the client to cope with heroin cravings. Introduce Group therapy to help the client acquire social skills and coping mechanisms to avoid relapse. Continue with Methadone.

Obsessive-Compulsive Disorder

Name: B.P

Age: 16 years

Diagnosis: Obsessive-Compulsive Disorder

S: B.P is a 16-year-old White female on psychotherapy for OCD. She reported being preoccupied with intrusive thoughts and beliefs of being contaminated after she became positive for the COVID-19 virus three months ago. The thoughts of being contaminated repeatedly intrude in her conscious mind. This compels her to wash exposed parts of her body, such as her hands and face. She reports that she has tried to resist the thoughts but has been unable. Besides, failure to resist the thoughts results in marked psychological distress, which alleviates when she washes her hands. The client reports that washing her hands relieves the psychological distress arising from the obsession with being contaminated with COVID-19. She also states that the obsessions and repeated hand washing behaviors have negatively impacted her interpersonal relationships since she avoids interacting with people. After every contact with another person, she is compelled to wash her hands or use a sanitizer. The PMHNP prescribed Clomipramine 25mg PO OD.

O: The client is well-groomed and alert. She maintains minimal eye contact and keeps on looking at her hands. Her self-reported mood is ‘nervous,’ and her affect is broad. She reports that she still feels at risk of getting COVID-19 in public places, and she develops an urge to wash her hands. She has a coherent thought process. Obsessions on contamination were noted. No hallucinations, delusions, or phobias were noted. She is oriented to person, place, and time. Memory, judgment, and abstract thought grossly were intact. Insight is present.

A: OCD-Washers type. Anxiety secondary to fear of contamination. She acknowledges the relationship between cognition, affect, and behavior and the presence of distorted automatic thoughts.

P: Continue with weekly CBT sessions, to allow the client to recognize and challenge the cognitive distortion of OCD symptoms. Incorporate Exposure and response prevention in the CBT.

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Social Anxiety Disorder

Initials: W.S

Age: 10 years

Diagnosis: Social Anxiety Disorder

S: W.S is a 10-year-old AA female client on psychotherapy due to social phobia. She reports having an intense fear of public occurrences, such as speaking in class, eating in a restaurant, and speaking in public. She fears that she might do or say something embarrassing while being watched. Consequently, she avoids being in public or acting in a manner that will make her a center of public attention. The patient states that she experiences intense anxiety when in public places, which interferes with her ability to socialize with others. The client further reported that she experiences episodes of profuse sweating, palpitations, and increased urinary frequency while in a public place or when asked to speak in class. This has affected her participation in class as well as her academic performance.

O: The client is neat and appropriately groomed. She is alert but appears nervous. She maintains minimal eye contact and occasionally fidgets on her chair. Her speech is clear with normal rate and volume. She exhibits a coherent thought process. Social phobia is apparent. No hallucinations, obsessions, delusions, or suicidal ideations were noted. Short-term and long-term memory is intact. She has good judgment. Insight is present.

A: The client has anxiety secondary to social phobia. Avoidance behavior has interfered with her academic and social functioning.

P: Initiate Cognitive behavioral therapy to alleviate anxiety related to public places and social awkwardness.

Separation Anxiety Disorder

Initials: A.P

Age: 7 years

Diagnosis: Separation Anxiety Disorder

S: A.P is a 7-year-old Hispanic female client on psychotherapy for Separation Anxiety Disorder. The mother states that the child develops an intense fear when being separated from her. She also becomes anxious when going to school and cries a lot when the mother or father drops her off at school. Besides, she insists on sleeping in the same room with her parents, which is becoming a growing concern. When she sleeps in her room, she gets nightmares and cries afterward. The child has a persistent and excessive fear of being left alone at home without a close family member. The mother reported that the child often complains of having stomachaches and headaches when going to school or when he is separated from his family.

O: The client is neat and appropriately dressed. She is alert and leans close to her mother throughout the session. She appears anxious and maintains minimal eye contact with the therapist. Her self-reported mood is nervous, and his affect is appropriate. She talks in low volumes and talks minimally. She demonstrates a logical thought process. No apparent hallucinations, delusions, obsessions, or suicidal ideations. Short-term and long-term memory is intact.

A: School refusal. Physical symptoms from separation anxiety.

P: Initiate the client on family CBT comprising psychoeducation and exposure to anxiety-producing stimuli and situations. Incorporate training of somatic management skills, such as diaphragmatic breathing and progressive muscle relaxation.

Adjustment Disorder with anxiety

Initials: D.L

Age: 30 years

Diagnosis: Adjustment disorder with anxiety

S: D.L is a 30-year-old White female client referred for psychotherapy after developing marked distress after losing her job in an insurance firm eight weeks ago. She reports facing difficulties adjusting to life after the job loss and considers it a major failure in her life. She also feels guilty for disappointing her employer, who had put much trust in her to do the job as expected. The client stated that in the past four months, she has had an excessive worry, anxiety, sleeping difficulties, and is constantly angry. She mentioned that although she got a new job a month later, she feels trapped and isolated and does not like the job. As a result, she has poor concentration levels and has not performed compared to her previous job. Furthermore, she states that she feels demoralized helpless, and her self-esteem has declined over time. She smokes 1PPD to relieve anxiety and forget about her failure.

O: The client is well-groomed and appropriately dressed. She is alert and oriented to person, place, time, and event. Her speech is clear, and she maintains adequate eye contact throughout the session. The self-reported mood is anxious, and affect is appropriate. She demonstrates a coherent thought process. No obvious obsessions, phobias, hallucinations, delusions, or suicidal ideations. Her short-term and long-term memory is intact. She demonstrates good judgment and abstract reasoning.

A: Anxiety related to job loss. Disruption in social functioning. Occupational impairment.

P: Initiate cognitive-behavioral therapy to help the client identify and reframe the meaning of the stressor. Incorporate supportive psychotherapy.

 Illness Anxiety Disorder

Initials: F.G

Age: 77 years

Diagnosis: Illness Anxiety Disorder

S: F.G is a 77-year-old White AA client on psychotherapy for Illness Anxiety disorder. Her PCP referred her following her persistent preoccupation with having a severe illness that the PCP has not diagnosed. The PCP could not persuade her that she had no major illness even after conducting numerous diagnostic studies. The client’s preoccupation with having a severe illness began when she was diagnosed with PUD 7 months ago. She was prescribed Omeprazole, which has alleviated the symptoms. However, the client believes that the epigastric pain was due to stomach cancer since her father had the same condition. Her conviction has persisted despite negative diagnostic results and reassurances from several physicians and various diagnostic tests. She has also become addicted to Internet searches about stomach cancer. The client states that she has had anxiety about having stomach cancer, which has caused her marked emotional distress and inability to function in her social life.

O: The client is neat and appropriately dressed. She is alert, oriented, and maintains adequate eye contact. The self-reported mood is nervous, and the affect is blunt. Her speech is clear with normal rate and volume, and she has a coherent thought process. She is preoccupied with thoughts of having stomach cancer and beliefs that it might spread to her lungs. No apparent hallucinations, phobias, delusion, or suicide ideations were noted. Long-term and short-term memory is intact, and she demonstrates good judgment. Insight is lacking.

A: The client has abnormal illness behavior. She has high anxiety levels.

P: Initiate CBT and incorporate cognitive and exposure therapy. Education on stress reduction techniques to help in coping with her current condition.

Postpartum Depression

Initials: P.S

Age: 27 years

Diagnosis: Postpartum Depression

S: P.S is a 27-year-old White female client on psychotherapy due to postpartum depression. P.S is a first-time mum and had delivered a live male infant nine weeks ago. She presented with uncontrollable worries about her child’s health and well-being. The client states that she developed a feeling of intense sadness and despair four weeks after delivery. She also reported being tearful most of the day and unable to experience the pleasure of activities she enjoyed before delivery. The client also states that she had sleeping difficulties and was constantly fatigued during the day. She mentions that she cannot sleep because the baby cries often, and she has to wake up frequently to breastfeed him. Furthermore, she states that she is constantly fatigued because she does not have someone to care for the baby. The symptoms have interfered with her ability to function.

O: The client is well-groomed and appropriately dressed. She is alert, maintains eye contact, and is oriented to person, place, and time. The self-reported mood is sad, and the affect is flat. Her speech is clear with normal rate and volume, and she demonstrates a coherent thought process. No apparent delusions, hallucinations, obsessions, phobias, or suicidal ideations. She denies having negative feelings toward the child or thoughts about harming her child. Long-term and short-term memory is intact. She demonstrated good judgment, and insight is present.

A:  Insomnia, adjustment difficulties, and difficulty coping with daily stressors associated with motherhood.

P: Initiate individual psychotherapy comprising cognitive-behavioral and interpersonal therapy. Introduce the client to a support group for nursing mothers.

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 Generalized Anxiety Disorder

Initials: R.O

Age: 47 years

Diagnosis: Generalized Anxiety Disorder

S: R.O is a 35-year-old male client on psychotherapy for GAD. He was diagnosed with GAD after presenting with symptoms of excessive worry about his job. The excessive worry began after he got a job promotion to the editor-in-chief in a media company six months ago. He reports having immense pressure to perform and meet the job’s expectations. The client reported that she has been unable to control her worries for the past six months. He is constantly restless, experiences muscle tension, and has concentration difficulties. Besides, he reports having difficulties falling asleep, which leads to constant fatigue during the day and headaches. However, the client said that the anxiety symptoms had gradually reduced after he started psychotherapy. He has managed to control the excessive thoughts to some degree and can concentrate on her job and family. Nonetheless, he is still having sleep disturbances since he cannot control his thoughts while he is not engaged in any activity.

O: The client is neat and appropriately groomed. He is alert and oriented to person, place, and time. He maintains adequate eye contact throughout the session. His speech is clear with normal volume and rate, and he demonstrates a coherent thought process. No apparent delusions, phobias, obsessions, hallucinations, or suicidal ideations. Short-term and long-term memory is intact. She demonstrates good judgment. GAD-7 score: 11

A:  The client has improved anxiety symptoms compared to the previous session. Reduced intrusive thoughts about her work. Improved social and occupational functioning. Sleep disturbances are present.

P: Continue with weekly CBT sessions. Incorporate sleep hygiene training to alleviate insomnia.

Somatic Symptom Disorder

Name: V.N

Age: 28-years

Diagnosis: Somatic Symptom disorder

S: V.N is a 28-year-old A.A female on psychotherapy for Somatic Symptom Disorder. The patient’s health record shows that she has had a chronic history of numerous physical complaints since her early 20s. She has sought frequent medical treatment for the various physical complaints affecting multiple body systems. In the last five years, she has presented to her PCP with various vague symptoms such as muscle, joint, and back pains, abdominal pain, headache, altered bowel patterns, food intolerance, sore throat, and heavy menstruation. The client states that the physical symptoms have significantly impaired occupational and social areas of functioning. Her PCP diagnosed Somatic Symptom disorder after conducting multiple diagnostic tests, which did not explain the cause of the various symptoms.

O: The client is neat and appropriately dressed for the weather. She appears mildly anxious and maintains minimal eye contact. The self-reported mood is depressed,’ and affect is full range and appropriate. Coherent thought process. She is preoccupied with thoughts of disease symptoms and complaints. No obsessions, compulsions, hallucinations, delusions, or suicidal ideations were noted. Attention and concentration levels were within the normal range. Orientation, memory, and judgment are intact, but insight appears limited.

A: Psychological distress with comorbid depression.

P: Weekly CBT sessions to decrease distorted symptoms associated with the Somatic symptom disorder.

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 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). By the end of Week 1, make sure you confirm your preceptor and clinical faculty are set up in 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:
• 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 patients by the end of this practicum.
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 — Students 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.
By Day 7
Record your clinical hours and patient encounters in Meditrek.

Please complete this assignment for 10 different patients’ 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