WEEK 5 Assignment 1: Clinical Hour and Patient Logs Paper

WEEK 5 Assignment 1: Clinical Hour and Patient Logs Paper

WEEK 5 Assignment 1: Clinical Hour and Patient Logs Paper

S: E.S is a 26-year-old AA male client on psychotherapy for Binge Eating Disorder. He has a history of binge eating episodes characterized by a lack of control in eating in the past three months. HE reported feeling that he cannot stop eating and has no control over the amount of food he eats. E.S often experiences psychological distress due to binge-eating episodes. He has had binge episodes 1-2 times a week in the past three months. However, he denied engaging in inappropriate compensatory behavior such as vomiting or using laxatives. The client admitted eating much more rapidly than usual until he felt uncomfortably full.

O: The client is neat and well-groomed.  He is alert, somewhat nervous, and fidgets throughout the session. The Self-reported mood is anxious and affect is expansive. His speech is clear with normal rate and volume. He has a coherent and goal-directed thought process. Oriented to person, place, and time. Short-term and long-term memory is intact. Concentration, abstract thought, and judgment are intact. Insight is limited. Wt-158 lbs. Ht- 5’1 BMI- 29.9

A: The client has an improved mood compared to previous sessions. Feelings of guilt are present. Obesity.

P: Continue with weekly CBT sessions and evaluate the client’s perception of body shape and weight. Include Behavioral weight-loss interventions focusing on self-monitoring strategies for weight loss.

Post-Traumatic Stress Disorder

Name: F.A

Age: 52-years

Diagnosis: Post-Traumatic Stress Disorder.

S: F.A is a 52-year-old White male on psychotherapy for PTSD. He is a Captain and reported re-experiencing traumatic events that occurred when he was in combat in Afghanistan. He experiences a persistent high anxiety level when he re-experiences the combat events. The client also reports experiencing intrusive recollections and nightmares of his worst experience in combat when he witnessed his colleague being shot by rebels. The intrusive memories usually result in intense psychological distress and the client reports that he avoids thoughts associated with the shooting of his colleague. In addition, he reports having increased arousal which was not present before the combat event, such as sleeping difficulties, outbursts of anger, and concentration difficulties. The symptoms have lasted for 8 weeks and have caused significant impairment in social and occupational functioning. He is on Zoloft 50 mg/day.

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O: The client is neat, alert, oriented, but appears anxious. He maintains adequate eye contact. The self-reported mood is nervous and affect is congruent. His speech is clear, but the rate and volume vary when the client talks about the combat event. He also becomes agitated and develops tremors when discussing the shooting event. His thought process is coherent and goal-directed. No delusions, hallucinations, or suicidal ideations were noted. Memory, abstract thought, judgment, and insight are intact.

A: Vigilance and startle response. Emotional distress when reminded of the combat events. Improved range of positive emotions.

P: Continue treatment with Zoloft and monitor for side effects. Initiate weekly sessions of Trauma-Focused CBT. Integrate Prolonged Exposure Therapy to CBT.

Borderline Personality Disorder

Name: W.P

Age: 28 years

Diagnosis: Borderline Personality Disorder

S: W.P is a 28-year-old Hispanic female referred for psychotherapy due to Borderline Personality Disorder. She states that she has self-image problems and is constantly concerned with what others perceive her. The client mentions that she develops marked psychological distress when she feels that friends are abandoning her and thus tries to impress them. Despite the efforts to avoid abandonment, she experiences difficulties in maintaining interpersonal relationships. She states that lately, most of her friends want nothing to do with her. The avoidance by her friends leaves her feeling empty, which has made her get into sexual liaisons to make friends. She admits to engaging in reckless spending, especially on alcohol, clothes, shoes, and cosmetic products. She also made impulsive decisions without thinking of the consequences. The client had tried injuring herself by cutting her to seek attention from her friends.

O: The client is well-groomed, appropriately dressed for the weather, but has exaggerated make-up. She maintains minimal eye contact and is somewhat uncooperative and uneasy during the session. Her self-reported mood is nervous, and her affect was constricted. The speech was clear with normal rate and volume. He exhibits a coherent and goal-directed thought process. No delusions, hallucinations, phobias, or suicidal ideations were noted. The client exhibited obsessions with her image and relationships. The concentration and attention span were varied. She was oriented to person, place, and time. Memory, judgment, and insight were intact.

A: Improved coping mechanisms compared to previous sessions. Self-image and self-esteem problems. Risk of self-directed violence.

P: Initiate weekly psychotherapy sessions of Dialectical Behavior therapy (DBT).

Obsessive-Compulsive Disorder

Initials: F.L

Age: 26 years

Diagnosis: Obsessive-Compulsive Disorder

S: F.L is a 26-year-old AA female on psychotherapy for OCD. The client has an obsession with doubt demonstrated by constantly checking doors and locks in her house. She reports experiencing constant worries about having forgotten to lock the door upon leaving the house. The doubt results in significant psychological distress, which compels her to frequently check the locks. She reports frequently waking up at night with doubts about having failed to lock the door. The obsession with doubt has contributed to poor concentration levels when at work since she is always concerned that she did not lock the house door. It has also led to sleep disturbances since the doubt results in difficulties in initiating and maintaining sleep.  She reports that the obsessions and compulsions are time-consuming and interfere extensively with her normal routine, occupational functioning, and normal social activities.  The client reports that the obsessive thoughts have alleviated in frequency since she started therapy. She can control the compulsions to some levels.

O: The client is neat and appropriately dressed. She is alert and oriented to person, place, and time. Her speech is clear with normal rate, tone, and volume. The self-reported mood is a bit nervous, and affect is appropriate.  She demonstrates a coherent thought process. Obsessions of doubt are apparent. No delusions, phobias, hallucinations, or suicidal ideations were noted. She demonstrates good judgment. Insight is present.

A: Pathologic doubt. The patient has improved significantly from the previous session.

P: Continue with exposure and response prevention sessions to manage obsessions. Incorporate thought-stopping and aversive conditioning.

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Post Traumatic Stress Disorder

Initials: L.G

Age: 45 years

Diagnosis: Post-traumatic stress disorder

S:  L.G is a 45-year-old AA female on psychotherapy for PTSD. She presents with complaints of experiencing intrusive thoughts about a fatal road accident she was involved in six months ago, where she sustained an arm fracture. She witnessed two people profusely bleeding, and these memories constantly intrude in her mind, leaving her with intense fear. The client mentions that she gets startled by car hooting and loud bangs as they remind her of the car accident, which she tries to forget.  She avoids driving to work and prefers taking a cab because she fears causing another accident. She sometimes gets distressed when on the road and experiences palpitations and profuse sweating. The client states that she has sleeping difficulties due to nightmares of the accident. She is on Zoloft 25 mg once daily.

O: The client is neat and appropriately dressed. She is alert and oriented to person, place, and time. The self-reported mood is anxious and affect is appropriate. She has a coherent thought process and clear speech with normal rate and volume. No obvious obsessions, phobias, delusions, hallucinations, or homicidal/suicidal ideations.  Long-term and short-term memory is intact. She demonstrates good judgment and abstract thought.

A: Impaired social functioning. Insomnia; Startle reactions; Acute episodes of anxiety and panic.

P: Start exposure therapy. Patient education on stress management techniques, such as relaxation techniques and cognitive approaches, to coping with stress.

Panic Disorder

Initials: S.V

Age: 15 years

Diagnosis: Panic Disorder

S:  S.V is a 15-year-old female client who presented with a history of having anxiety attacks. She reports experiencing acute attacks of worry, which are not related to any stimuli. The attacks occur suddenly and become more intense within 20-30 seconds. When having anxiety attacks she experiences difficulty in breathing, chest discomfort, palpitations, and profuse sweating. The attacks occur mostly in public places, which makes her avoid public places.  She feels anxious when in public places due to the fear that she might get a panic attack leaving her in an embarrassing situation.  The client is currently on Imipramine.

O: The client was well-groomed and appropriately dressed. She is alert but appears anxious and maintains minimal eye contact. Her self-reported mood is anxious and her affect is appropriate. The speech is clear but the rate varies. She demonstrates a coherent thought process. No obsessions, hallucinations, delusions, or suicidal/homicidal ideations were noted. She demonstrates clear judgment and abstract thought. Insight is present.

A: The client has anticipatory anxiety.  She demonstrates worries about losing control. The panic attacks have caused a maladaptive behavioral change to avoid future attacks.

P: Initiate cognitive behavioral therapy to help control anxiety and panic attacks. Integrate Panic-Focused Psychodynamic Therapy to alleviate panic symptoms and associated maladaptive behaviors.

Pediatric Major Depressive Disorder

Name: A.B

Age: 16-years

Diagnosis: Major Depressive Disorder

S: A.B is a 16-year-old AA female client on psychotherapy for MDD. She was referred for psychotherapy by her PCP. The client presented with symptoms of a prolonged sad mood and loss of interest in her school work and sports. She reports having lost interest in interacting with her friends at school and home, something she previously enjoyed. She states that she feels sad and empty most of the time for most days. In addition, A.B reports that she is constantly tired and has low energy in school which negatively affected her concentration in class. She states that she feels sleepy most of the days and has a hard time waking up in the morning. She always longs for weekends so that she can sleep more.

O: The client is well-groomed and dressed appropriately. She is alert and maintains adequate eye contact. The self-reported mood is bored and affect is constricted. Her speech is clear but the volume and rate vary from normal to low. Coherent and logical thought process. No phobias, delusions, hallucinations, or suicidal/homicidal ideations are present.  She is oriented to person, place, and time. Her short-term and long-term memory is intact.  Judgment, abstract thought, and insight are grossly intact.

A: Depressed mood. Disturbed sleep pattern. No risk of self-mutilating behavior.

P: Initiate psychotherapy with weekly CBT sessions. Incorporate Problem-solving therapy in psychotherapy sessions.

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Generalized Anxiety Disorder

Name: L.J

Age: 17-years

Patient Number: 0193/021

Diagnosis: Generalized Anxiety Disorder

S: L.J is a 17-year-old AA female on psychotherapy due to GAD. She expressed excessive worries about her school work and whether she would get good grades to pursue her dream course of Medicine and Surgery. The fear of not attaining the required grades has resulted in excessive and uncontrollable worries, which leave her restless. She states that the restlessness affects her concentration levels, and she often goes blank in class or when doing her assignments. Besides, she reports being easily fatigued, having insomnia, and constant headaches and muscle tension.

O: The client is well-groomed and appropriately dressed for the weather. She is alert and cooperative during the session but maintains minimal eye contact. Besides, she appears uneasy and occasionally fidgeted. Her speech is clear, but the volume and rate vary. She has a coherent and logical thought process. The client has a preoccupation with her grades. No obsessions, compulsions, delusions, hallucinations, or suicidal/homicidal thoughts are present. Her short and long-term memory was intact. She demonstrates good judgment. GAD score-12

A: Disruption in academic functioning; Sleep disturbances.

P: Initiate weekly CBT sessions to change distorted thoughts causing anxiety. Incorporate social skills training to help the client create and maintain relationships, and manage her stressors.

Attention Deficit Hyperactive Disorder

Name: A.W

Age: 5-years

Diagnosis: Attention Deficit Hyperactive Disorder

S: A.W is a 5-year-old Hispanic male referred for psychotherapy by a pediatrician following due to ADHD. The patient presented with hyperactive-impulsive behavior and inattention, which was first, noticed when he was 3 years. A.W has temper tantrums cannot manage his anger similar to children his age. His behavior has disrupted learning since he cannot stay still in class. His teacher reported that it is difficult to contain the child in class since he moves around when a class is in progress, and he talks excessively without waiting his turn. He is also easily distracted and makes impulsive decisions. He is on Methylphenidate 36 mg P.O. OD.

O: The client is well-groomed and appropriately dressed for the weather. He fidgets on the chair and does not maintain eye contact. He walks around the office during the session. The self-reported mood is bored, and the affect is constricted. His speech is clear but loud and he intrudes on conversations.  No hallucinations or delusions were noted. No self-injurious thoughts are present. He has a short attention span and is easily distracted. Deficits are noted in calculation and concentration. Judgment and abstract thought are intact.

A: Hyperactivity and Impulsivity. Impaired attention span and easy distractibility. Thinking and memory deficits.

P: Initiate Behavioral psychotherapy in addition to medical therapy. Involve the boy’s class teacher to make the environment conducive to allow the child to focus and maintain attention in class. Include Behavioral parent training. Introduce the child to a social skills group for children with ADHD.

Anorexia Nervosa

Name: D.S

Age: 16 years

Diagnosis: Anorexia nervosa

S: D.S is a 16-year-old Mexican female on psychotherapy for Anorexia nervosa. She has a history of avoiding meals and taking very small food portions due to the fear of gaining weight. Her meals are mostly fluid diets and fruits and she restricts herself from eating starchy foods or meats. She at times takes larger portions of food which causes guilt and results in inducing vomiting.  She aims to have the right body size and shape to be a lingerie runway model when she completes high school. Therefore, she avoids eating a lot due to the fear of getting fat or having a high-fat content that the ideal for models. She has always looked up to VS angels and wishes to be like them in her modeling career.

O: The client is neat and appropriately dressed. She is alert but looks emaciated and anxious. Her self-reported mood is happy, and her affect is broad. Her speech is clear with normal rate and volume. She has a coherent thought process, and no hallucinations, delusions, or 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. Impaired self-esteem.

P: Initiate weekly Cognitive-behavioral and cognitive remediation therapies. Include Insight-oriented Individual therapy and Motivational enhancement therapy.

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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 DAY