PRAC 6645 CLINICAL HOUR AND PATIENT LOGS WEEK 4
PRAC 6645 CLINICAL HOUR AND PATIENT LOGS WEEK 4
Clinical Logs
Insomnia
Name: A.L
Age: 33 years
Diagnosis: Insomnia
S: A.L is a 33-year-old client that came to the unit today for his regular follow-up. He was diagnosed with insomnia five months ago and has been on individual psychotherapy. The client recalled that his diagnosis with insomnia was made due to a number of problems that he had been experiencing. They included persistent lack of quality and quantity sleep. The client reported that he found it hard to fall asleep and maintain it. He had used sleep enhancing medications but without any success. The client also reported that he often fell asleep during the day at his workplace due to lack of sleep the previous nights. The lack of quality and quantity sleep was affecting his performance in workplace, as he always felt that he did not have enough energy to undertake his assigned duties. The client denied any history of medical conditions, drug, or substance abuse that could have contributed to the symptoms. As a result, he was diagnosed with insomnia and initiated on individual psychotherapy sessions.
O: The client appeared dressed appropriately for the occasion. His orientation to self, others, time, and events were normal. His judgment was intact. He did not appear tired during the assessment. He maintained normal eye contact. His speech was of normal rate and volume. He denied illusions, hallucinations, and delusions. He also denied suicidal thoughts, attempts and plans.
A: The desired outcomes of treatment have been achieved. The client reports that he no longer experiences insomnia and his functioning has improved tremendously.
P: The individual psychotherapy sessions were terminated with consent from the client. The termination was reached because the treatment goals had been achieved.
Major Depression
Name: D.K
Age: 40 years
Diagnosis: Major Depression
S: D.K is a 40-year-old client that came to the unit as a referral by his physician. He was referred for further psychiatric review for what the physician felt that the health problem was not medical. The client reported that he felt hopeless in life and wanted to take his life. His hopelessness was due to his perception that he had failed his family in providing the best they needed. The client was further probed, which revealed that the feelings of hopelessness persisted in most days throughout the day. He also experienced depressed mood in most days. He also reported that he has trouble in falling asleep. His appetite had declined significantly leading to his lack of energy in most of the days. He also reported having suicidal thoughts without plans. He noted that his ability to make decisions and concentrate had worsened significantly over the past month. The symptoms were not attributable to any medical condition, medication or substance abuse. As a result, he was diagnosed with major depression and initiated on treatment.
O:The patient appeared poorly groomed for the occasion. His speech was reduced in terms of rate with normal volume. His self-reported mood was depressed. The client denied illusions, delusions, and hallucinations. He maintained normal eye contact during the assessment. His thought content was future oriented. He reported suicidal thoughts without a plan or attempt.
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A: The client is experiencing symptoms of major depression.
P: The client was initiated on antidepressants and group psychotherapy to help improve mood and coping skills of the client with depressive symptoms. He was scheduled for a follow-up visit after four weeks.
Alcohol Use Disorder
Name: K.P
Age: 38 years
Diagnosis: Alcohol use disorder
S: K.P is a 38-year-old male who came to the clinic today for his regular follow-up visit. K.P was diagnosed with alcohol use disorder five months ago and has been on pharmacological and psychotherapy treatments. The client recalled that he was diagnosed with the disorder after he presented with several complaints that related to alcohol abuse. The client had complained of three years binge consumption of alcohol. The binge consumption of alcohol was beyond his control. This was despite his efforts such as abstaining from it, which were fruitless. He was worried that the binge consumption of alcohol was becoming difficult for him to control. K.P reported that the withdrawal symptoms made it difficult for him to abstain from alcohol. He also reported that alcohol abuse had affected his social and occupational functioning adversely. The socioeconomic wellbeing of his family has also been affected adversely. As a result, he was willing to participate in any treatment that could have helped him to overcome his addition problem. Therefore, he was diagnosed with alcohol use disorder and initiated on treatment.
O: The patient was dressed appropriately for the occasion. His orientation to self, others and events were intact. He did not demonstrate any abnormal behaviors such as tics. His thought content was intact. He denied any recent history of illusions, delusions, and hallucinations. He also denied suicidal thoughts, attempts, plans, and intent. His speech was normal in terms of tone, rate, content and volume.
A: There is continuous improvement in the symptoms of alcohol use disorder.
P: The client was advised to continue with the treatment. He was scheduled for a follow-up visit after four weeks.
Insomnia
Name: J.T
Age: 25 years
Diagnosis: Insomnia
S: J.T is a 25-year-old female who came to the unit with complaints of severe lack of quality sleep. She reported that she has been experiencing the symptoms for the last six months. She has been finding it extremely difficult for her to fall and maintain sleep. J.T also reported that the difficult in sleeping was accompanied by other symptoms such as awakenings at night and finding it hard to fall asleep again. The disturbances in sleep were reported to have significant distress as well as impairment in social, educational, occupational and behavioral areas of functioning of the client. The lack of quality sleep was not attributed to any causes such as substance abuse, medication use or medical condition. As a result, she was diagnosed with insomnia and initiated on psychotherapy.
O: The client appeared appropriately dressed for the clinical visit. She was oriented to self, place, time and events. She appeared tired during the assessment. She attributed it to lack of sleep the previous night. Her judgment was intact with the absence illusions, delusions, and hallucinations. She denied history of suicidal thoughts, attempts and plans.
A: The client is experiencing the symptoms of insomnia as stated in DSMV. The insomnia is affecting negatively her quality of life.
P: The client was initiated on group psychotherapy sessions. She was also educated on use of effective interventions to enhance sleep such as avoiding caffeine close to bedtime and eliminating any distractors. She was scheduled for a follow-up visit after four weeks.
Major Depression
Name: X.Y
Age: 44 years
Diagnosis: Major Depression
S: X.Y is a 44-year-old female who came to the unit for his regular follow-up visits. The client was diagnosed with major depression eight months ago and has been on antidepressants and group psychotherapy sessions. The client recalled that he had come to the unit with complaints of persistent feeling of having depressed mood in most of the days. He also reported that his interest in pleasurable things had declined significantly. He was also socially withdrawn, as he liked spending his time indoors. X.Y also reported an increase in his appetite. In some cases, she experienced feelings of being worthless and failure in life. He however denied any history of suicidal thoughts, attempts, and plans. Based on the above symptoms, the client was diagnosed with major depression and initiated on treatment.
O: X.Y appeared dressed appropriately for the occasion. His self-reported mood was ‘I no longer experience incidences of depressed mood for the last three months.’ His judgment was intact. He had normal speech in terms of rate and volume. The client denied illusions, delusions and hallucinations. He also denied any history of suicidal thoughts, attempts or plans.
A: There has been optimal improvement in the symptoms of major depression.
P: The use of group psychotherapy sessions was terminated with consent from the client. He was advised to continue with the antidepressants. He was scheduled for a follow-up visit after two months to determine his response to the use of antidepressants alone.
Schizophrenia
Name: J.L
Age: 30 years
Diagnosis: Schizophrenia
S: J.L is a 30-year-old female that has been undergoing treatment in the unit due to schizophrenia. She was diagnosed with the disorder five months ago and has been on pharmacological and psychotherapy treatments. Today she came to the unit for her regular follow-up visits. J.L recalled that she was diagnosed with schizophrenia after she started experiencing symptoms that included seeing imaginary things, hearing voices, and having a disorganized speech. The client also reported that the symptoms had affected severely her level of functioning in areas that included interpersonal relations, work, and self-care. The symptoms had persisted for more than five months. The spouse of the client could not attribute the symptoms to causes such as medication use, substance abuse, and medical conditions. As a result, she was diagnosed with schizophrenia and initiated on treatment.
O: The client appeared well groomed for the occasion. She was oriented to space, time, events, and self. She denied any recent experience of illusions, delusions, and hallucinations. She also denied any abnormality in speech content, volume and rate. She denied suicidal thoughts, attempts, and plans. Her thought content was future oriented. She did not demonstrate any abnormal behaviors such as avoidance of eye contact and tics.
A: The assessment findings show that the improvement in the symptoms the client is experience has stabilized. The client also tolerates the pharmacological and psychotherapeutic interventions used in the management of her health problem.
P: The psychotherapy session were discontinued with the consent of the client. The discontinuation was because the treatment goals had been achieved. She was advised to continue with the pharmacological treatments. She was scheduled for the next follow-up visit after four weeks.
Post-Traumatic Stress Disorder
Name: N.N
Age: 57 years
Diagnosis: Post-traumatic stress disorder
S: N.N is a 57-year-old female client who came to the with complaints of abnormal health and wellbeing since the death of her spouse. The client reported that she always experiences flashbacks of the events that led to the death of her husband. She also experienced nightmares and avoidance of any stimuli or events that led to his death. The symptoms often led to her emotional distress, which impaired her normal functioning as a teacher. The family members of the client also reported that N.N was demonstrating abnormal behaviors. They included the presence of exaggerated negative thoughts about the world, negative affect, decline in interest in activities, and self-isolation. The family members had noted that the client was becoming easily irritated, experiencing difficulties in sleeping and concentration. Based on the above symptoms raised by the client and her family members, N.N was diagnosed with post-traumatic stress disorder and initiated on treatment.
O: The client was well groomed for the occasion. Her orientation to self, others, environment, and events were intact. Her self-expressed mood was depressed. Her level of judgment was intact. She denied suicidal thoughts, plans or attempts, illusions, delusions, and hallucinations.
A: The client is experiencing moderate symptoms of post-traumatic stress disorder. She needs treatment that aims at normalizing her moods and coping with the depressive symptoms.
P: The client was initiated on antidepressants and group psychotherapy. Antidepressants were prescribed to help the client improve her mood. Group psychotherapy aimed at helping the client cope with the distressing symptoms of post-traumatic stress disorder. She was scheduled for the next follow-up visit after four weeks.
Generalized Anxiety Disorder
Name: A.X
Age: 22 years
Diagnosis: Generalized Anxiety Disorder
S: A.X is a 22-year-old female who came to the department with complaints of excessive fear and worry of the unknown. According to her, she had been experiencing intensive anxiety and fear of things over the past few months. She feared that she might die of unknown cause and that her life was in danger. The excessive fear had made it difficult for her to concentrate in her academics. The additional complaints that she raised were that she getting fatigued easily and lacked control over her excessive worry and fears. The excessive fear and anxiety could not be attributed to any cause such as medical condition, medication, or substance use and abuse. The client also reported that she occasionally experienced chest pains and palpitations during her episodes of anxiety attacks.
O: The patient appeared well kempt. She was oriented to place, time, and self. The speech rate and volume were normal. The mood of the patient was normal with some anxiety. The client denied any history of hallucinations, delusions, and illusions. The memory of the client was intact.
A: The client appears to have moderate anxiety.
P: The client was started on group psychotherapy sessions with the aim of equipping her with effective skills that she could use to manage her excessive worry and anxiety. She was scheduled for the next follow-up visit after one month.
Bipolar Disorder
Name: T.E
Age: 28 years
Diagnosis: Bipolar disorder
S: T.E is a 28-year-old client that came to the unit for his fifth follow-up visit. He has been on antidepressant and psychotherapy treatments for bipolar disorder. He was diagnosed with bipolar disorder after he presented to the unit with complaints that included periods of elevated mood. The mood elevation was characterized by behaviors that that included over activity, engaging in goal-directed initiatives, excitement, euphoria and delusions. There was also the alternation of the above symptoms with periods where the client would feel to be significantly depressed. The depressive symptoms included lack of energy, too much sleeping, difficulties in concentrating and making decisions. The depressed mood could happen almost every day for a specific period such as two weeks, followed by elated mood. Further examination of the client had revealed that the symptoms were not severe to cause any impairment in the normal functioning of the client. The symptoms were also not associated with drug use, medical problem or substance and alcohol abuse. As a result, he was diagnosed with bipolar disorder and initiated on treatment.
O: The client appeared appropriately dressed for the occasion. He was oriented to self, place, time and events. His judgment was intact. He denied any recent experience of delusions, hallucinations, illusions, suicidal thoughts, plans, and attempts.
A: The adopted treatments have been effective in improving the manic and depressive symptoms of bipolar disorder. There is gradual improvement in symptoms, which demonstrate treatment effectiveness.
P: The client was advised to continue with the current treatments. The decision was made because of the improvement in symptoms and tolerability of the treatments. He was scheduled for a follow-up visit after one month.
Binge Eating Disorder
Name: M.O
Age: 32 years
Diagnosis: Binge eating disorder
S: M.O is a 32-year-old female who came to the unit for her fifth follow-up visit. The visit was due to her diagnosis with binge eating disorder. She has been undergoing psychotherapy treatment in the unit. The client recalled she was diagnosed with the disorder after she presented with symptoms included recurrent episodes of binge eating. The symptoms associated with binge eating included eating within a discrete period of time food that was perceived more than what most people would eat during that time. She also reported the lack of control over her eating habits. The binge eating was associated with eating more than normal, eating alone or avoiding others during meals, and being distressed by her eating behaviors. There was also the absence of use of compensatory behaviors such as fasting and purging. The above symptoms led to the diagnosis of binge eating disorder. The client has been undergoing psychotherapy sessions in the unit.
O: The client appeared dressed appropriately for the occasion. She was oriented to self, time, others and events. Her judgment was intact. Her self-reported mood was normal. She denied any instances of altered judgment. Her speech was of normal rate and volume. She denied suicidal thoughts, plans, and attempts, illusions, delusions and hallucinations.
A: The client has demonstrated progressive improvement in the symptoms of binge eating disorder. She is confident that she can use the knowledge and skills gained from the psychotherapy sessions to manage her problem.
P: The psychotherapy sessions were terminated with consent from the client. The treatment goals had been reached. She was scheduled for a follow-up visit after two months.
