PRAC 6645 CLINICAL HOUR AND PATIENT LOGS WEEKS 1-10
PRAC 6645 CLINICAL HOUR AND PATIENT LOGS WEEKS 1-10
Clinical Hour and Patient Logs
- Schizophrenia Spectrum and Other Psychotic Disorders
Name: G.H
Age: 45 years old
Gender: Female
Diagnosis: Schizophrenia Spectrum and Other Psychotic Disorders
S: G.H. is a 45-year-old Caucasian female who was admitted to the psychiatric hospital at the request of her sister. The patient stated that she frequently feels as though somebody is observing her from outside the window. She believes she can hear them. As she stated, these encounters had been going on for weeks. The patient alleges that when watching television, persons on it seek to murder her by poisoning her meals. Denies using medicines or having a history of seizures. There were no reports of suicidal thoughts or self-harming conduct.
O: Examinations of the patient’s mental health demonstrate that she is well-oriented in time, location, and person. She, on the other hand, appears disturbingly uncomfortable. She cooperates during the interview, although she is often distracted and has a limited attention span. Her mental process has been hampered. She seemed to be depressed. Has adequate short-term and long-term memory. She also exhibits symptoms of delusion and delirium. Denies having suicidal thoughts or engaging in self-harming actions.
A: The patient has schizophrenia disorder because she exhibits bizarre actions as a result of a lack of contact with reality. She also has hallucinations, delirium, and disordered speech, and thinking, indicating that she meets the DSM-V criteria for this condition.
P: Engage the patient in realistic activities such as card games, writing, drawing, rudimentary arts and crafts, or listening to music. Cognitive behavioral group therapy sessions that focus on real-life plans, concerns, relationships, and coping skills are advised.
- Major Depressive Disorder (MDD):
Name: B.E
Age: 14 years old
Gender: Male
Diagnosis: MDD
S: B.E. is a 14-year-old white male patient who was brought into the clinic by his mother because he was depressed. Her mother claims that the patient stopped taking his medication since it made him feel horrible. He was diagnosed with ADHD at the age of six and has been on and off medication for mood problems ever since. The patient denies using any illegal drugs. He complains of useless sensations and claims to hear voices from time to time, making it difficult for him to sleep. She withdraws from friends and often misses school because she does not want to be evaluated or discussed by her peers. She is depressed and lonely.
O: The patient arrived at the psychiatric unit in a great mood and dressed appropriately for his age. Despite being agreeable with the assessment, he avoids eye contact. He appears furious and dejected, even crying at points during the test. His influence varies just slightly. His energy level has decreased and he appears restless. His speech is age-appropriate, relaxed, and combative. He also thinks slowly but coherently. He occasionally shows indications of weariness with poor attention for a lengthy period. The patient has no memory problems since he recalls events correctly. Person, time, and place orientation are all intact. The patient shows no signs of causing harm to himself or others. He denies having suicidal thoughts, hallucinations, or deliria.
A: According to DSM-V diagnostic standards, the patient meets the criteria for MDD based on the described signs and symptoms.
P: Encourage people to vent their feelings and devise alternative coping mechanisms for their anger and frustration. CBT and family therapy are also recommended psychotherapeutic techniques.
- Alzheimer’s Disease
Name: T.C
Age: 66 years old
Gender: Male
Diagnosis: Alzheimer’s Disease
S: T.C. is a 66-year-old Asian male who was brought in for mental examination by his daughter because he was forgetful. She claims that the patient has misplaced his auto keys multiple times. She further notes that when the patient goes to the store, he occasionally gets lost and asks for assistance. According to his daughter, the patient states that he began forgetting approximately two years ago and that it has become worse since then. The patient denies having any of the related symptoms. There are no hallucinations or delirium.
O: A physical examination revealed that the patient seems healthy and cooperative during the assessment, with a cheerful demeanor. He has no chills, fever, tiredness, or recent weight fluctuations. The CN II-VII and the DTR are not affected, according to a neurological assessment. Denies experiencing a headache, syncope, or dizziness. Confirms growing memory loss over the last two years.
A: The patient has been experiencing deteriorating memory loss for the last two years, indicating Alzheimer’s disease in its terminal stages as the primary diagnosis.
P: Reality-orienting approaches will assist patients to become more aware of themselves and their surroundings. Family therapy is advised to help the patient’s family members learn how to help with the patient’s memory.
- Generalized Anxiety Disorder
Name: K.D
Age: 9 years old
Gender: Male
Diagnosis: GAD and SAD
S: The 9-year-old child and his mother were brought to the clinic for mental assessment. The patient’s mother states that her kid has been worried about death most of the time and is even frightened to go to school. The youngster claims to be terrified of his family member being injured by criminals, dying in a vehicle accident, or being pulled into a black hole. When he goes to school, he is scared of being apart from them. His instructor states that he is unable to concentrate at school, which has a negative impact on his academic achievement. Denies having melancholy or hallucinations.
O: The patient looked to be well-groomed. He is aware of his surroundings, time, and self. The rate and volume of speaking are both normal. During the interview, he appears anxious and fidgets a lot. With the sight of her mother, he is cooperative. His short and long-term memory are age-appropriate. His attention span is limited. Denies engaging in self-harming behavior.
A: Based on the patient’s symptoms and mental state assessment findings, the patient meets the DSM-V diagnostic criteria for both generalized anxiety disorder and separation anxiety disorder.
P: Group Applied Behavior Analysis (ABA) is recommended to encourage desired behaviors and discourage unwanted ones to develop a range of talents.
- Alcohol use disorder
Name: S.K
Age: 33 years old
Gender: Male
Diagnosis: AUD
S: S.K. is a 33-year-old Caucasian man who presented to the clinic with a history of alcohol intoxication, alcohol use problem, and a ruling out of anxiolytic and sedative use disorder, accompanied by his father. According to the father, the patient has auditory hallucinations, hubris, a lack of sleep, and the ability to damage himself and others. His most recent visit to the clinic occurred in April of this year. The guy claims he had a nail puncture wound on his arm earlier today and is demanding a tetanus injection. During the current appointment, the patient denies having sleep problems, being sad, having poor energy, or having a loss of appetite. He also rejects suicidal thoughts while admitting to a history of suicide attempts.
O: Upon assessment, the patient appears depressed and preoccupied, with threats to harm everyone. He does, however, answer questions during the interview in a nasty tone. He seemed disturbed. His demeanor is suitable yet uninteresting. Even though the procedure is hampered. His father claims that the patient has been hearing voices, has been having sleeping issues and has been depressed, which the patient denies. His short-term and long-term memories are both intact. His perspective is correct. Suicide thoughts can be confirmed by a history of suicidal attempts.
A: Based on his history of alcohol intoxication and suicidal ideation by Tylenol overdose, the patient satisfies the DSM-V criteria for this illness. He also went to the clinic in a slurred manner, even though he denies using any.
P: Suggest to the patient that he or she try group cognitive behavioral treatment. Substance abuse support group sessions can also be beneficial to the patient. When the patient is ready, consider rehabilitation.
- Obsessive Compulsive Personality Disorder (OCPD)
Name: D.G
Age: 10 years old
Gender: Male
Diagnosis: OCPD
S: D.G. is a 10-year-old white male patient who came in with his mother for a mental examination. The patient is constantly washing his hands and is scared to even touch his classmates for fear of infecting him. During the early stages of the Covid-19 epidemic, the patient’s mother’s elder sister died from the virus. Since then, the patient has been terrified of acquiring the infection and has been continuously washing his hands. He has been reclusive at school and has been unable to play with his classmates. He also prefers to spend his time at home indoors.
O: The patient’s cognitive function was normal after a mental status examination. He denies having anxiety or depression symptoms. He is, nevertheless, lonely and terrified of social interaction. He occasionally acknowledges having caught the virus through dreams. Denies engaging in self-harming behavior.
A: According to the DSM-V diagnostic criteria, the patient met the criteria for Obsessive Compulsive Personality Disorder (OCPD).
P: Suggest to the patient that psychotherapy treatments such as psychoeducation, group therapy, and support therapy be considered. Cognitive restructuring is a strategy that assists clients in recognizing negative ideas and feelings and replacing them with constructive patterns of thinking.
- Bipolar Disorder Mixed Episodes
Name: M.G
Age: 23 years old
Gender: Female
Diagnosis: Bipolar Disorder with Mixed Episodes
S: M.G. is a 23-year-old female patient who came to the psychiatric unit for a check-up on her mental condition. She claims that her psychiatric drugs are causing her to lose her identity. She was diagnosed with bipolar illness in her teens after being unable to sleep for 4 to 5 days and experiencing auditory hallucinations. She states she is unsure of which medicine she is on, but she has experienced depression at least four to five times every year since the diagnosis. Associated symptoms include fatigue, loss of interest, and a sense of worthlessness. The patient denies feeling frightened, disturbed, or experiencing nightmares. She, on the other hand, verifies illusion and hallucination.
O: Further examination of the patient revealed that she has an appealing appearance and is fairly confident in responding to questions during the interview. Her mental process is well structured, and she speaks clearly and fluently. She, on the other hand, appears preoccupied, her attitude shifting depending on the topic of conversation. She demonstrates ordinary understanding and judgment. Her short- and long-term memory are both intact. She denies having suicidal thoughts or engaging in self-harming behavior. She, on the other hand, verifies illusion and hallucination.
A: The patient satisfies the DSM-V criteria for Bipolar Disorder with Mixed Bouts because she has a depressive mood, recent episodes of hypomania and mania, psychomotor slowness, lost interest, a sense of worthlessness, low energy levels, and recurring thoughts of death.
P: Suggest talk therapy or cognitive behavioral group therapy. Discuss with patients how to overcome their troublesome feelings, attitudes, and behaviors during therapy sessions.
- Rumination Syndrome
Name: D.J
Age: 19 years old
Gender: Female
Diagnosis: Rumination Syndrome
S: D.J. is a 19-year-old African-American male patient who came to the clinic with complaints of frequent meal regurgitation. Since the regurgitation began, he has also complained of sleeping difficulties, dizziness, bloating, nausea, and pain. He, on the other hand, denies experiencing diarrhea, swallowing difficulty, or discomfort. He maintains that the symptoms began after he was removed from his mother, who was unfairly imprisoned for drug charges. He denies any family history of drug abuse or any other psychological problem. He denies having used any medicine to treat his problems. He has no history of chronic illnesses or hospitalization. He verifies eating a good diet and exercising regularly. He confirms that he has seasonal allergies.
O: The physician conducted a thorough physical examination, which revealed abdominal distention. The abdomen, on the other hand, was not tender. The lab findings were normal. A psychiatric assessment reveals a sad mood and significant stress as a result of the patient’s mother, his only parent, being imprisoned. The patient also demonstrated feelings of worthlessness, loneliness, and separation from others.
A: According to the subjective data, the patient has rumination syndrome. The objective statistics show no evidence of GERD, but rather high stress as a result of the psychological examination. The patient’s rumination condition might have been caused by stress.
P: Help the patient develop nutritious eating habits and identify emotions and develop coping techniques. Family therapy is also recommended for support and to help reduce the patient’s shame and depression from the eating disorder.
- Posttraumatic Stress Disorder (PTSD)
Name: T.R
Age: 49 years old
Gender: Female
Diagnosis: PTSD
S: T.R. is a 49-year-old female patient who came to the psychiatric unit complaining of poor mental health and frequent nightmares following her husband’s death. The lady admitted to having regular flashbacks of her husband’s death. She also claims she can’t sleep at night because she sees him in her dreams. She is depressed and believes she should have died as well so they could be united in paradise. She has been unable to work and claims that she no longer attends church, alleging that God did not assist her when her husband was dying. Other symptoms include negative impacts, self-isolation, and feelings of worthlessness. The patient denies any previous mental health issues. She admits to having suicidal thoughts from time to time, but she has never attempted suicide. Denies engaging in self-harming behavior.
O: The patient was appropriately dressed for the visit. Her mood is gloomy, with regular complaints about why she needs to remain living while her spouse is no longer alive. Her short-term and long-term memories were both intact. Her cognitive process was complete. Denies any suicidal or self-harming behavior. However, she admits to having suicidal thoughts.
A: The patients match the DSM-V diagnostic criteria for post-traumatic stress disorder as a result of her husband’s death, which she describes as a painful event.
P: Suggest to the patient that he or she try group cognitive behavioral treatment. Prolonged exposure treatment and eye movement desensitization and reprocessing therapy are also indicated to assist in controlling the patient’s PTSD symptoms.
- Attention-Deficit Hyperactivity Disorder (ADHD)
Name: M.K
Age: 9 years old
Gender: Female
Diagnosis: ADHD
S: M.K., an 8-year-old girl, arrives at the psychiatric unit exhibiting symptoms of attention deficit hyperactivity disorder (ADHD). Given the patient’s presenting signs and symptoms, the mother and class instructor were requested to complete the ADHD questionnaire. She exhibits symptoms of short-term memory loss and difficulty paying attention. She is frequently forgetful and must be reminded to finish her schoolwork. She also fidgets a lot, which interferes with her attention. The patient agrees that her ADHD symptoms began as soon as she started school. Daydreaming is one of the other symptoms. The patient has never been prescribed medication for the present ailment and has no history of developmental issues. Because of the patient’s fidgety symptoms, the primary care practitioner states that the patient has decent sleeping habits but rather a poor eating.
O: The patient enters the room dressed appropriately for her age. Unable to keep eye contact. Time, person, and place are all well-organized. She can’t get comfortable on the chair since she fidgets a lot. Unable to focus for a lengthy amount of time. The impact is complete and consistent with a depressed state. With evidence of daydreaming, he is easily sidetracked. Short-term memory is impaired, while long-term memory is unaffected. There are no indicators of delusion or delirium. There is no evidence of possible danger to oneself or others.
A: The child is eight years old and exhibits the majority of the symptoms listed in the DSM-V, justifying the diagnosis of ADHD.
P: Instead of taking medicine, think about trying psychotherapy. Cognitive behavioral group therapy can assist the child in reducing hyperactivity, impulsiveness, and inattention.
- Enuresis Disorder
Name: J.V
Age: 7 years old
Gender: Male
Diagnosis: Enuresis Disorder
S: J.V. is a 7-year-old child who is healthy and has no social issues. Except for one issue, the patient’s growth phases are fully intact. He has never been able to achieve nocturnal dryness. The patient, according to the mother, still wears pull-ups at night. The patient states that he has no trouble remaining dry during the day. He also denies having any bowel movements at any time of day or night. His primary issue is that he wants to go to sleepovers with his friends, but he is embarrassed that they will reject him because of his bedwetting. At home, he plays with his toys but appears depressed. He has no history of any other health issues. There are no allergies.
O: A comprehensive physical examination of the patient’s genitalia was performed to establish the source of his bedwetting. By palpating the renal and suprapubic regions, the doctor sought an enlarged bladder or kidney. In the lab, his excrement was also tested for hard texture or blood. A neurological examination was also performed, as well as an examination and palpation of the lumbosacral spine. However, the data did not point to a specific reason for the patient’s bedewing.
A: The purpose of the patient evaluation was to determine the underlying cause of the patient’s nocturnal enuresis. To assess the integrity of the S2-4 spinal reflex arc, the anal wink and the patient’s ability to stand on his or her toes were used.
P: Encourage the child while reassuring the parents in family therapy. Encourage bladder retention training (drink more in the morning and early afternoon, reduce the number of times you urinate during the day, try to hold for at least eight hours, and interrupt urination (stop-start training)) and behavior modification.
- Insomnia
Name: M.X
Age: 33 years old
Gender: Female
Diagnosis: Insomnia and MDD
S: M.X is a 33-year-old female patient who came to the clinic complaining about negative automatic thinking, anxiety, and poor self-esteem. She also experiences nightmares, feelings of loneliness, dizziness, difficulty falling asleep, feelings of inferiority, headache, palpitations, dizziness, weariness, stiff shoulders/neck racing thoughts, panic attacks, bowel disruption, and melancholy. She does, however, note that the dreams have become more regular, around four times per week, while the other symptoms have become virtually every day.
O: The findings of the mental examination show that the patient is aware and well-oriented in person, place, and time. Her mother’s activities are routine. During the interview, she is cooperative and talked in a clear and regular tone. Her disposition is depressed. She has a restricted appearance and exceptional perception and judgment. Her memory is intact, and her mental process is ordinary. Her functional condition, on the other hand, is somewhat degraded. Denies hallucinating or delusions.
A: According to the DSM-V diagnostic criteria, she is eligible for the diagnosis of MDD, which she has previously managed. However, the major focus of this appointment is on controlling the patient’s sleeplessness.
P: Suggest cognitive behavioral group therapy teaches sleep hygiene and relaxation techniques to enhance the patient’s sleeping quality and length.
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.
