PRAC 6645 WEEK 3 Clinical Hour and Patient Logs

Sample Answer

Enuresis Disorder

Name V. L
Age 8 years old
Gender Male
Diagnosis Enuresis Disorder

V.L. is an eight-year-old male patient who came to the facility accompanied by his mother for a psychiatric visit. The mother reports that her son has developed a habit of wetting his bed more frequently. She indicates that the patient is otherwise healthy with no other health or social complications. His developmental milestones and stages are also as expected. His problem of not being able to stay dry at night has brought him much pain since he also has to put on pull-ups at night, which has been unpleasant. The patient denies bowel accidents at night or during the day. The patient reports that he really wants to visit his friends for sleepovers, but he feels ashamed of bedwetting. He has since developed a character of wanting to be alone, and he looks sad. The mother reports no other health complications or allergies.

• O: The patient is smartly and appropriately dressed. The boy is also alert and oriented. He is capable of creating and maintaining eye contact. His speech is coherent and has normal volume. The patient’s memory is intact, with both short-term and long-term memory intact. The patient denies suicidal ideation or actions. He also denies phobias or obsessions.
• A: A comprehensive physical exam revealed no specific cause of the patient’s bedwetting. However, the assessment and patient reports show that the patient has a nocturnal enuresis disorder, which needs to be managed.
• P: The patient needs to start weekly sessions of psychotherapy. Cognitive behavioral therapy should be used to help the patients with their thought patterns. Pharmacological approaches can then be integrated later.

Major Depression

Name T.R
Age 51 years
Gender Male
Diagnosis Major Depression

T.R is a fifty-one-year-old male patient who was referred to the facility by their family physician with a request for psychiatric assessment and review. The patient indicated that he had only come due to the request made by his doctor. He indicates that it is better that he dies since he doesn’t see any meaning in life. He reports hopelessness since he has not accomplished what he thought he would accomplish by the age of fifty. Other factors that make him sad include the fact that one of his sons is heavily drinking and uses other drugs. His son’s life has made him stressed and depressed. Therefore, the patient has been experiencing problems such as difficulty falling asleep, and he also easily wakes up. He also has a reduced appetite, hence struggling to eat. The patient also struggles with concentration and finds it hard to concentrate on tasks. These symptoms are not connected to any other medical condition.

• O: The patient is not appropriately dressed and is not well groomed. He is alert and oriented. The patient’s self-reported mood is depressed. He seems to drag his speech, but he is soft-spoken. He also has future-oriented thoughts. He also indicates that he has had suicidal thoughts and ideations. However, he has not acted on such plans. He, however, denies illusions, delusions, or hallucinations.
• A: According to the DSM-V diagnostic criteria, the symptoms displayed by the patient are an indication of major depression. As such, the patient needs an appropriate care approach.
• P: The patient is reporting these symptoms, which have persisted for some time now. Therefore, as part of the treatment plan, there is a need for the patient to start weekly cognitive behavioral therapy to help the patient deal with his thought patterns.

Oppositional Defiant Disorder

Name B.C
Age 10-years
Gender male
Diagnosis Oppositional Defiant Disorder

B.C is a ten-year-old male patient who was brought to the clinic by his mother for a psychiatric assessment. The mother indicates that she thinks her son needs help as soon as possible. She reports being worried by his son’s defiant behavior. What worries her more is that her son has shown defiance symptoms more frequently as he continuously defies orders and instructions both in school and at home. The boy hates taking directions and instructions from older siblings at home and sometimes even gets angry when instructed by the mother. He also shows similar symptoms in school as he argues a lot with fellow learners and doesn’t like following teachers’ instructions. Consequently, he finds it hard to complete home and school work as he should. The patient also throws tantrums and displays anger and aggression whenever he is corrected. Reports from school also show that he frequently gets into verbal disagreements and likes disrupting others.

• O: The patient has well and appropriately been dressed by the mother. He is also well-groomed. The patient is also alert and oriented in person, time, and place. His speech is clear and coherent. The boy is, however, argumentative and asks lots of questions. The patient’s concentration is low, and he keeps walking up and down in the examination room. His thought process is age-appropriate and coherent. The patient’s short-term and long-term memory are also intact. He denies suicidal thoughts or ideations. He also denies hallucinations, obsessions, or phobias.
• A: The symptoms shown by this patient are indicative of oppositional defiant disorder. He constantly defies orders and hates following instructions and directions. He also throws tantrums whenever he is corrected.
• P: The patient needs an appropriate management approach to help him deal with the symptoms. Therefore, he should start weekly sessions of family therapy to help in the management of his defiant behaviors.

Postpartum Depression

Initials G.M
Age 22 years
Gender Female
Diagnosis Postpartum Depression

G.M. is a twenty-two-year-old African-American female patient who came to the facility after she was advised by her friend to come for a psychiatric check and assessment. The patient recently gave birth to her first child and has been experiencing overwhelming thoughts concerning her child and what the future holds for the child. She indicates that she doesn’t think she can be a good mother, which has been worrying her. The patient also reports trouble with sleep as the child cries a lot at night, which makes it difficult for her to sleep at night, making her lack enough sleep. The lack of sleep has negatively affected her daily functioning and activities. As such, she no longer enjoys activities she used to like, such as cooking, going for walks, and reading. She thinks her life is not going according to plan; hence, she needs help to make it productive.

• O: The patient is well-groomed and appropriately dressed. She is also alert and oriented in person, time, and place. She has a clear and coherent speech. The patient’s mood looks sad, and she looks sleepy, tired, and exhausted. She has intact short-term and long-term memory. Her thought process is also coherent. She denies suicidal thoughts or mind. She denies thoughts of harm to the baby or self-harm. She also denies delusions, phobias, or hallucinations.
• A: The patient is displaying depressive symptoms associated with the birth of her first child; hence, the patient has post-partum depression. As such, she needs appropriate management.
• P: The patient needs to start weekly psychotherapy sessions to help deal with her symptoms. Therefore, she needs to start family therapy sessions.

Nightmare Disorder

Name S.W
Age 9 years old
Gender Female
Diagnosis nightmare disorder

S.W is a nine-year-old female patient who came to the facility accompanied by her elder sister. The sister reports that their mother is living in another town and only comes home during weekends. Therefore, she requested that S.W be brought to the facility for a psychiatric check. The patient has been experiencing nightmares, which leave her devastated and sad. She frequently wakes up in the middle of the night and screams while breathing heavily. She also sweats a lot during the nightmares. These experiences make her not want to sleep alone in her room but prefer sleeping in her sister’s room.

• O: The patient is well-groomed and dressed. The patient is also alert and oriented. She has a coherent speech and thought process. Her mood is sad as she seems bothered by her frequent nightmares. Her short and long-term memory are both intact. She denies suicidal thoughts or ideation. She admits to experiencing frequent and disturbing nightmares.
• A: The patient’s symptoms point to frequent nightmares, which is a disorder that should be treated and managed. The symptoms have persisted for some time; therefore, the diagnosis for this patient is nightmare disorder.
• P: The patient needs to start weekly sessions of cognitive behavioral therapy. The patient should attend the sessions for a period of four weeks before coming back for a review.

Panic Attack Disorder

Name F.D
Age 37 years old
Gender Male
Diagnosis Panic Attack Disorder

F.D. is a thirty-seven-year-old male patient who visited the facility, indicating he needs a psychiatric checkup. The patient reports that he has been experiencing uncomfortable chest pain. The pain has been there for the last few weeks, and the patient reports that there is a need to resolve it. He reports that he fears that he may experience a heart attack since one of his friends once experienced such symptoms and went on to experience a heart attack. These thoughts have since made him depressed, and he feels a lot of sadness. During such chest pains, the patient reports experiencing other symptoms such as anxiety, shortness of breath, choking, and pressure sensations.

• O: The patient is well-dressed and appropriately groomed. He is also alert and oriented in person, place, and time. The patient’s mood is sad, and he appears anxious. The patient also cooperated well during the interview. The patient’s speech is pressured. He has a coherent thought process. His short-term and long-term memory are both intact. He denies suicidal ideations or actions. The patient also denies hallucinations or delusions.
• A: The patient reported that he panics in some instances, which then comes with chest pain. In addition, he becomes anxious and depressed during such moments. Therefore, these symptoms point to the presence of panic attack disorder, hence needing appropriate management.
• P: The patient should start psychotherapy sessions on a weekly basis to help her deal with the thought patterns.

Binge Eating Disorder

Name D.S
Age 14 years old
Gender Female
Diagnosis Binge Eating Disorder

D.S is a fourteen-year-old female patient who visited the facility after she was referred by their family doctor, who indicated that she needed a psychiatric check and help. The patient indicates that, for some time now, she has been consuming large quantities of food, which makes her unhappy and leaves her feeling embarrassed. She has developed a tendency to eat and wants to eat even when she is full. She has been encouraged by her family members to stop the habit. She indicates that her mother has urged her to put effort into eliminating the behavior. However, she has so far failed to stop or control the habit. She expresses the fear of obesity and indicates that she might become obese if her eating trend continues. She has since started engaging in physical exercise to keep fit and stop her body from becoming big.

• O: The patient is well-dressed and groomed. She is alert and oriented in person, space, and time. She looks sad and depressed. The depressed mood has been caused by her eating behaviors, which she is not happy with. She reports low self-esteem due to her poor eating habits, which makes her feel embarrassed and unworthy. Her thought process is coherent. Her short and long-term memory is intact. The patient denies suicidal thoughts, hallucinations, and delusions.
• A: The patient has developed a habit of consuming large meals, and she has struggled to stop the behavior. As such, the diagnosis is binge eating disorder, and therefore, there is a need to manage the condition
• P: The patient needs to start weekly psychotherapy sessions to help her deal with her thought patterns, which are making her engage in binge eating. There will be a need to check how she fares with the therapy and explore other options depending on the outcomes.

Insomnia

Name K.G
Age 53 years old
Gender Male
Diagnosis Insomnia

K.G. is a fifty-three-year-old male patient who visited the facility with complaints of lack of quality sleep, which bothers him a lot. Therefore, he feels that he needs immediate help. He has been experiencing sleep problems, and he finds it hard to sleep. He also reports that, even if he falls asleep, he gets easily distracted from sleep. As such, he frequently wakes up in the middle of his sleep and finds it difficult to sleep again until the daybreak. Therefore, he finds it difficult to concentrate on his day-to-day activities. The sleeping problems worsened when he started having negative worries and thoughts regarding his retirement life, which is already in sight. The patient also finds it hard to concentrate and, in some cases, experiences fatigue during the day.

• O: The patient is appropriately dressed and well-groomed. He is also alert and oriented. The patient looks fatigued, sleepy, and tired. He struggles to concentrate and gets distracted easily. He has a coherent thought process and intact long-term and short-term memory. The patient denies any suicidal thoughts, ideations, or actions. The patient also denies hallucinations.
• A: The symptoms exhibited by the patient point to insomnia. As such, he needs appropriate treatment and management approaches.
• P: It is important for the patient to start weekly psychotherapy sessions. As such, the patient should commence family therapy sessions to help him deal with the current symptoms and explore strategies for improving his sleep quality.

Generalized Anxiety disorder

Name R.S
Age 38 years
Gender Male
Diagnosis Generalized Anxiety Disorder

R.S. is a thirty-eight-year-old male patient who came to the clinic for a psychiatric review and checkup. The patient had been diagnosed with anxiety disorder before, and he has been attending psychotherapy sessions to help him deal with the symptoms. The patient reports that he has not been consistent with the therapy sessions, hence recurring symptoms. The patient recently secured a job, and he has been worried about what to do to keep his current job. He has been informed that high standards are expected of him, and he needs to perform to such levels to ensure that he keeps his job. Consequently, he has experienced constant worries, anxiety, and fear, which has also led to inadequate sleep. He easily gets distracted from sleep and, hence, feels a lot of fatigue during the day. The patient has also continually become irritable. The patient reports that he has not used any medication since he last visited the facility.

• O: The patient is well-dressed and groomed. He is also alert and oriented. However, he appears anxious about so many things. He is unable to maintain appropriate eye contact and is restless. The patient’s speech is normal without pressure. He has a coherent thought process and intact short and long-term memory. He denies delusions and hallucinations. The patient also denies any suicidal thoughts, ideation, or actions.
• A: The patient had been diagnosed with anxiety in the previous weeks. While he has been undergoing psychotherapy, his non-compliance, combined with the start of a new job, has triggered anxiety symptoms. Therefore, the diagnosis is a recurrent generalized anxiety disorder.
• P: The patient should continue with psychotherapy sessions and adhere to the psychotherapy plan to avoid any cases of relapse. He also needs to visit the facility again after four weeks for a review

Attention Deficit Hyperactive Disorder

Name D.N
Age 8 years
Gender Male
Diagnosis Attention Deficit Hyperactive Disorder

D.N. is an eight-year-old boy who visited the clinic accompanied by his mother for the purposes of psychiatric assessment. The mother reports that her son has been exhibiting explosive moods and has increasingly become irritable. She also reports that it is not the first time the patient has exhibited these symptoms, as he had shown similar symptoms before, but they disappeared on their own. However, she is worried since the current symptoms have persisted and don’t seem to be going away as she thought they would. The patient also exhibits some other unwanted symptoms, such as being unable to complete tasks assigned to him. The patient’s concentration and attention span are also low; hence, he struggles to complete tasks assigned in school. In addition, he is disruptive and not easy to control in school.

• O: The patient has been well dressed by the mother and is also well groomed. He is alert and oriented in person, place, and time. He finds it difficult to establish and maintain eye contact. His speech has a louder-than-normal volume. He appears restless as he moves up and down the assessment room all the time. The patient’s thought process is coherent. He denies hallucinations, obsessions, or delusions. The patient has a distorted short-term memory but an intact long-term memory.
• A: The patient has various symptoms, such as shortfalls in memory and thinking, easily getting distracted, impulsivity, and hyperactivity. Therefore, the current diagnosis is ADHD.
• P: The patient needs an appropriate treatment and management strategy to help with the symptoms. Therefore, he should start dialectical behavioral therapy to help with the symptoms.

Adjustment Disorder

Name C.Y
Age 37-years
Gender Female
Diagnosis Adjustment disorder

C.Y is a thirty-seven-year-old female patient who came to the clinic for a psychiatric assessment and with reports of constantly experiencing bad feelings. These feelings started when she relocated to a new neighborhood after securing a new job. She indicates that her current residential area is not as attractive as her previous place. In addition, the new neighborhood is full of noise, and people don’t look friendly. Therefore, she admits that coping with the current environment has been an uphill task, but she still has some hopes that it will improve with time. The patient also reports that she has a challenge with her new workstation as she is expected to be at the site earlier than she is used to. Her son and daughter are also struggling to adjust to their new surrounding, which makes her stressed. These problems have caused the patient to experience other unwanted symptoms, such as fatigue and tiredness during the day due to lack of sufficient sleep.

• O: The patient is well-dressed and groomed. She is also alert and oriented. However, she looks anxious, worried, and tired. She is easily distracted and finds it hard to maintain eye contact. The patient denies delusions, hallucinations, suicidal thoughts, ideations, or actions. His thought process is coherent, and she has intact short-term and long-term memory.
• A: The patient has shown unwanted symptoms of worry, anxiety, and depression due to the change of her residence and workplace. Therefore, these symptoms can be associated with adjustment disorder.
• P: The patient needs to start psychotherapy sessions. As such, she needs to start weekly sessions of cognitive behavioral therapy to help with the symptoms. The patient needs to visit the facility after four weeks for a review.

Bipolar Disorder

Name G.V
Age 43 years
Gender Male
Diagnosis Bipolar Disorder

G.V is a forty-three-year-old male patient who came to the clinic for a psychiatric checkup since he was told to seek help after exhibiting symptoms related to bipolar disorder. The patient has been exhibiting periods of elevated moods, which also alternate with depressive mood periods. The elevated mood periods are characterized by excitement and, in some cases, delusions. Other symptoms experienced by the patient include being overactive, restless, and talking more than usual. He has also experienced problems falling asleep and easily gets distracted from sleep. Consequently, he experiences fatigue and feels tired during the day, which negatively affects his ability to complete his tasks.

• O: The patient is well-dressed and appropriately groomed. He is also alert and oriented in person, place, and time. His mood is excited, he appears restless, and he easily gets distracted. He has a pressured speech. He denies suicidal thoughts, ideation, or actions. He also denies hallucination. However, he has grandeur delusions. His judgment and thought process are both distorted. The patient exhibits distorted thoughts.
• A: The patient has shown manic symptoms and problems with falling asleep, and he is also easily distracted from sleep. The symptoms shown by the patient point to bipolar disorder.
  P: The patient needs to start weekly sessions of cognitive behavioral therapy to help him deal with the symptoms as appropriate. It is important that the patient visits the facility after a period of four weeks for a psychiatric review and new treatment plans.

Borderline personality disorder

Name L.J
Age 16 years
Gender Female
Diagnosis Borderline personality disorder

L.J. is a sixteen-year-old female patient who visited the facility for a psychiatric visit. The patient reports frequent and constant undesirable feelings. The patient was diagnosed with borderline personality disorder some months ago and has been attending psychotherapy sessions. The patient stopped the sessions after a period of three weeks, and thereafter, she has been exhibiting various symptoms, such as constant frequent suicidal thoughts, which have been a source of fear and worry to her family members. In addition, she has also been experiencing other symptoms, such as frequent mood swings, anger, sadness, grandiosity, and feelings of emptiness. She finds it difficult to maintain friendships and finds it hard to get along with them as she labels them liars and dishonest people. Consequently, she prefers being alone and away from crowds.

• O: The patient is well-dressed and appropriately groomed. She is also alert and oriented. She finds it hard to concentrate and constantly gazes around. Her thought process is coherent. The patient is positive for suicidal thoughts and self-harm. She denies delusions and hallucinations. Her speech is normal and not pressured.
• A: The patient’s current symptoms still indicate the existence of borderline personality disorder, as she did not complete her psychotherapy plan. There is a need to quickly manage her symptoms, especially suicidal ideation and thoughts.
• P: The patient should restart her cognitive behavioral therapy sessions for a period of four weeks before visiting the facility for a review. It is important that the patient adheres to the psychotherapy schedule and plan.

Alcohol Use Disorder

Name D.R
Age 33 years old
Gender male
Diagnosis Alcohol Use Disorder

D.R. is a thirty-three-year-old male patient who visited the facility for a psychiatric visit. He reports that he can get help after he has tried ending his binge alcohol consumption with no positive results. The patient has been drinking alcohol for the last seven years. However, his consumption rate has substantially increased in the past year. Consequently, the patient has problems both at work and in his family. He gets late to work and struggles to complete the assigned task. In addition, he has tension with his family members, who accuse him of wasting his resources on alcohol. However, amidst all these problems, the patient finds it difficult to leave the use of alcohol, and he reports feeling sick whenever he doesn’t consume alcohol. The patient had attended a rehabilitation program a few years ago, but it did not work, and he reported that he did not have any motivation to participate in the program. He reports that he needs immediate help before he loses both his family and job.

• O: The patient is well-dressed and appropriately groomed. He is also alert and oriented. He manages to keep eye contact. However, he appears stressed over the possibility of losing his job and family. The patient has unsteady speech as he at times manages to speak clearly, while at times he just mumbles words. His thought process is coherent. He denies suicidal thoughts, actions, or ideations. He also denies hallucinations and delusions.
• A: The patient’s symptoms point to alcohol abuse disorder; hence, he needs to be helped. The patient is willing to be helped hence should be committed to the treatment course.
• P: The patient should start psychotherapy sessions focusing on helping him develop social skills and coping mechanisms. The psychotherapy sessions should proceed for four weeks before visiting the facility for review.