PRAC 6665 week 2 CLINICAL HOUR AND PATIENT LOGS ESSAY
PRAC 6665 week 2 CLINICAL HOUR AND PATIENT LOGS ESSAY
Post-partum Depression
Diagnosis: Post-Partum Depression
R.C. is a twenty-five-year-old female patient who came to the clinic accompanied by her elder sister and a week-old baby. The sister indicated that she brought the patient to the facility since she gets it difficult to cope with her new status of motherhood. The patient indicates that her baby cries a lot which is irritating. The worst part is a lot of cries at night, which disturbs her sleep and sleeping patterns. She indicates that she is sometimes filled with sadness and feels hopeless since she can’t stop the baby from crying. She has also reported feelings of being overwhelmed and loss of appetite.
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O: The patient is well-dressed and groomed. She is also well-oriented to space and time. She has coherent speech and speaks fluently. She has a sad mood and has trouble concentrating. The patient has intact short-term and long-term memory. She denies suicidal mind, thoughts or actions. She also denies any thoughts of causing harm to the baby, as she indicated that she loves her baby so much.
A: the symptoms displayed by the patient are an indication of post-partum depression. The client is a first-time mother hence a high likelihood of post-partum depression.
P: There is a need to treat the patient so that she can have relief from the depression symptoms. CBT sessions should be used to enhance her ability to cope with difficulties and feelings. She can also join support groups.
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Attention-Deficit/Hyperactivity Disorder (ADHD)
Diagnosis: ADHD
D.S is an eight-year-old boy who came to the facility accompanied by his mother. The mother indicated that she is worried about the patient’s behaviour in recent times. For example, in the last few weeks, the boy has been showing signs of inattention, hyperactivity, and impulsivity. He has increasingly become disruptive both in school and at home and rarely completes assigned tasks. However, the boy has not been defiant since he takes in instructions. The symptoms improve when he is reprimanded.
O: The patient is appropriately dressed and well-groomed. He is also alert and oriented. Even though he responds to questions, he does so hastily. He also finds it difficult to maintain eye contact. The patient has a low concentration span. He denies suicidal thoughts, actions, or ideation.
A: Based on the DSM-V criteria, the patient’s symptoms point to ADHD. While ODD can also be considered a diagnosis, his mother has indicated that he takes instructions and is that he is not defiant.
P: The patient needs to undergo psychotherapy sessions. Especially family therapy sessions to improve his coping skills.
Insomnia
Diagnosis: Insomnia
N.S is a fifty-year-old male patient who came to the clinic for a psychiatric follow-up. The patient had been diagnosed with insomnia recently after reports of struggling with sleep problems before. The patient is reporting what looks to be a relapse in symptoms. He continually finds it has to fall asleep, and he is also easily distracted from sleep whenever he manages to fall asleep. He also finds it difficult to concentrate during the day, which negatively affects his daily life. He thinks sleeping pills can help, but he does not want to buy them over the counter without a proper prescription.
O: The patient is well-dressed and appropriately groomed. He is also well-oriented to space and time. He is also alert but dosed off in the middle of the session. The patient has a short concentration span. He also has a coherent thought process and intact memory. He denies hallucinations, suicidal ideation, actions, or attempts.
A: The patient already had an insomnia diagnosis before and is displaying a relapse in symptoms. Hence, the diagnosis is still insomnia.
P: The patient needs to start psychotherapy sessions to help with the symptoms.
Binge Eating Disorder
Diagnosis: Binge Eating Disorder
N.T. is a fourteen-year-old patient who visited the facility with her mother. The patient indicates that she feels embarrassed about how she has been eating. She feels she consumes a lot of food and sometimes eats gluttonously, even when she is full. She has tried using various strategies to stop the behavior but has found it difficult to stop. While her parents and siblings have shown her some support by trying to help her stop the habit, little has improved, and she strongly believes that she can be helped medically. She has been depressed due to her inability to control her appetite and binge eating. She is concerned that this habit will soon make her obese.
O: The patient is well-dressed and groomed. She is also alert and oriented. Her mood is sad and depressed as she has been unable to stop her appetite for consuming large meals. She has also reported feelings of low self-esteem, unworthiness, and hopelessness. The patient denies any suicidal thoughts or ideation. She has a coherent thought process and clear speech.
A: The patient has shown a consistent appetite for large chunks of food, even when she feels full. Therefore, the diagnosis is a binge eating disorder.
P: The patient needs to commence CBT sessions to help her with her thinking patterns and how she can control the habit.
Bipolar Disorder
Diagnosis: Bipolar Disorder
T.S is a thirty-nine-year-old patient who came for a psychiatric visit at the facility. This indicates that she has been having extreme mood swings, which make her unhappy. She has also shown various symptoms, such as delusions, euphoria, excitement, and over-activity. In addition, the patient also sometimes experiences symptoms such as depression which has been bothering her normal life. The depression experiences come with struggling with decision-making, complications with concentrating, feeling sleeping, and reduced energy levels. She also indicates that she has no impaired function or drug abuse.
O: The patient is appropriately dressed and well-groomed. She is also well-oriented. She has a coherent thought process with intact judgment. The patient denies any symptoms of suicidal thoughts or mind and hallucinations. However, she is positive for delusions.
A: According to the DSM-V criteria, the symptoms are shown by this patient lead to a diagnosis of bipolar disorder.
P: The patient needs to start cognitive behavioral therapy sessions to help with the thinking patterns.
Panic Attack Disorder
Diagnosis: Panic Attack Disorder
S.W is a thirty-one-year-old male patient who came to the facility with experiences of bothering chest pain. He indicates that the chest pain makes him feel uncomfortable. He has been worried of late and feels that he may experience a heart attack soon if the problem is not resolved. He also feels depressed by the condition since he fears the symptoms might get worse. The chest pain comes with pressure sensations, choking, shortness of breath, and anxiety.
O: The patient is well-dressed and groomed. He is also alert and oriented. The patient looked anxious. He cooperated throughout the assessment. He had pressured speech and responded to questions appropriately. He had an intact memory and a coherent thought process. He denies any delusion, hallucination, suicidal actions, or ideation.
A: The patient’s symptoms, exams, and history indicate panic attack disorder hence a need for proper management.
P: psychotherapy approaches should be used to help the patient manage the conditions.
Nightmare Disorder
Diagnosis: nightmare disorder
S.K. is an eight-year-old female patient who came to the facility accompanied by her mother. She indicates that her daughter has been experiencing consistent nightmares which disturb her sleep. She patient doesn’t have complications with falling asleep, but she easily gets awake in the middle of her sleep following episodes of nightmares. The patient breathes heavily and screams during the episodes. She also sweats a lot and indicates that some animals chase her in her dreams, making her scream. She fears sleeping in her room alone and doesn’t want to walk in the dark.
O: The patient is appropriately dressed, well-groomed, and healthy. She is alert and oriented. The mother indicates that the patient’s nightmares are associated with scary animals which chase her in the dark, wanting to harm her. She denies delusions, hallucinations, or suicidal attempts.
A: The patient has been experiencing consistent nightmares. Hence according to the DSM-V criteria, she has nightmare disorder.
P: The patient needs a psychotherapy approach, especially CBT, to help the patient deal with the thought patterns.
Psychotic Disorder
Diagnosis: Psychotic Disorder
J.C. is a twenty-three-year-old male patient who came to the facility accompanied by his parents. The parents report observing some strange behavior with their son since he came back from the city. The patient lived with friends for some time but came home after several disagreements following a consistent abuse of marijuana and cocaine. In addition, the police started following them. Hence the patient indicates that going back home would be the best option. He has been experiencing hallucinations, both visual and auditory. He accuses his siblings of intending to destroy his life by spying on him and reporting to the police.
O: The patient put on clean clothing butt had shaggy hair and was unclean. He finds it hard to maintain eye contact. His mood is depressed, and he shows a sad face and an angry expression. He also reports symptoms of hopelessness and helplessness. He has an incoherent thought process and is positive for hallucinations. He also had self-injurious thoughts and behavior.
A: According to the DSM-V criteria, the patient has a substance-induced psychotic disorder
P: Psychotherapy sessions are needed to help the patient first quit substance abuse. Such a step may be key in solving the psychotic disorder
Generalized Anxiety Disorder
Diagnosis: GAD and SAD
V.C. is a ten-year-old female patient who was brought to the facility by her mother. The mother indicates that her daughter has been showing worrying symptoms which need attention for better results. The patient is scared and worries over several things. She is concerned about what might be if she finds herself all alone on earth and what can happen if her mother and siblings die or leave her all alone and move to another city. She has increasingly shown resistance to going to school since she doesn’t want to leave her mother and siblings behind. She also finds it difficult to concentrate in school leading to poor performance.
O: The patient is appropriately dressed and well-groomed. She is also well-oriented in place, person, and time. She has an eloquent speech and a coherent thought process. However, she looks worried and uneasy. She has intact short and long-term memory. However, she has challenges concentrating. The patient denies any suicidal thoughts or ideation.
A: The symptoms shown by the patient point to generalized anxiety disorder with a separation anxiety disorder.
P: The patient needs to start cognitive behavioral therapy sessions to help with her thought patterns and symptoms.
Post-Traumatic Stress Disorder
Diagnosis: Post-traumatic stress disorder
A.D. is a sixteen-year-old patient who visited the facility with her mother with reports of undesirable symptoms. The patient’s sister recently died in a motor car accident which has made the patient have various symptoms such as self-destructive behaviors, irritability, trouble sleeping, trouble concentrating, and getting frightened. She also sometimes takes off when she hears the sound of care. She has also been having nightmares of cars crashing into each other and killing people. Sometimes she shows anger outbursts and aggressive behavior.
O: The patient is well-dressed and groomed. She has a rushed speech. She is easily angered and so irritable. The patient’s memory is flawed, but she has a coherent thought process. She denies any suicidal actions, ideations, or thoughts.
A: The patient has developed the symptoms after experiencing the trauma of passing on her sister through a road accident. As such, the patient’s diagnosis is PTSD.
P: The patient needs to start weekly cognitive behavioral sessions to help her deal with the stress symptoms.
Oppositional Defiant Disorder
Diagnosis: Oppositional Defiant Disorder
D.V. is an eleven-year-old patient who came to the facility accompanied by his mother. The mother indicated that her son is showing unbearable behavior and strange symptoms. He has been disrespectful and disobedient to both his teachers and siblings and usually shows aggressive behavior whenever an adult corrects him. The teachers also complain that the patient likes arguing and talks aggressively whenever he is not satisfied with something. He also throws tantrums whenever he gets corrected and is also ready to fight whenever things seem not to go his way.
O: The patient is neatly dressed and well-groomed. He is also alert and oriented. The boy is argumentative and resists instruction. The boy is restless and finds it hard to maintain eye contact. He has a coherent thought process and an intact memory. The patient denies any phobias, obsessions, hallucinations, or suicidal thoughts.
A: According to the DSM-V criteria, the patient’s symptoms point to opposition defiant disorder.
P: The patient needs to start family therapy sessions to help him deal with his anger and aggression.
Major Depression
Diagnosis: Major Depression
D.B. is a fifty-two-year-old male patient who visited the facility after a referral by his family doctor. He indicates that he feels hopeless and does not see why he should continue living. He indicates that he is soon retiring, but he has not invested anything and fears that he could struggle during his old age after retirement. In addition, he has a son who is addicted to cocaine and is almost psychotic. He doesn’t know what to do to him anymore to help him. He has been having a depressed mood and finds it difficult to fall asleep. He also has a reduced appetite and, therefore, struggles to eat. He has suicidal thoughts and thinks he better takes away his life.
O: The patient is poorly dressed and is not appropriately groomed. He has unsteady speech and speaks softly. The patient has a depressed mood. He also displays future-oriented thoughts. He also has suicidal thoughts, though he has made no attempts to take his life. He denies illusions or delusions.
A: The patient’s symptoms indicate the presence of major depression
P: The patient needs to commence weekly cognitive behavioral therapy.
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CLINICAL HOUR AND PATIENT LOGS
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 in order to earn the points associated with this assignment. You may only log hours with Preceptors that are approved in Meditrek.
Students 2018 must complete a minimum of 160 hours of supervised clinical experience. You may not complete your hours sooner than 8 weeks. You will enter your approved preceptor and clinical faculty as part of each time and patient encounter you log.
Your clinical hour log must include the following:
- Dates
- Course
- Clinical Faculty
- Approved Preceptor
- Total Time (for the day)
RESOURCES
Be sure to review the Learning Resources before completing this activity.
Click the weekly resources link to access the resources.
PATIENT LOG
Throughout this course, you will also keep a log of patient encounters using Meditrek. You must record at least 80 encounters with patients by the end of this practicum (40 children/adolescents and 40 adult/older adult).
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: You 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 OF WEEK 2
Record your clinical hours and patient encounters in Meditrek.
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Rubric
PRAC_6665_Week2_Assignment1_Rubric
| Criteria | Ratings | Pts | ||
|---|---|---|---|---|
| This criterion is linked to a Learning OutcomePart 1: Time logs and patient logs are completed within 48 hours of completing clinical time. |
|
5 pts | ||
| This criterion is linked to a Learning OutcomePart 2: Patient logs meet the minimum documentation requirements. *Each entry includes Date, Course, Clinical Instructor, Preceptor, Patient number, Client information, Visit information, Practice management, Diagnosis, Procedures (if applicable), Treatment plan and notes, Notes section (Students must include a brief summary/synopsis of the patient visit—this must include enough information to understand how the patient presnted and the student intervention. Do NOT include EMR SOAP notes. *LOGS MUST BE SUBMITTED WITHIN 48 HOURS TO BE ELIGIBLE FOR ANY POINTS |
|
5 pts | ||
| Total Points: 10 | ||||
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