Assignment 1: PRAC 6645 WEEK 2 Clinical Hour and Patient Logs

Clinical Logs
Post-Traumatic Stress Disorder
Name: D.S
Age: 34 years
Diagnosis: Post-traumatic stress disorder
S: D.S is a 34-year-old patient who came to the department today for his follow-up visit. He was diagnosed with post-traumatic stress disorder seven months ago, and has been on treatment. The symptoms of post-traumatic stress disorder occurred following his involvement in a sexual assault incident. According to the patient, he experienced the symptoms three months after the incidence. The complaints that led to the diagnosis were varied. They incurred recurrence in distressing memories of the encounter. The recurrence was involuntary and often distressing for the patient. The patient also reported nightmares and flashbacks about the incident, which were emotionally distressing. There was also the complaints of avoidance of any stimuli or conditions that reminded him about the incident. The above symptoms had affected severely the ability of the patient to function optimally in his social and occupational roles. The assessment had further revealed that the symptoms were not attributed to any other cause such as medication use, medical condition or substance abuse. He was diagnosed with post-traumatic stress disorder and has been using antidepressants and attending group psychotherapy sessions.

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O: The patient appeared well groomed for the visit. He was oriented to self, place, time and events. The mood was normal with speech within the expected range in terms of rate and volume. He denied any recent experience of illusions, delusions, hallucinations, and suicidal thoughts, attempts, and plans.
A: The treatment objectives have been achieved for this client. He has developed the desired knowledge and skills for managing the distressing symptoms of post-traumatic stress disorder.
P: Psychotherapy sessions were terminated with consent from the patient. He was advised to continue using antidepressants. He was scheduled for next follow-up visit after two months.

Alzheimer’s disease
Name: C.H
Age: 73 years
Diagnosis: Alzheimer’s disease
S: C.H is a 73 year-old client that was brought to the clinic for psychiatric assessment due to his abnormal behaviors. The accompanying family members reported that C.H had been demonstrating weird behaviors over the past six months, which could not be considered to be due to medical problem. The complaints included his gradual decline in memory, as evidenced by him getting lost in his familiar environments. The patient had also forgotten the names of his family members and needed to be reminded frequently. The patient was also reported to be wandering at night, which predisposed him to harm. The family members were worried that his ability to perform basic financial calculations had deteriorated, as evidenced by errors in his calculations. The level of anxiety in the patient had risen significantly over the past few days. He was reported to be easily irrigated and agitated. The symptoms had affected his ability to engage in his activities of the daily living, as he relied on the family members. Based on the above complaints, the patient was diagnosed with Alzheimer’s disease and initiated on treatment.
O: The patient appeared poorly dressed for the occasion. He was anxious. He did not demonstrate any abnormal movements such as tremors. His orientation to time was altered. He lacked memory of recent events. His speech was of normal rate and volume. He denied delusions, illusions, hallucinations and suicidal thoughts, attempts, plans and intentions.
A: The client demonstrates the symptoms of initial stages of Alzheimer’s disease. The aim of treatment should be to slow the disease process and assist the client cope with the cognitive changes in functioning.
P: The client was initiated on pharmacological treatment and psychotherapy. The aim of the pharmacological treatment was to slow the progression of the condition. Psychotherapy was administered to help him manage anxiety due to changes in functioning.

Major Depression
Name: E.H
Age: 36 years
Diagnosis: Major depression
S: E.H is a 36-year-old client that has been undergoing treatment in the unit due to major depression. The client was diagnosed with the condition eight months ago and has been undergoing group psychotherapy sessions and using antidepressants. The client recalled that she was diagnosed with depression after she presented with some complaints to the department. They included feeling sad most of the days almost all the days, feeling worthless and guilty most of the times. She also reported changes in her appetite, as she did not want to eat any food. She also started becoming socially withdrawn. Her interest in pleasure also declined significantly. The energy levels of the client were also always low. The symptoms had affected significantly her ability to work as a banker. The symptoms could not be attributed to other causes such as medication use, medical conditions or substance abuse. She was therefore diagnosed with major depression and has been undergoing treatment in the facility.
O: The patient appeared dressed appropriately for the occasion. She was oriented to self, place, time and events. Her judgment was intact. She denied any suicidal thoughts, attempts or plans as well as illusions, delusions and hallucinations. Her mood was normal.
A: The client has responded well to the treatments. Her mood has improved. She has developed the desired coping skills for the effective management of her health problem.
P: Psychotherapy sessions were terminated with consent obtained from the client. She was advised to continue with antidepressant therapy. She was scheduled for follow-up visit after two months.
General Anxiety Disorder
Name: J.O
Age: 29 years
Diagnosis: General anxiety disorder
S: J.O is a new client that came to the unit for assessment, as she experienced abnormal levels of anxiety. The client reported that she has been experiencing intense anxiety and fear of failing to produce the expected results in her workplace. According to her, she experienced symptoms of excessive worry that was difficult for her to control. There was also the fear of impending doom should she fail to achieve the set targets in her institution. The feelings of excessive worry were accompanied with a wide range of complaints that included irritability, chest pains, and difficulty in breathing, sweating, and trembling. There was also the complaints that the quality of sleep that the client received in the past month has been poor, as she remained awake throughout the night. The client denied any use of medications, medical condition or substance abuse. As a result, she was diagnosed with general anxiety disorder and initiated on group psychotherapy session.
O: The patient appeared well dressed for the occasion. She was anxious during the assessment. She also constantly yawned due to the lack of enough sleep the previous night. She denied illusions, delusions, hallucinations, and suicidal thoughts, plans, and attempts.
A: The client is experiencing moderate symptoms of generalized anxiety disorder.
P: The client was initiated on group psychotherapy to help her develop effective skills for managing her anxiety.

Insomnia
Name: E.O
Age: 32 years
Diagnosis: Insomnia
S: E.O is a 32-year-old male who has been undergoing treatment in the facility due to insomnia. E.O was diagnosed with insomnia five months ago after he presented to the clinic with a number of complaints. They included the lack of quality and quantity sleep for the last four months prior to the hospital visit. He also complained that he found it difficult to maintain sleep once he fell asleep. There were also the complaints that the sleep disturbance had affected significantly his ability to concentrate in his academic activities. He was worried that his academic performance would have worsened if the condition was not managed. Further assessment of the client had revealed that the symptoms were not attributed to any factors such as medication use, medical condition or substance abuse. He was therefore diagnosed with insomnia and initiated on treatment.
O: The patient appeared well groomed for the occasion. His orientation to self, others, time and events were intact. His judgment was also intact, as he denied illusions, delusions and hallucinations. The client also denied suicidal thoughts, attempts and plans. The speech was of normal rate and volume. He reported enhanced satisfaction with treatment effectiveness, as he no longer experienced troubles in getting and maintaining sleep.
A: The treatment goals for the client have been achieved. There are no complaints of poor quality of sleep. The functioning of the client has also improved with the treatment.
P: Group psychotherapy was terminated with the consent from the client, as the treatment objectives had been achieved.

Major Depression
Name: Z.S
Age: 38 years
Diagnosis: Major Depression
S: Z.S is a 38-year-old female that came today to the unit for her regular checkup. Z.S was diagnosed with major depression three months ago and has been on antidepressants and psychotherapy treatments. She was diagnosed with depression because of a number of reasons. One of the symptoms was the persistent feeling of worthlessness. Her persistent feelings of worthlessness had mad her contemplate committing suicide. The client also reported that she preferred spending her time indoors and alone. She locked herself in her room most of the times to help her avoid contact with people in her environment. The client also reported a decrease in her appetite, which led to weight loss and lack of energy in most of the days. There was also the complaint of lack of concentration and difficulty in making decisions. The client also complained that she experienced insomnia for the last three weeks prior to the hospital visit. The above symptoms were noted to have affected adversely the ability of the client to perform optimally in her social and occupational roles. As a result, she was diagnosed with major depression and initiated on treatment.
O: The client was appropriately dressed for the occasion. She reported that her mood had improved significantly following the changes in her treatment in the last visit. The orientation to self, place, time, and events were intact. She denied any illusions, delusions, ad hallucinations. The client also denied any recent experience of suicidal thoughts, plans, and attempts.
A: The client has responded well to the treatment. There is moderate improvement in the symptoms of depression.
P: The client was advised to continue using the current prescription and attend psychotherapy sessions for sustained improvement in the symptoms of depression.

Binge Eating
Name: M.E
Age: 22 years
Diagnosis: Binge Eating Disorder
S: M.E is a 22-year old college student who has been undergoing treatment in the unit for binge eating disorder. The client was diagnosed with the disorder six months ago and has been on individual psychotherapy treatment. She was diagnosed with binge eating disorder based on a number of complaints that she provided today during our interaction. The complaints included uncontrolled eating that was beyond the normal intake by other students of her age. She also complained that the excessive eating was beyond her control. In some cases, she was embarrassed of her eating habits such that she had to hide from her friends during meal times. Further history taking from the client showed that she did not engage in any compensatory behaviors such as vomiting. The eating habits had affected adversely the social and mental health of the client. As a result, she had come seeking assistance in the unit where she was initiated on individual psychotherapy sessions.
O: The client appeared well groomed for the occasion. Her body weight was within the normal range for her age. She was oriented to self, others, time and place. She did not demonstrate any signs of anxiety or depression. She denied negative perception of her self-image, illusions, delusions, and hallucinations.
A: The client has responded well to the treatment. She reported that she now has control over her binge eating habits. She no longer eats large amounts of food than normal. She is also confident of her new coping skills.
P: The treatment outcomes for this client have been achieved. Therefore, the treatment was terminated. She was however linked with the social support group for individuals with eating disorders in the community to ensure that the coping skills were sustainable.

Schizophrenia
Name: C.H
Age: 44 years
Diagnosis: Schizophrenia
S: C.H is a 44-year old client that came to the unit for psychiatric review. The client’s family felt that he was experiencing abnormal symptoms that were highly likely to be attributed to a mental health problem. The symptoms that the client experienced were varied. They included false identity of self. He believed that he was an alien and could rule over the world in issues related to technological innovations. The client also demonstrated behaviors that were inappropriate for his age. The emotional expression was flat. The family had noted that C.H was easily irritated and experienced significant difficulties in making decisions or concentrating in the things that he was doing. A further assessment during the interaction with the client and his family showed that the symptoms that the client experienced could not be attributed to any cause such as medication use, substance abuse and medical condition. As a result, he was diagnosed with schizophrenia and initiated on treatment.
O: The patient appeared poorly groomed. His orientation to space, time and others was altered. The judgment of the client was also altered. He demonstrated flight of ideas. The patient was delusional. He denied illusions and hallucinations. He also denied suicidal thoughts, attempts and plans.
A: The client experiences moderate symptoms of schizophrenia. His cognitive functioning is impaired.
P: The client was initiated on pharmacotherapy and cognitive behavioral therapy to help him develop effective skills for managing the symptoms of schizophrenia. He was scheduled for a follow-up visit after four weeks.

Bipolar Disorder
Name: A.M
Age: 40 years
Diagnosis: Bipolar Disorder
S: A.M is a 33-year-old male who has been undergoing treatment in the facility due to bipolar disorder. A.M was diagnosed with bipolar disorder two months ago and has been on pharmacological treatment and psychotherapy. A.M was diagnosed with bipolar disorder after he presented with symptoms that aligned with those of bipolar disorder as stated in DSMV. They included an expansive mood that was characterized by the patient feeling that he was in control of everything. A.M also reported that he was easy irritable and agitated. His ability to concentrate in doing tasks and making critical decisions was also altered. The symptoms were presented in most of the days and almost every day. The patient reported additional symptoms during this period. The symptoms included lack of sleep, increased talkativeness, and being easily distracted. The patient also engaged significantly in goal directed activities and impulsive behaviors. The client was worried that the episodes of the above symptoms had a negative effect on his social and occupational functioning. As a result, he was diagnosed with bipolar disorder and has been on treatment with the aim of stabilizing his mood.
O: A.M was dressed appropriately for the visit to the hospital. He was oriented to self, time, space and others. He reported improvement in his mood due to the adopted treatment interventions. The client noted improvements in his concentration and decision making abilities. His judgment was intact. The speech was of normal rate and volume. He denied illusions, delusions, and hallucinations. He also denied suicidal thoughts, attempts and plans.
A: The treatment appears to be effective, as evidenced by the moderate improvement in symptoms.
P: The client was advised to continue with the current treatment modalities. The client was scheduled for a follow-up care after a month.

Borderline Personality Disorder
Name: Z.C
Age: 30 years
Diagnosis: Borderline Personality Disorder
S: Z.C is a 30-year-old female that has been undergoing treatment in the unit for borderline personality disorder. The client was diagnosed with the disorder two months ago following complaints that aligned with those of borderline personality disorder. The complaints included instability in her relationships, being concerned with her self-image and excessive fear of abandonment. The client also reported engagement in self-destructive behaviors to get the attention of her boyfriend. The above symptoms were beyond the control of the client. As a result, she was concerned since it was affecting her health and wellbeing. The client was diagnosed with borderline personality disorder and initiated on treatment.
O: The client appeared appropriately dressed for the occasion. The client self-expressed mood was that I am anxious. The orientation of the client to self, place, time and events were intact. The judgment was intact as evidenced by the absence of illusions, delusions, and hallucinations. The client denied suicidal plans, attempts and thoughts.
A: The treatment is effective in improving symptom management.
P: The client was advised to continue with the current treatment attend the psychotherapy sessions as scheduled. She was scheduled for a follow-up visit after one month.

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Assignment 1: Clinical Hour and Patient Logs

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Clinical Hours

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 be counted. You may only log hours with preceptors that are approved in Meditrek.

Students with catalog years before Spring 2018â€¯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 inâ€¯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 â€” Students must include a brief summary/synopsis of the patient visitâ€”this does not need to be a SOAP note; however, the note needs to be sufficient to remember your patient encounter.