Assignment 1: PRAC 6645 WEEK 8: Clinical Hour and Patient Logs
Assignment 1: PRAC 6645 WEEK 8: Clinical Hour and Patient Logs
Clinical Logs
Insomnia
Name: X.X
Age: 24 years
Diagnosis: Insomnia
S: X.X is a 24-year-old male who came to the clinic for his fifth follow-up visit after being diagnosed with insomnia six months ago. He was diagnosed with insomnia after he presented to the unit with complaints of difficulties in falling asleep and maintaining sleep. He also reported frequent episodes of waking up while asleep and finding it hard to get sleep afterwards. The energy levels of the client during the day were significantly reduced. As a result, he was worried that his productivity was not to the expected level in his organization. The difficulties in sleep could not be attributed to any medical condition, medication, or substance abuse. Due to the above complaints, the patient was diagnosed with insomnia, and has been undergoing group psychotherapy sessions in the unit.
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O: The client appeared appropriately dressed for the occasion. His orientation to self, place, time and events were intact. The self-reported mood of the client was normal. The judgment of the client was intact. He denied any history of delusions, hallucinations, and illusions. He also denied any history of suicidal thoughts, attempts, and plans.
A: The use of group psychotherapy treatment has been effective in improving the symptoms of insomnia being experienced by the client
P: The participation of the client in the group psychotherapy sessions was terminated, as the treatment objectives had been achieved. He was informed to visit the clinic should the symptoms relapse.
Schizophrenia
Name: B.T
Age: 38 years
Diagnosis: Schizophrenia
S: B.T is a 38-year-old female that came to the unit for her sixth follow-up visit after being diagnosed with schizophrenia seven months ago. She recalled that she had come to the unit with complaints 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 symptoms could not be attributed 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 denied suicidal thoughts, attempts, and plans. Her thought content was future oriented. She did not demonstrate any abnormal behaviors such as tremors and flight of ideas.
A: The treatment objectives have been achieved with the adopted treatment interventions. The client also demonstrates no side effects to the adopted treatments.
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.
Attention-Deficit Hyperactive Disorder (ADHD)
Name: K.P
Age: 9 years
Diagnosis: ADHD
S: K.P is a 9-year-old boy who came to the unit for his regular assessment in the company of his parents. He was diagnosed with ADHD at the age of 7 years and has been on treatment. The parents recalled that K.P was diagnosed with the disorder due to symptoms that included the lack of attention alongside impulsivity and hyperactivity for more than six months after being enrolled in school. The symptoms of impulsivity were reported to affect negatively the social and academic performance of the client. The client also demonstrated the above symptoms both in school and at home. The teacher had reported that the client day dreamed and seemed distant while in class. He also fidgeted and failed to complete her assignments on time.. A further assessment of the client showed that the symptoms were not attributable to any cause, hence, the diagnosis with ADHD.
O: The client appeared appropriately dressed. His orientation to self, others, time and space was intact. His attention span was moderate. The client demonstrated flight of ideas. The teacher reported that his daydreaming had stopped with the interests of the client on learning activities improved significantly.
A: The symptoms of ADHD have improved with the currently adopted treatment.
P: The parents of the client were advised to continue with the medications and attend the monthly follow-up visits.
Post-Traumatic Stress Disorder
Name: D.D
Age: 40 years
Diagnosis: Post-traumatic stress disorder
S: D.D is a 28-year-old client that came to the unit for her regular follow-up visits after being diagnosed post-traumatic stress disorder eight months ago. She was diagnosed with the disorder following her experience with a violent relationship. The client raised a number of symptoms that included the persistent recurrence of the distressing memories about the traumatic events she underwent in the relationship. There was also the report of flashbacks and intense distress following the exposure of the patient to the stimuli that related to the traumatic events. The client also demonstrated avoidance behaviors of the stimuli that related to the traumatic events. The symptoms had a negative effect on the ability of the client engage in her occupational and family roles. As a result, she was diagnosed with post-traumatic stress disorder and has been on treatment in the unit. She was initiated on antidepressants and group psychotherapy sessions.
O: The client was dressed appropriately for the occasion. She was oriented to self, others, time and events. Her judgment was intact. She denied illusions, delusions, and hallucinations. She also denied suicidal thoughts, attempts, and plans. She also denied avoidance behaviors and distressing emotional experiences associated with the accident.
A: There has been continued improvement in the symptoms of post-traumatic stress disorder being experienced by the client. The client also reports no side or adverse effects to the treatment.
P: Group psychotherapy sessions were terminated with consent from the client. She was advised to continue with antidepressant treatment. She was scheduled for a follow-up visit after one month.
Major Depression
Name: K.B
Age: 30 years
Diagnosis: Major Depression
S: K.B is a 30-year old client that was brought today to the unit by his family with history of suicidal attempt. The client had attempted to commit suicide by drinking an organophosphate. K.B reported that he wanted to take his life because he always feels depressed and hopeless. He also reported that he not want to interact with people and often locked himself indoors. The family noted with concern that K.B lacks interest in things and pleasure in most of the days. He also gets easily irritated with things. The client also reported that his energy levels were low in most of the days. When asked about changes in his appetite, the client reported that his appetite had increased significantly over the past few days. He denied current suicidal plan. Due to the above complaints, the client was diagnosed with major depression and initiated on treatment.
O: The client appears poorly groomed for the occasion. He maintains minimal eye contact during the assessment. His orientation to self, others, place, time and events were intact. K.B denied hallucinations, illusions, and delusions. His speech was normal in rate and volume. He reported recurrent suicidal thoughts with one attempt. He does not have any suicidal plan now. The judgment is intact with thoughts that are future oriented.
A: The assessment findings show that the client is experiencing severe symptoms of depression and is at risk of self-harm.
P: The client was admitted for inpatient monitoring. He was prescribed antidepressants, antibiotics, and wound cleaning. He would be initiated on psychotherapy once stabilized
Major Depression
Name: C.Y
Age: 43 years
Diagnosis: Major Depression
S: C.Y is a 40-year-old client that came to the unit as a referral by his family physician for psychiatric assessment. C.Y came with complaints of feeling hopeless in life and wanted to take his life. Further assessment showed that the feelings of hopelessness persisted in most days throughout the day. He also experienced depressed mood in most days. He 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 normal 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.
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
Major Depression
Name: R.E
Age: 40 years
Diagnosis: Major Depression
S: R.E is a 29-year-old male client who was brought today to the unit for psychiatric assessment after being reported to act abnormally for the last two months. The spouse reported that R.E had lost interest and pleasure alongside depressed mood most of the days. R.E reported that he dislikes interaction with people and prefers spending his time indoors. He acknowledged his depressed mood and added that he feels worthless. R.E also reported poor sleeping habits, as he has been experiencing insomnia in most of the days. R.E was also concerned about his health, as he found himself easily irritated and experienced difficulties in making informed decisions. History taking about suicidal thoughts plans, and attempts showed that R.E was contemplating committing suicide. However, he did not disclose any plans. Based on the above data, the client was diagnosed with major depression and initiated on treatment.
O: The client appeared poorly groomed for the clinical visit. His mood was depressed. His insight was altered with flat affect. His speech was reduced in terms of rate and volume. His orientation to self, others, time, and events were intact. The client reported suicidal thoughts without plans or attempts.
A: The client is experiencing symptoms of major depression.
P: The client was initiated on antidepressants and group psychotherapy sessions. He was scheduled for a follow-up visit after four weeks to determine his response to treatment.
Conduct Disorder
Name: L.N
Age: 15 years
Diagnosis: Conduct Disorder
S: L.N is a 15-year-old client that came to the unit as a referral by his physician for psychiatric assessment. The mother to the client reported that her son has been showing abnormal behaviors for the last one year. According to her, she hoped that the symptoms would resolve, as they were part of his development. The symptoms included showing significant aggression towards others. L.N was always found to have violated the rights of others by ways such as causing harm and destroying properties. The mother also reported that the son had been reported to be a bully in school and the community church. The additional complaints that were raised concerning L.N’s behavior included initiating fights with others, threatening to harm, stealing, and engaging in deceitful acts to gain favors. The client denied any recent substance use or abuse. The above symptoms could not be attributed to other causes such as medications, medical condition, or substance abuse. Therefore, he was diagnosed with conduct disorder and initiated on treatment.
O: The client appeared appropriately dressed for the occasion. He maintained normal eye contact during the assessment. His speech was of normal rate and volume. His orientation to self, others, place and time were intact. He denied illusions, delusions and hallucinations. He also denied suicidal thoughts, attempts and plans.
A: The client appears to experience intrusive symptoms of conduct disorder.
P: The client was initiated on individual psychotherapy to assist him develop effective skills for overcoming the abusive symptoms and behaviors. He was scheduled for a follow-up visit after four weeks.
Generalized Anxiety Disorder
Name: M.C
Age: 24 years
Diagnosis: Generalized Anxiety Disorder
S: M.C is a 24-year old client that came to the unit for follow-up visit after being diagnosed with generalized anxiety disorder five months ago. The client had come to the unit initially with complains of excessive worry and anxiety about anticipated negative experiences in her life. She raised persistent fear of unknown impending doom, which was beyond her control. Her experiences had made her avoid any situations that could precipitate the excessive fear and anxiety. A further inquiry showed that she experienced other symptoms that included chest tightness and chest pains during periods of anxiety attack. The client had denied any history of medication use, substance abuse and medical condition. The client also was significantly worried that the symptoms would affect her performance in her academics. As a result, she was diagnosed with generalized anxiety disorder and initiated on group psychotherapy treatment.
O: The client appeared well groomed for the occasion. She was oriented to self, others, time and events. She was alert during the assessment and maintained normal eye contact. She denied illusions, delusions, and hallucinations. She also denied suicidal thoughts, attempts and plans.
A: The client has continued to demonstrate improvement in symptoms over the last five months. She is confident about her abilities to manage the triggers of anxiety attacks.
P: The client’s participation in the group psychotherapy sessions was terminated with her consent. The developed treatment objectives had been achieved. She was informed to come to the unit should the symptoms relapse in the future.
Bipolar Disorder
Name: R.D
Age: 28 years
Diagnosis: Bipolar Disorder
S: R.D is a 28-year-old client that came to the unit for her follow-up after she was diagnosed with bipolar disorder eight months ago. She had been diagnosed with the disorder after she came to the unit with complaints of cycles of elevated and depressed mood. The elevation in mood was associated with symptoms such as engaging in goal-directed initiatives, excitement and delusions. She further reported that the symptoms alternated with those of depression such as the lack of energy and difficulties in concentrating and feelings of worthlessness. The depressed mood could happen almost every day for a specific period such as one month, followed by elated mood. The above symptoms had affected significantly the ability of the client to engage in her daily routines. The symptoms were also not associated with drug use, medical problem or substance and alcohol abuse. As a result, she was diagnosed with bipolar disorder and initiated on treatment.
O: The client appeared appropriately dressed for the occasion. She was oriented to self, place, time and events. Her judgment was intact. She denied any recent experience of delusions, hallucinations, illusions, suicidal thoughts, plans, and attempts.
A: The treatment objectives have been achieved. The client tolerates the treatment well.
P: The psychotherapy sessions were terminated due to the realization of the desired treatment objectives. She was advised to continue with the prescribed medications. The client was scheduled for a follow-up visit after four weeks.
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Assignment 1: Clinical Hour and Patient Logs
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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.
Students with catalog years before Spring 2018 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 in 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 — Students 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
Record your clinical hours and patient encounters in Meditrek.