Assignment: Clinical Hour and Patient Logs/PRAC 6645

Assignment: Clinical Hour and Patient Logs/PRAC 6645

Assignment: Clinical Hour and Patient Logs/PRAC 6645

Clinical Hour and Patient Logs
Name: S.T.
Age: 18-64 years
Gender: Male
Site: Hospital
Student Level of Function: Joint Care
Practice Management: Assessment
Diagnosis: Adjustment disorder
S: S.T. is a 28-year-old client who visited the facility for psychiatric assessment. His family care provider referred him for psychiatric assessment and treatment. S.T.’s complaints included finding it difficult to fit into the new workplace and experiencing a depressed mood. He reported that his mood has been low ever since he reported to a new workplace three months ago. He often experiences emotional outbursts and easy irritability that affect his performance and productivity.
O: S.T. was dressed well for the clinical visit. He was alert and oriented. He denied anxiety, illusions, delusions, hallucinations, suicidal thoughts, plans, or attempts. He acknowledged a mildly depressed mood.
A: Adjustment disorder
P: S.T. was prescribed oral sertraline 50 mg once daily in the morning and scheduled for a follow-up visit after two weeks.

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Name: E.Y.
Age: 18-64 years
Gender: Female
Site: Hospital
Student Level of Function: Joint Care
Practice Management: Assessment
Diagnosis: Insomnia
S: E.Y. is a 32-year-old female who came to the facility for her follow-up visit. She was diagnosed with insomnia a month ago and started treatment. She has been on oral triazolam for the past seven days. She denied any negative experiences with the drug.
O: E.Y. was dressed well for the occasion. She appeared pleasant with no evidence of fatigue, depression, or anxiety. She denied illusions, delusions, hallucinations, or suicidal thoughts and attempts.
A: Insomnia that is responsive to treatment.
P: Oral Triazolam was stopped. E.Y. was educated on the use of relaxation techniques and distraction minimization interventions to improve her quality of sleep.

Name: D.T.
Age: 18-64 years
Gender: Female
Site: Hospital
Student Level of Function: Joint Care
Practice Management: Assessment
Diagnosis: Obsessive-compulsive disorder
S: D.T. is a 24-year-old female client who visited the facility with complaints of distressing behavior. According to her, she always engages in repetitive behaviors such as checking things and hand washing whenever she is stressed. She noted that the activities help her overcome her stressors. Despite their benefits, she found that she spends too much time and energy engaging in these activities. D.T. has tried managing the obsessions but has been unsuccessful.
O: D.T. was dressed appropriately for the occasion. She was alert and oriented. She denied a depressed mood, anxiety, illusions, delusions, hallucinations, or suicidal thoughts.
A: Obsessive-compulsive disorder, rule out generalized anxiety disorder
P: D.T. was prescribed oral escitalopram 10 mg once daily for two weeks. Her follow-up visit was scheduled at the end of the two weeks.

Name: R.N.
Age: 0-18 years
Gender: Male
Site: Hospital
Student Level of Function: Joint Care
Practice Management: Assessment
Diagnosis: Oppositional defiant disorder
S: R.N. is a 16-year-old male client whose parents brought him to the facility for psychiatric assessment and management. The parents reported that their son often shows disruptive behaviors that are not expected of him. His teachers have recommended that the child be brought for psychiatric assessment and treatment. The behaviors include being overly temperamental, easily annoyed, arguing with authority figures, defying rules, and deliberately annoying others. The family denied any use of medications, medical conditions, or substance use, which could be attributed to their child’s problem.
O: R.N. was dressed well for the occasion and weather. He was alert and oriented. He did not show any abnormal behaviors such as eye avoidance during the assessment. R.N. denied a depressed mood, anxiety, illusions, delusions, or hallucinations.
A: Oppositional defiant disorder, rule out attention-deficit hyperactive disorder
P: Parenting skills training and psychotherapy were offered to the child and his family. A follow-up visit was scheduled after four weeks to assess treatment response.

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Name: H.N.
Age: 18-64 years
Gender: Male
Site: Hospital
Student Level of Function: Joint Care
Practice Management: Assessment
Diagnosis: Generalized Anxiety Disorder
S: H.N. is a 43-year-old client who visited the facility with complaints of experiencing severe worry beyond her control. She reported that she has been experiencing the problem for the last five months. She always fears that bad things would happen to her daughter who joined the university a few months ago. The accompanying reported symptoms include restlessness, fatigue, difficulty concentrating, and muscle pains. She denied substance use or abuse, medication use, or medical conditions that could be associated with her problems.
O: H.N. was dressed well for the weather and clinical visit. She reported anxiety. She denied depressed mood, illusions, delusions, hallucinations, or suicidal thoughts. She did not show any abnormal mannerisms during the assessment.
A: Generalized anxiety disorder, rule out reactive attachment disorder
P: H.N. was prescribed oral paroxetine 20 mg once daily in the morning. She was scheduled for a follow-up visit after two weeks.

Name: K.W.
Age: 18-64 years
Gender: Male
Site: Hospital
Student Level of Function: Joint Care
Practice Management: Assessment
Diagnosis: Major depression
S: K.W. is a 37-year-old male female who came to the facility for his follow-up visit. He was diagnosed with major depression a month ago and started treatment. K.W. reported that his symptoms of major depression such as being depressed almost daily, fatigue, lack of interest, and difficulty concentrating were improved. However, he was worried that his sexual drive had decreased ever since he started the treatment.
O: K.W. was well groomed for the clinical visit and weather. He was pleasant, alert, and oriented. He denied a depressed mood, anxiety, illusions, delusions, hallucinations, or suicidal thoughts.
A: Major depression that is responsive to treatment
P: K.W. was advised to continue with oral sertraline 50 mg once daily in the morning and started on individual psychotherapy treatment. He was educated that the decreased sexual drive is a side effect associated with antidepressants and would improve over time. He was scheduled for a follow-up visit after four weeks to assess his treatment response.

Name: M.R.
Age: 18-64 years
Gender: Male
Site: Hospital
Student Level of Function: Joint Care
Practice Management: Assessment
Diagnosis: Psychosis
S: M.R. is a 33-year-old female client who visited the facility for psychiatric assessment and treatment. She complained of hearing voices, seeing things, and feeling someone touching her. She noted that she had been experiencing the symptoms for the past week and believed they would subside on their own. She denied suicidal thoughts, plans, or attempts.
O: M.R. was groomed well for the visit to the facility. She was alert and oriented. Her insight was grossly intact. Her affect was flat with a euthymic mood. She reported illusions and hallucinations. She denied delusions or suicidal thoughts.
A: Psychosis
P: M.R. was prescribed oral haloperidol 2 mg once daily for two weeks and scheduled for a follow-up visit after two weeks to assess her response to treatment.

Name: C.L.
Age: 18-64 years
Gender: Male
Site: Hospital
Student Level of Function: Joint Care
Practice Management: Assessment
Diagnosis: Bulimia nervosa
S: C.L. is a 22-year-old male who visited the facility for psychiatric assessment and treatment. His parents recommended the need for a psychiatric review and assistance for his eating problem. According to him, he has been suffering from binge eating problems for the past two years. He often engages in behaviors such as self-induced vomiting and using laxatives to prevent weight gain. C.L. noted that he fears gaining weight, which would make him less attractive and prone to health problems such as diabetes and hypertension. He denied substance use, abuse, or medical conditions that could be associated with his problem.
O: C.L. was dressed well for the occasion. He appeared underweight for his age and gender. He denied anxiety, illusions, delusions, hallucinations, or suicidal thoughts. He reported mild anxiety.
A: Bulimia nervosa
P: C.L. was prescribed oral sertraline 25 mg once daily in the morning and started psychotherapy sessions to help him overcome his eating problems. He was scheduled for a follow-up visit after two weeks.

Name: R.T.
Age: 0-18 years
Gender: Male
Site: Hospital
Student Level of Function: Joint Care
Practice Management: Assessment
Diagnosis: Selective mutism
S: R.T. is a 13-year-old male child who was brought to the facility for assessment and treatment. The family complained that their child at times uses gestures or monosyllabic utterances to communicate despite being normally talkative when at home. They were worried that their child could be suffering from other mental disorders such as ADHD and autism.
O: The child was dressed appropriately for the clinical visit and weather. He was alert and oriented. He demonstrated selective mutism during the assessment. He denied suicidal thoughts, illusions, delusions, hallucinations, or depression.
A: Selective mutism, rule out ADHD and autism
P: R.T. was prescribed oral fluoxetine 10 mg once daily for seven days. They were scheduled for a follow-up visit after two weeks to assess his treatment response.

Name: K.R.
Age: 18-64 years
Gender: Female
Site: Hospital
Student Level of Function: Joint Care
Practice Management: Assessment
Diagnosis: Alcohol use disorder
S: K.R. is a 45-year-old female client who visited the facility for her third follow-up visit. He was diagnosed with alcohol use disorder and started treatment. She denied taking alcohol for the past three months. She has also not experienced any withdrawal symptoms.
O: K.R. was dressed appropriately for the occasion. She appeared alert and oriented. She did not have tremors or speech impairment issues. She denied depression, anxiety, illusions, delusions, or hallucinations.
A: Alcohol use disorder
P: K.R. was advised to continue with oral naltrexone and her participation in the Alcoholics Anonymous group. She was scheduled for a follow-up visit after four weeks.

Name: C.R.
Age: 18-64 years
Gender: Female
Site: Hospital
Student Level of Function: Joint Care
Practice Management: Assessment
Diagnosis: Agoraphobia
S: C.R. is a 35-year-old female who visited the facility for psychiatric assessment and treatment. C.R. complained that she has developed an intense fear of using public transport and being in open spaces alone. She has been avoiding traveling by public means and being alone in open spaces because of feelings of impending doom. The fear is beyond her control or the potential harm in these spaces. She denied any traumatic experiences or substance abuse that could be attributed to her problems.
O: C.R. was well-groomed for the occasion. She was alert and oriented. She reported mild anxiety and denied depression, illusions, delusions, hallucinations, or suicidal thoughts.
A: Agoraphobia, rule out posttraumatic stress disorder
P: C.R. was prescribed oral sertraline 50 mg once daily in the morning and started psychotherapy. She was scheduled for a follow-up visit after four weeks.

Name: N.K.
Age: 18-64 years
Gender: Female
Site: Hospital
Student Level of Function: Joint Care
Practice Management: Assessment
Diagnosis: Post-traumatic stress disorder
S: N.K. is a 34-year-old female who visited the facility for her follow-up visit. She was diagnosed with posttraumatic stress disorder two months ago and started treatment. She was involved in an accident, which led to the development of posttraumatic stress disorder symptoms. She denied a depressed mood, avoidance behaviors, nightmares, or distressing memories of the accident.
O: N.K. was dressed well for the clinical visit. She was alert and oriented. She denied a depressed mood, anxiety, illusions, delusions, hallucinations, or suicidal thoughts, plans, and attempts.
A: Posttraumatic stress disorder that is responsive to treatment.
P: N.K. was advised to continue with oral sertraline 50 mg once daily in the morning and psychotherapy sessions. She was scheduled for a follow-up visit after four weeks.

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Clinical Hour and Patient Logs

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 to earn the points associated with this assignment. You may only log hours with Preceptors that are approved in Meditrek.

Students 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)

Notes/Comments

Resources

Be sure to review the Learning Resources before completing this activity.

Click the weekly resources link to access the resources.

WEEKLY RESOURCES

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. You must record at least 80 patients by the end of this practicum. You must see at least 5 pediatric/adolescent patients and 5 adult/older adult patients.

The patient log must include the following:

Date

Course

Clinical Faculty

Approved 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 of Week 7

Record your clinical hours and patient encounters in Meditrek.

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