PRAC 6675 WEEK 2 Assignment 1: Clinical Hour and Patient Logs Essay

PRAC 6675 WEEK 2 Assignment 1: Clinical Hour and Patient Logs Essay

 

WEEK 2 Assignment 1: Clinical Hour and Patient Logs

ADHD

Name: D.D

Age- 7-years

Diagnosis: ADHD

S: D.D is a 7-year-old White male client who is on psychotherapy due to ADHD. The client was referred for psychotherapy because he exhibited a persistent pattern of inattention and hyperactive, impulsive behavior that was more severe for children of his age. The mother reported that his impulsive behavior led to consistent problems at school and in public places. The inattention and impulsive behavior have interfered with the boy’s academics. The boy is also easily distractible, and the mother reports that he is often irritable and has difficulties keeping up with a task or topic. He is currently on Concerta 36 mg PO once a day.

O: The child is restless and unable to sit still throughout the session. He has an explosive and irritable mood and an elevated affect with emotional liability. He is hyperactive and distractible, which made the psychotherapy session difficult. Speech is a bit louder, and attention is limited. The patient also exhibits deficits in memory and thinking, with the recent memory and calculation tasks being affected. Orientation, remote memory, and abstract are grossly intact.

A: Hyperactivity with Impulsivity. Short attention span and easy distractibility. General coordination deficiency. Thinking and memory deficits.

P: Behavioral psychotherapy in combination with drug therapy. Work with the client’s parents and school to ensure that the environment is conducive to allow him to focus and maintain attention.

Anorexia Nervosa

Name: G.N

Age: 17-years

Diagnosis: Anorexia nervosa

S: T.D is a 17-year-old White female on psychotherapy for Anorexia Nervosa. She was referred for psychotherapy by a nutritionist since she cannot maintain a normal body weight. T.D has a profound psychological disturbance with an overwhelming concern about her body size, shape, and weight. She is terrified of gaining weight because it would lower her chances of becoming a model. She reports using appetite suppressors laxatives, inducing vomiting, and limiting fluid intake. Besides, she takes very small food portions, mostly vegetables, and fruits, and takes minimal carbs due to the fear of getting fat.

O: BMI- 16.3. G.N is well-groomed and appropriately dressed. She is alert and maintains adequate eye contact. Her self-reported mood is anxious, and her affect is appropriate. Her speech is clear with normal rate and volume. Exhibits preoccupation with food and weight gain. She is concerned with personal appearance and how others see her.

A: Severely underweight; Purging behaviors present; Presence of self-degradation symptoms.

P: Advise the client to continue taking appetite boosters. Initiate weekly Cognitive-behavioral and remediation therapy. Integrate Insight-oriented Individual therapy and Motivational enhancement therapy. Introduce the patient to Group psychotherapy for teenagers with Anorexia nervosa.

 

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Insomnia

Name: W.S

Age: 16-years

Diagnosis: Insomnia

S: W.S is a 16-year-old A.A male who presented with complaints of difficulties sleeping and frequent night-time awakening. He has had difficulties initiating sleep for the past 12 weeks. He reports taking more than an hour before falling asleep, and most of the time, he is forced to get out of bed. As a result, he sleeps barely 4 hours a day. The insomnia is not connected with any medical or psychological disorder. He denies using alcohol, tobacco use, or substance use.

O: The client is neat and dressed appropriately. The self-reported mood is good, and affect is euthymic. He appears rather bored and tired during the psychotherapy session and says that he feels fatigued. His speech is clear, and his thought process is coherent and goal-directed. No delusions, hallucinations, or suicidal ideations present. He is oriented to person, place, and time. Memory, judgment, abstract thought, and insight are grossly intact.

A: Disturbance in Mood. Impaired interpersonal and social functioning.

P: Weekly training on sleep hygiene. The patient will be advised: To have a light meal in the evening. Have physical exercises in the late afternoon or early evening. Avoid daytime naps. Avoid taking caffeine and alcohol in the evening. Try to wake up at the same time every day regardless of the time he slept. Incorporate stimulus control therapy to enable the patient to associate the bed with sleep and to have a rigid wake and sleep times.

Autism Spectrum Disorder

Name: R.D

Age: 7-years

Diagnosis: Autism Spectrum Disorder

S: R.D is a 7-year-old AA male referred for psychotherapy for Autism Spectrum Disorder (ASD). The child was diagnosed with ASD after presenting with various developmental and behavioral features suggestive of the disorder, including: Developmental regression; Abnormal social interactions for a child of his age; Repetitive and stereotyped behavior; Abnormal reactions to environmental stimuli; Lack of Symbolic play. The boy’s mother states that he had normal development until he was two years when she noted that he had deficits in verbal and nonverbal communication skills. Besides, R.D did not develop the skill of using the index finger to point to an item he wanted when he was a toddler. The mother also reported that he exhibited unusual responses to auditory stimuli, such as noise and hooting from motor vehicles. He would often scream when exposed to loud noise or thunder and lightning. The boy also has a high pain threshold

O: The child is well-groomed and alert. He was uncooperative at the start of the session but calmed down with time. Speech abnormalities are present with the child repeating phrases after someone. Language delays are also present. The child exhibits no social smile when greeted. Has exaggerated stimuli to touch and has abnormal motor movements with an unusual walk. In addition, the child has no symbolic play and proto-declarative pointing. He also exhibits self-injurious behavior, such as teeth banging and head punching.

A: Deficits in executive function, speech, and language. Self-injurious behaviors. Difficulties in social interactions.

P: Weekly psychotherapy comprising: Auditory integration training, Sensory Integration therapy, and Exercise and Physical therapy. Integrate assisted communication to the weekly psychotherapy using word boards, letter boards, and keyboards to assist the patient in communication. Connect the child to special education learning institutions.

Post-Traumatic Stress Disorder

Name: G.A

Age: 10-years

Diagnosis: Post-Traumatic Stress Disorder.

S: G.A is a 10-year-old Asian female on psychotherapy for PTSD. The patient started exhibiting anxiety symptoms six weeks after being involved in a road traffic accident where she witnessed her father sustain an arm fracture. She reported experiencing constant intrusive thoughts and memories about the accident. She constantly gets flashbacks of seeing her father wail in pain when he fractured his arm, yet she could do nothing to help him. The constant flashbacks caused an intense negative emotional reaction. Besides, she reported experiencing intense emotional reactions when reminded of the RTA. She experienced frequent flashbacks and nightmares of the accident at night, which caused sleeping difficulties. She states that she has an increased vigilance for potential danger, especially when on the road, and a high startle reaction when a car is overspeeding.

O: The patient is well-groomed. She is calm and maintains eye contact. The self-reported mood is nervous, and affect is congruent. Her speech is clear, but the rate and volume reduce when the client talks about the traumatic event. She also develops tremors and agitation when discussing the traumatic event. Her thought process is coherent and goal-directed. No delusions, hallucinations, or suicidal ideations were noted. Orientation, memory, abstract thought, judgment, and insight are intact. Concentration is limited.

A: Reduced range of positive emotions with persistent negative emotional states.

Increased vigilance and startle response. Physiological, emotional distress when discussing the RTA.

P: Continue with weekly psychotherapy sessions of Trauma-Focused Cognitive-behavioral therapy (TF-CBT) and Prolonged Exposure (P.E.) Therapy. Introduce Eye movement desensitization and reprocessing (EMDR). Frequently assess the patient for suicidal ideations.

Major Depressive Disorder

Name: B.P

Age: 44-years

Diagnosis: Major Depressive Disorder

S: B.P is a 44-year-old AA male on psychotherapy after presenting with symptoms of depressive disorder. He states that he has lost interest in most activities in the past six weeks, including his job and hobbies. He reported feeling sad most of the time for the past six weeks, and his wife complains that he has changed. He states that his energy levels had reduced drastically and he felt fatigued most of the day. The patient also reports having insomnia which caused the fatigue and reduced his ability to work. He states that the symptoms have affected his work since his concentration levels have reduced, and he often feels incapable of making decisions independently. He takes whiskey alcohol 3-4 glasses on weekends and smokes tobacco 1PPD. The PCP prescribed Citalopram 20mg once a day.

O: The client is well-groomed and dressed appropriately. He is alert and maintains adequate eye contact. His self-reported mood is sad, and his affect is constricted. His speech is clear, but the tone and volume vary. He demonstrates a logical and goal-directed thought process. Delusions, hallucinations, or suicidal/homicidal ideations are absent. His short-term and long-term memory is intact. Judgment, abstract thought, and insight are intact.

A: Depressed mood; Disturbed sleep pattern; No risk of self-injurious behavior. PHQ-9 score- 13.

P: Continue treatment with Citalopram; Frequently assess the drug’s side effects. Continue weekly CBT sessions. Include Mindfulness-based cognitive therapy in the CBT to minimize the risk of relapse of depressive symptoms.

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Brief Psychotic Disorder

Name: F.G

Age: 35 years

Diagnosis: Brief Psychotic Disorder

S: F.G is a 38-year-old AA male diagnosed with Brief Psychotic disorder. The client’s spouse reports that he had an abrupt onset of psychotic symptoms, including auditory hallucinations, bizarre behavior, and disorganized speech about ten days ago. He exhibited emotional distance and a lack of human response and developed a drastic loss of function, causing an inability to maintain social norms. The client’s spouse further reported that he has lost interest in his business and hobbies and lacks motivation for work. He can also not initiate and persist in completing a task or activity.

The client was prescribed Haloperidol 2mg twice daily for the psychotic symptoms.

O:  The client is shabby and overdressed. He was uncooperative and restless at the beginning of the interview and had verbal aggression. The self-reported mood is nervous, and the affect is expansive. His speech is limited, and he uses few words. An incoherent thought process with looseness of association with poverty of speech. Poverty of content was observed with the patient occasionally going mute. Auditory hallucinations are present, but no delusions or suicidal ideations were noted. He is oriented to person and place but disoriented to time. Impaired memory of recent events, but long-term memory is intact. Attention and concentration are limited. Judgment is grossly intact, but insight is limited.

A: Moderate psychotic agitation. Mood disturbance and impaired judgment.

P: Continue therapy with Haloperidol; Assess for side effects. Initiate weekly psychotherapy sessions on social skills training and social cognition training to enhance social and occupational functioning. Advise the patient’s family to create a safe and therapeutic environment, with calm, empathetic patient interactions, essential in managing psychotic symptoms. Regularly assess the client for self-harm behaviors.

 

 

Schizophrenia

Name: K.M

Age: 49-years

Diagnosis: Schizophrenia

S: K.M is a 49-year-old AA female client referred for psychotherapy after exhibiting psychotic symptoms. The client’s daughter reported that her mother was going crazy since she saw and talked to inexistent. K.M stated that others could not see and hear like her because she had been given magical powers by God similar to Jesus. She further said that she was suspicious of the psychiatrist because of prescribing her injections that would take away his magical powers. She also stated that her friends are now jealous of her since she was given special powers by God and not them. The psychiatrist prescribed her Fluphenazine decanoate 25mg IM 2 weekly.

O: The client is untidy with unbrushed hair and long dirty nails. She is overdressed for the weather. She is alert but maintains minimal eye contact. Her self-reported mood is nervous, and her affect is blunted with a loss of expressiveness. Her speech is incomprehensible with varying rates and tone, and she demonstrates poverty of speech. She cannot associate ideas and speaks very minimal, using brief and empty phrases. She exhibits persecutory delusions and delusions of grandeur and auditory and visual hallucinations. She is oriented to person and place but disoriented to time. Recent memory is impaired, but long-term memory is intact. Impaired abstract thought and judgment and low concentration levels. The client has no insight into her condition.

A: The client is unpredictable with untriggered agitation. Neurocognitive deficits. Delusions of persecution and grandiose. Lack of interest in psychotherapy.

P: Continue medical therapy with Fluphenazine decanoate. Regularly assess for side effects. Continue with weekly cognitive-behavioral therapy, Cognitive remediation therapy, and social skills training. Initiate. Connect the client with a social worker for vocational training.

 

 

Bipolar Disorder

Name: M.W

Age: 33-years

Diagnosis: Bipolar Disorder

S: M.W is a 33-year-old Hispanic male client referred for psychotherapy by a psychiatrist for Bipolar disorder. The client has a history of having episodes of severely elevated mood, followed by episodes of low and depressed mood. He states that he gets in a delighted mood for some months, but this rapidly changes to a sad mood and a lack of interest in almost all pleasurable activities. The client is currently having episodes of severely elevated mood and excitement. He states that he does not see the need for sleep since he has many plans to implement. He is currently on Lithium 300 mg orally, twice a day.

O: The client is well-groomed but inappropriately dressed for the weather. He is alert and oriented but restless and distracted. Her self-reported mood is happy, and her affect is expansive. Speech is loud, and the client is very talkative. An incoherent thought process with pressure of speech and flight of ideas and. The client is very talkative with a high volume and rate of speech. Delusions of grandeur are present, with the client exhibiting an elevated sense of self-worth. Hallucinations are absent, and he denies suicidal or homicidal thoughts. Recent and long-term memory is intact. Judgment is impaired, and insight is lacking. Young Mania Rating Scale score- 13.

A: Severe mania; Poor judgment; Client was less engaged and interested in psychotherapy sessions. No reported side effects with Lithium.

P: Continue with Lithium therapy. Initiate weekly Interpersonal therapy. Train the client to channel his energy to constructive activities.

 

 

Insomnia

Name: S.P

Age: 46-years

Diagnosis: Insomnia

S: S.P is a 46-year-old White male on psychotherapy for sleeping difficulties. He states that he experiences difficulties initiating and maintaining sleep and sleeps for less than 4 hours. He started experiencing difficulties initiating sleep six months ago, which has worsened over time. He stays 1-2 hours before falling asleep and often rolls on the bed as he waits to fall asleep. The client also reports frequently waking up at night and having difficulties maintaining sleep. The sleeping difficulties have affected her work since he feels fatigued and sleepy during the day. He admits to taking lots of coffee since it stimulates him during the day. He also takes 2-3 beers 4-5 times a week but denies smoking or using other illicit substances. He has been taking OTC sleeping pills to induce sleep.

O: The client is neat and dressed appropriately for the weather. His self-reported mood is okay, and his affect is appropriate. He seems distant during the psychotherapy session. Speech is clear, and the thought process is coherent and goal-directed. No delusions, hallucinations, or suicidal ideations present. He is oriented to person, place, and time. Memory, judgment, abstract thought, and insight are grossly intact.

A: Impaired interpersonal and social functioning.

P: Weekly CBT sessions for insomnia to help the client identify and replace thoughts and behaviors that cause sleeping difficulties with habits that promote sound sleep. Sleep hygiene education focusing on modification of lifestyle habits that influence sleep, such as drinking too much caffeine late in the day or not getting regular exercise.

 

Assignment 1: Clinical Hour and Patient Logs
Please write for 5 children or Adolescents and 5 adults or older adults

Photo Credit: auremar / Adobe Stock
Assignment 1: Clinical Hour and Patient Logs

Photo Credit: auremar / Adobe Stock
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.

Please complete this assignment for 10 different patients’ thanks
MY CLINICAL PRACTICUM IS A PRIVATE PRACTICE, MY CLINICAL WORKING HOURS WILL BE Thursday AND FRIDAY 8 AM- 5 PM,
I WILL BE WORKING ALONG WITH MY PRECEPTOR WHO IS A PSYCHIATRIC MENTAL HEALTH NURSE PRACTITIONER.

MY CLINICAL SITE IS A PRIVATE PRACTICE THAT PROVIDES DIRECT CLINICAL SERVICES SUCH AS PSYCHIATRIC EVALUATION, CRISIS INTERVENTION, PSYCHOPHARMACOLOGY TREATMENTS, AND REFERRALS AS NECESSARY TO PATIENTS WITH DIFFERENT PSYCHIATRIC DIAGNOSES.

ON EACH OF MY CLINICAL DAYS I WILL BE SEEING 5 PATIENTS AT MY PRACTICUM PER CLINICAL WHICH MEANS THAT I WILL HAVE TO WRITE 5 DIFFE