Week 5: Clinical Hour and Patient Logs PRAC 6645

 

 

           

 Week 5: Clinical Hour and Patient Logs PRAC 6645

 

 

 

Student Name

College of Nursing

Course

Faculty Name

Assignment Due Date

 

 

 

 

 

 

 

 

 

 

 

Psychotherapy for Eating, Sleeping, and Elimination Disorders

1. Binge Eating Disorder

Name: T.P

Age: 26 years old

Gender: Female

Diagnosis: Binge Eating Disorder

S: T.P is a 26-year-old African American female who works as the administrative manager of a large federal agency. She reported to the clinic as a result of failed attempts in the management of her binge eating disorder. She confirms previous counseling when she was still in college after an incidence of sexual assault. She mentioned her eating disorder to the counselor who ignored it and told her to focus on her sexual abuse. She claims that living with this condition has been embarrassing. She has experienced weight gain ever since she was diagnosed with binge back in college. The patient denies a family history of an eating disorder. She is currently on antihypertensives and statins for the management of her hypertension and high cholesterol levels. She denies the use of any drug of abuse. She denies any allergies.

O: All the patient’s vitals were normal except for her elevated blood pressure of 150/98 mmHg, and BMI of 27. Physical examination revealed no signs of abnormalities. A psychiatric evaluation revealed low self-esteem, depressed mood, and the feeling of being unworthy.

A: The patient’s subjective data demonstrate symptoms such as weight gain and trauma. The patient was already diagnosed with binge eating disorder, but with failed treatment. However, the psychiatric evaluation reveals symptoms of depression. The patient’s treatment failure might be associated with her trauma symptoms.

P: The patient was recommended CBT and interpersonal psychotherapy (IPT) to help with her Binge Eating Disorder symptoms. She was also referred to a dietician to help with her weight gain.

2. Bulimia Nervosa

Name: P.L

Age: 19 years old

Gender: Male

Diagnosis: Bulimia Nervosa.

S: P.L is a 19-year-old male patient who recently revealed himself as gay. He came to the hospital as a result of binge eating, fatigue, dehydration, and weight gain. The patient claims that he cannot control his eating. He thus vomits after a heavy meal. He is worried about his increase in body weight. He feels embarrassed among his peers and is also bullied most of the time. He claims to spend most of the time by himself. He displays signs of self-harm, with razorblade cuttings below his arm, near the armpit. He denies any history of psychological conditions or eating disorders. He denies taking any medication or having a history of hospitalization. He has no allergies. He denies the use of tobacco or any other drug of abuse.

O: The patient’s vitals were taken, which revealed normal results except for the patient BMI of 26. Blood works were all within normal limits. Drug tests were negative. Physical examination of the patient’s abdomen displayed no abnormalities. Psychiatric evaluation however revealed signs of self-harm, depression, isolation, the feeling of worthlessness, and agitation.

A: The patient displays signs of bulimia nervosa, which is the reason behind his psychiatric symptoms. He exhibits uncontrolled eating habits and has gained weight as a result of eating too much.

P: The management of the patient’s symptoms incorporated both pharmacological and psychological approaches. The pharmacological approach involved the use of antidepressants to manage the patient’s psychiatric symptoms. Psychotherapy was also recommended to help the patient understand his condition better and adopt appropriate eating patterns.

3. Rumination Syndrome

Name: Y.Y

Age: 21 years old

Gender: Male

Diagnosis: Rumination Syndrome

S: Y.Y is a 21-year-old African American male patient who presented to the clinic complaining of frequent regurgitation of food. He also complains of sleeping difficulties, dizziness, bloating, nausea and discomfort ever since the regurgitation started. He however denies symptoms of diarrhea, swallowing difficulties, or heartburn. He claims that the symptoms started when he was separated from his mother who was jailed wrongfully for possession of drugs. He denies a family history of substance use disorder or any other psychiatric issue. He denies taking any medication for his symptoms. He reports no history of chronic conditions or hospitalization. He confirms consuming a healthy diet and exercising regularly. He confirms seasonal allergies.

O: The physician performed a comprehensive physical examination, with findings of distention of the abdomen. The abdomen was however non-tender. Lab works revealed normal results. Psychiatric evaluation reveal a depressed mood, with severe stress as a result of the patient’s mother, who was his only parent being jailed. The patient also displayed signs of worthlessness, loneliness, and self-isolation.

A: Based on the subjective data, the patient displays signs of rumination syndrome. The objective data reveal no signs of GERD, but instead severe stress from the psychiatric evaluation. The stress might have been the cause of the patient’s rumination syndrome.

P: The patient was started on baclofen to help with the abdominal discomfort, and amitriptyline to help with the stress. Habit reversal behavior therapy was also recommended to promote the patient’s motivation and adopt new skills to help with both the stress and eating disorder.

4. Anorexia Nervosa

Name: F.T

Age: 11 years old

Gender: Female

Diagnosis: Anorexia Nervosa

S: F.T is an 11-year-old Caucasian female who was brought to the clinic for lack of appetite for the past one week. The patient claims to be unable to eat. She reports nausea and vomiting when she tries to convince herself to eat. She also reports weight loss over the past few months due to her inability to eat. Additional symptoms include fatigue and pale and dry skin. The patient has tried multivitamins in the past which she claims to be ineffective. She has denied using any other OTC medication for the management of her current symptoms.

O: Upon arrival at the clinic, the patient appeared well-groomed in age-appropriate clothing. She is alert and well-oriented in person, place, and time. Her mother’s activity is unremarkable. She is cooperative during the interview and communicates in a clear and normal tone. Her mood is dysphoric. She displays a constricted affect, with good insight and judgment. Her memory is intact, with an unremarkable thought process. Her functional status is however mildly impaired.

A: From the patient’s history, it is clear that she is suffering from anorexia nervosa. She displays pale and dry skin, which indicates dehydration. She has also been unable to eat for the past one week which qualifies for the diagnosis of anorexia nervosa.

P: The patient was started on appetite stimulants and multivitamin supplements to help with her appetite. She was also put on multivitamin supplements.  She was then referred to a dietician, to help with her weight gain. Counseling was also recommended to help manage the distress and embarrassment because of her condition.

5. Enuresis Disorder

Name: T.B

Age: 9 years old

Gender: Male

Diagnosis: Enuresis Disorder

S: T.B is a 9-year-old boy who was brought in by her mother for bedwetting at night. Her mother claims that the patient’s pediatrician prescribed Desmopressin (DDAVP) which seems to be ineffective. She claims that one day when the patient went camping, they shared a bed with a friend at night, who noticed that the patient wet the bed at night. Ever since they have been making him and calling him names. He has lost interest in routine activities and doesn’t even want to go to school. The patient calms to have problems sleeping at night. The patient’s vaccinations are up to date, with appropriate development. No history of medical conditions was reported. No history of nocturnal enuresis. Apart from the DDAVP, the patient is not taking any other medication. No known drug or food allergies.

O: The patient is generally healthy, with no signs of any delays in the developmental stages. Palpation of the bladder and kidney display no abnormalities or enlargement. Neurological examination through inspection of the lumbosacral spine displays no abnormalities. Psychiatric evaluation reveals sadness and embarrassment as a result of bedwetting.

A: The subjective data reveal signs of nocturnal enuresis. Objective data confirm the diagnosis with no know apparent cause of the patient’s symptoms. The patient also displays negative psychiatric symptoms which must be addressed.

P: The patient was advised to continue taking Desmopressin (DDAVP). She was recommended cognitive therapy and counseling to help with coping mechanisms as a result of how he is treated at school. His mother was also advised to limit fluid intake around bedtime hours.

6. Anorexia Nervosa

Name: D.V.

Age: 23 years old

Gender: Female

Diagnosis: Anorexia Nervosa

S: D.V is a 23-year-old female patient who reported to the clinic complaining of the absence of menses and extreme weight loss over the past few months. She also reports that she has been fatigued, and unable to sleep most nights. Sometimes, she is constipated with abdominal pain. She is unable to eat even when she is hungry. She claims to be embarrassed by her weight. She denies the use of tobacco or alcohol or any other drug of abuse. She denies being diagnosed with any serious condition in the past. She has not been taking any medication for her present symptoms. She denies any history of surgery or hospitalization. No known, drug or food allergies.

O: The vitals display normal results except for a BMI of 17.5. Physical examination reveals thin hair, amenorrhea, dry skin, swollen arms, and bluish discoloration of the fingers. Abdominal examination reveals constipation and tenderness. The patient looks malnutrition, with signs of weakness. A phycological review reveals extreme distress.

A: From the patient’s history, it is clear that she is suffering from anorexia nervosa. The objective data confirm this diagnosis with signs of dehydration, lack of appetite, and malnutrition. She is also distressed as a result of her weight.

P: The patient was started on appetite stimulants and multivitamin supplements to help with her appetite. She was also put on multivitamin supplements.  She was then referred to a dietician, to help with her weight gain. Counseling was also recommended to help manage the distress and embarrassment because of her condition.

7. Insomnia and General Anxiety Disorder

Name: S.D

Age: 35 years old

Gender: Female

Diagnosis: GAD

S: S.D is a 35-year-old female patient who reported to the clinic with a chief complaint of negative automated thinking, anxiety, and low self-esteem. She also reports symptoms of nightmares, feelings of loneliness, dizziness, inability to fall asleep, inferiority feeling, headache, palpitations, dizziness, fatigue, stiff shoulders/neck racing thoughts, panic attacks, bowel disturbance, and depression. She however reports that the nightmares have been more frequent like 4 times a week, while other symptoms occur almost daily.

O: The 35-year-old female patient is well-groomed in age-appropriate clothing. She is alert and well-oriented in person, place, and time. Her mother’s activity is unremarkable. She is cooperative during the interview and communicates in a clear and normal tone. Her mood is dysphoric. She displays a constricted affect, with good insight and judgment. Her memory is intact, with an unremarkable thought process. Her functional status is however mildly impaired. Denies hallucination or delusion.

A: Based on the DSM-V diagnostic criteria, the patient is positive for negative automated thinking, anxiety, low self-esteem, inability to fall asleep, in addition to nightmares, feelings of loneliness, dizziness, inferiority feeling, headache, palpitations, dizziness, fatigue, stiff shoulders/neck racing thoughts, panic attacks, bowel disturbance and depression, which qualify for the diagnosis of MDD. However, in the present visit, the main concern is in managing the patient’s insomnia.

P: Advise the patient to continue taking her current medication such as diazepam 2mg to help with sleeping some nights; Alprazolam 25mg once daily only for emergencies. Consider psychotherapeutic approaches such as cognitive-behavioral therapy and mindfulness training.

8. Enuresis Disorder

Name: L.V

Age: 10 years old

Gender: Male

Diagnosis: Enuresis Disorder

S: L.V is a 10 years old African American boy who is healthy with no social concerns. The patient’s developmental stages are all intact, except for only one problem, he has never been able to attain nighttime dryness. The mother claims that the patient still puts on pullups at night. The patient claims that he has no problems staying dry during the day. He also denies any bowel accidents during the day or night. His main concern is that he wants to go to sleepovers like his friends, but currently, he finds it very embarrassing that they will turn him down due to his bedwetting. At home, he plays with his toys but seems sad. He has no history of any other health complications. No allergies.

O: To determine the cause of the patient’s bedwetting, a thorough physical examination of his genitalia was carried out. The physician looked for an enlarged bladder or kidney by palpating the renal and suprapubic areas. His stool was also examined in the lab for hard texture or blood. Neurological examination was also carried out, with inspection and palpation of the lumbosacral spine. The findings, however, directed to no specific cause of the patient’s bedewing.

A: The assessment of the patient was aimed at determining the actual cause of the patient’s nocturnal enuresis. The anal wink and the patient’s ability to stand on the toes were carried out to assess the integrity of the S2-4 spinal reflex arc.

P: The patient was prescribed Desmopressin (DDAVP) to help with the bedwetting. The patient was also started on enuresis alarm therapy and referred to a pediatric urologist for further evaluation.

9. Rumination Syndrome

Name: D.T

Age: 22 years old

Gender: Male

Diagnosis: Rumination Syndrome

S: D.T is a 22-year-old African American male patient who presented to the clinic complaining of frequent regurgitation of food. He also complains of sleeping difficulties, dizziness, bloating, nausea and discomfort ever since the regurgitation started. He, however, denies symptoms of diarrhea, swallowing difficulties, or heartburn. He claims that the symptoms began when he was separated from his mother, who was jailed wrongfully for possession of drugs. He denies a family history of substance use disorder or other psychiatric issues. He denies taking any medication for his symptoms. He reports no history of chronic conditions or hospitalization. He confirms consuming a healthy diet and exercising regularly. He confirms seasonal allergies.

O: The physician performed a comprehensive physical examination, with findings of distention of the abdomen. The abdomen was, however, non-tender. Lab works revealed normal results. The psychiatric evaluation shows a depressed mood, with severe stress resulting from the patient’s mother, whose only parent was jailed. The patient also displayed signs of worthlessness, loneliness, and self-isolation.

A: The patient displays signs of rumination syndrome based on the subjective data. The objective data reveal no symptoms of GERD but instead severe stress from the psychiatric evaluation. The stress might have been the cause of the patient’s rumination syndrome.

P: The patient was started on baclofen to help with the abdominal discomfort and amitriptyline to help with the stress. Habit reversal behavior therapy was also recommended to promote the patient’s motivation and adopt new skills to help with both the stress and eating disorder.

10. Insomnia

Name: T.J

Age: 39 years

Gender: Female

Diagnosis: Insomnia

S: T.J is a 39-year-old female patient who came to the unit as a referral by her physician. She was referred for further psychiatric review for the physician felt that the patient’s insomnia is worsening despite the initial diagnosis of major depressive disorder. She has been experiencing a depressed mood on most days. She also reported that she has trouble falling asleep. Her appetite had declined significantly, leading to his lack of energy on most of the days. She also reported having suicidal thoughts without plans. She noted that her ability to make decisions and concentrate had worsened significantly over the past month due to a lack of sleep. The symptoms were not attributable to any medication, or substance abuse.

O: The patient appeared appropriately dressed for the clinic. Her speech was reduced in terms of rate with average volume. Her self-reported mood was depressed. The client denied illusions, delusions, and hallucinations. She maintained regular eye contact during the assessment. Her thought content was future-oriented. She reported suicidal thoughts without a plan or attempt.

A: Since the patient is currently on antidepressant therapy, our main focus is on the management of the patient’s insomnia.

P: The client was recommended to continue taking antidepressants such as sertraline for management of the previously diagnosed depressive disorder. She was however advised to seek group psychotherapy to help improve her mood and try traditional yoga and meditation interventions to help with her insomnia.