W1A3_Clinical Hour and Patient Logs PRAC 6645

 

 

           

W1A3_Clinical Hour and Patient Logs PRAC 6645

 

 

 

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 Clinical Hour and Patient Logs

1. Major Depression

Name: T.N

Age: 37 years

Gender: Male

Diagnosis: MD

S: T.N is a 37-year-old white male who came to the psychiatric unit as a referral by his physician. He was referred for further psychiatric review for the physician felt that the health problem was not medical. The client reported that he felt hopeless in life and wanted to take his life. His hopelessness was due to his perception that he had failed his family in providing the best they needed. The client was further probed, which revealed that the feelings of hopelessness persisted on most days throughout the day. He also experienced a depressed mood on most days. He also reported that he has trouble falling asleep. His appetite had declined significantly, leading to his lack of energy on most 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 treatment.

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

A: The client qualifies for the diagnosis of major depressive disorder based on the DSM-V diagnostic criteria.

P: The client was initiated on antidepressants such as sertraline and group psychotherapy to help improve the mood and coping skills of the client with depressive symptoms. He was also advised to try traditional yoga and meditation interventions to help manage his depression. He was scheduled for a follow-up visit after four weeks.

2. Post-Traumatic Stress Disorder

Name: F.R

Age: 14 years old

Gender: Male

Diagnosis: Post-traumatic stress disorder (PTSD)

S: F.R is a 14-year-old white male patient with a chief complaint of nightmares following a recent motor vehicle accident, which led to his father being injured. His parents report that the patient has been irritable and agitated ever since the accident. However, they have never opted to seek psychiatric evaluation until yesterday, when he was about to fall from the rooftop of their house. Associated symptoms include lack of sleep, severe anxiety, hostility, social isolation, and emotional detachment. The patient denies a family history of mental disorders. He also denies hallucination or delirium. He is currently not taking any medication for the presenting symptoms.

O: The patient walked into the room well-groomed. He seemed slightly distracted but well oriented in person, time and place. His thought process is intact with appropriate short and long-term memory. He, however, fidgets a lot, with signs of severe anxiety. He confirms having suicidal thoughts but only tried to take his life once. He, however, denies delirium or hallucination

A: The patient qualifies for PTSD diagnosis according to DSM-V diagnostic guidelines, following a car accident as a traumatic experience.

P: The treatment plan for the patient included both pharmacological agents and psychotherapy. Pharmacotherapy will entail the use of Zoloft 25 mg once daily at bedtime. The psychotherapeutic intervention recommended was family therapy to focus on the relationship between the patent and his family members crucial in promoting the patient emotions to fasten the recovery process.

3. Alcohol Use Disorder

Name: R.M

Age: 32 years old

Gender: Male

Diagnosis: AUD

S: R.M is a 32-year-old male patient who reported to the clinic today for his regular follow-up visit. The patient was diagnosed with alcohol use disorder five months ago and has been on pharmacological and psychotherapy treatments. The client recalled that he was diagnosed with the disease after presenting with several complaints related to alcohol abuse. The client had complained of three years of binge consumption of alcohol. The binge consumption of alcohol was beyond his control, despite his efforts, such as abstaining from it, which were fruitless. He was worried that the binge consumption of alcohol was becoming difficult to control. The patient reported that the withdrawal symptoms made it difficult to abstain from alcohol. He also reported that alcohol abuse adversely affected his social and occupational functioning. The socioeconomic well-being of his family has also been affected adversely. As a result, he was willing to participate in any treatment that could have helped him overcome his addiction problem. Therefore, he was diagnosed with alcohol use disorder and initiated treatment.

O: The patient has dressed appropriately for the occasion. His orientation to self, others, and events was intact. He did not demonstrate any abnormal behaviors, such as tics. His thought content was intact. He denied any recent history of illusions, delusions, and hallucinations. He also denied suicidal thoughts, attempts, plans, and intent. His speech was normal in terms of tone, rate, content, and volume.

A: There is continuous improvement in the symptoms of alcohol use disorder. He qualifies for this diagnosis to the specification outlined by the DSM-V diagnostic criteria.

P: The patient was prescribed naltrexone to help reduce alcohol craving and lower the withdrawal symptoms in addition to group therapy and joining an alcohol anonymous support group.

4. Insomnia

Name: P.R

Age: 29 years old

Gender: Female

Diagnosis: Insomnia

S: P.R is a 29-year-old female with a chief complaint of lack of adequate sleep for the past year. She reports finding it extremely difficult to fall and maintain sleep. She also reported that the difficulty in sleeping was accompanied by other symptoms such as awakenings at night and finding it hard to fall asleep again. The disturbances in sleep were reported to have significant distress as well as impairment in social, educational, occupational, and behavioral areas of functioning of the client. The lack of quality sleep was not attributed to any causes such as substance abuse, medication use, or medical condition. As a result, she was diagnosed with insomnia and initiated psychotherapy.

O: The client appeared appropriately dressed for the clinical visit. She was oriented to self, place, time, and events. She seemed to be tired during the assessment. She attributed it to a lack of sleep the previous night. Her judgment was intact with the absence of illusions, delusions, and hallucinations. She denied a history of suicidal thoughts, attempts, and plans.

A: The client is experiencing insomnia symptoms as stated in DSMV. The insomnia is negatively affecting her quality of life. However, his sleeplessness is increasing in severity; hence timely intervention is needed to prevent further complications.

P: The patient was prescribed amitriptyline 25 mg at bedtime to help him sleep. He was also initiated into group psychotherapy sessions.

5. Schizophrenia Spectrum and Other Psychotic Disorders

Name: T.R

Age: 49 years old

Gender: Female

Diagnosis: Schizophrenia Spectrum and Other Psychotic Disorders

S: T.R is a 49 years old Asian female who reported to the clinic as requested by her sister. She claims that people are watching her outside the window, and she can hear them. She claims that this has been happening for weeks. She cannot sleep well due to the loud voices, which keep her awake all night for days. When watching T.V., she claims that they watch her through the screen and even come in to poison her food. The patient denies blackouts and seizure-related to drug intake. She denies suicidal ideation or self-injurious activities

O: The patient appears decent and well oriented in person, time, and place. She displays odd beliefs and delusive character, like seeing a bird in the examination room. She avoids eye contact, gazing all over the room throughout the interview. Her affect is somehow flat. She admits experiencing hallucinations frequently, responding to auditory and visual stimuli. Her thought process is disorganized and inconsistent, with a speech difficult to follow as she loses her association during the interview. She uses many repetitive words to respond to simple questions. She displays little insight into why she reported to the psychiatry unit. She, however, denies suicidal ideation or self-injurious behaviors.

A: According to the DSM-V diagnostic criteria, the patient qualifies for the diagnosis of Schizophrenia Spectrum and Other Psychotic Disorders

P: Administer quetiapine (Rx) Extended-release 300 mg/day orally on day one. Increase the dose by up to 300 mg daily to a maintenance dose of 400-800mg/day depending on the patient’s treatment outcome. Individual psychotherapy and cognitive behavior therapy (C.B.T.) are also recommended to help promote positive thinking and appropriate behavior.

6. Generalized Anxiety Disorder (GAD)

Name T.O

Age: 12 years old

Gender: Female

Diagnosis: GAD

S: T.T is a 12-year-old Asian female with a history of GAD, who reported to the clinic for psychiatric evaluation and therapeutic drug monitoring. She reports having suicidal ideation which started about 10 days ago, rating it on a scale of 7 out of 10. She also reports bad crying spells 2 days before the present visit. She claims that her medication is not helping in managing her condition. A genetic test was thus recommended for the identification of the most effective agent. The consent for genetic testing was signed by the patient’s mother. She however confirms that counseling is helping. Confirms good appetite and sleeping patterns. Denies visual/auditory hallucination or homicidal ideation. Received a refill of her medication and was encouraged to go on with psychotherapy. There were no changes made to the treatment regimen, as the genetic test results had not yet been received.

O: The patient displays normal muscle tone and strength. Her gait is upright and appears hygienic with age-appropriate clothing. She seems well-nourished with appropriate behavior as displayed by her level of cooperation and speech tone all through the examination period.

A: The patient displays signs of generalized anxiety disorder, with a need for therapeutic drug monitoring.

P: Aripiprazole 5 MG Orally once daily, Oxcarbazepine 300 MG twice daily by mouth, and Sertraline HCl 75mg twice daily. Once genetic tests are out, the treatment regimen can then be changed. Family therapy was also recommended as the best alternative treatment for this disorder among children.

7. Bipolar Disorder

Name: Y.R

Age: 29 years old

Gender: Male

Diagnosis: Bipolar disorder

S: Y.R is a 29-year-old African American male client that came to the unit for his fifth follow-up visit. He has been on antidepressant and psychotherapy treatments for bipolar disorder. He was diagnosed with bipolar disorder after presenting to the unit with complaints that included periods of elevated mood. The mood elevation was characterized by overactivity behaviors, engaging in goal-directed initiatives, excitement, euphoria, and delusions. The alternation of the above symptoms was also with periods where the client would be significantly depressed. The depressive symptoms included lack of energy, too much sleep, and difficulties in concentrating and making decisions. The depressed mood could happen almost every day for a specific period, such as two weeks, followed by a joyful spirit. Further examination of the client revealed that the symptoms were not severe to cause any impairment in the normal functioning of the client. The signs and symptoms were also not associated with drug use, medical problem, or substance and alcohol abuse. As a result, he was diagnosed with bipolar disorder and initiated treatment.

O: The client appeared appropriately dressed for the occasion. He was oriented to self, place, time, and events. His judgment was intact. He denied any recent experience of delusions, hallucinations, illusions, suicidal thoughts, plans, and attempts.

A: The adopted treatments have effectively improved the manic and depressive symptoms of bipolar disorder. There is a gradual improvement in symptoms, which demonstrates treatment effectiveness.

P:  The client was advised to continue with the current treatments in addition to cognitive-behavioral group therapy.

 

8. Attention Deficit Hyperactivity Disorder (ADHD):

Name: R.B

Age: 11 years old

Gender: Female

Diagnosis: ADHD

S: R.B. is an 11-year-old white female with signs of ADHD. The patient’s mother and class teacher were asked to fill out the ADHD questionnaire, given the patient’s presenting signs and symptoms. She displays signs of short-term memory loss and difficulties in paying attention. Most of the time, she is forgetful and even must be reminded to complete her homework. She also fidgets a lot, which affects her concentration levels. The patient confirms that the ADHD symptoms started immediately when she joined the school. Additional symptoms include daydreaming. The patient has never received any medication for the current symptom, and with no history of developmental problems. The primary care practitioner reports good sleeping patterns for the patient, but relatively poor nutrition because of the patient’s fidgety symptoms

O: The patient walks into the room in age-appropriate clothing. Unable to maintain eye contact. Well oriented in time person and place. Unable to settle down on the chair as she fidgets a lot. Unable to concentrate for an extended period. Affect is intact and consistent with a sad mood. Easily distracted with signs of daydreaming. Short-term memory is compromised while long-term memory is still intact. No signs of hallucination or delirium. Displays no potential harm to self or others.

A: The patient is 11 years old and displays most of the symptoms outlined in the DSM-V qualifying the diagnosis of ADHD.

P: The patient was advised on considering cognitive-behavioral group therapy first, before deciding on the use of medication.

9. Separation Anxiety Disorder (SAD):

Name: C.R.

Age: 10 years old

Gender: Male

Diagnosis: SAD

S: C.R is a 10 years old boy who was brought to the clinic for psychiatric evaluation following his anxiety symptoms. The patient’s mother claims that he has always been anxious and worried all the time about silly things such as whether she is going to die, or will not pick him up from school. The patient’s excessive worry is not associated with a specific trigger. His mother claims that the patient normally feels like she likes his younger brother more than him. He tends to be stubborn most of the time, throwing objects around the house, which even puts him in danger when in school. He finds it difficult to sleep at night due to frequent nightmares. When at school, he consistently asks for permission to go home complaining of stomach aches or headaches. His mother claims that the patient won’t eat, and even lost about 3 pounds over the past few days. The patient also bed wets some nights even though he was given DDVAP by his pediatrician which seems to be ineffective.

O: Generally healthy in appearance. Intact orientation in person, place, and time. the patient is cooperative and answers questions appropriately while maintaining eye contact. The patient looks energetic with an upright posture. Communicate in a clear tone with the provision of answers in a fluent speech. Displays a sad mood, with consistent distractions when looking at his mother. Well-organized thought process. High conscious level, and intact memory with an appropriate thought process. Displays appropriate insight. Denies potential harm to self or others. Denies suicidal ideations, hallucination, or delirium.

A: The patient was separated from his father when he was only 5 years of age, with signs and symptoms qualifying for the diagnosis of separation anxiety disorder based on DSM diagnostic criteria.

P: The patient was advised to continue taking Desmopressin (DDAVP). He was also recommended group and family therapy to help build his relationship with both his peers and family members.

10. Major Depressive Disorder (MDD):

Name: T.U

Age: 16 years old

Gender: Male

Diagnosis: MDD

S: T.U is a 16 years old white male patient who was brought into the clinic by his mother with signs of depression. His mother reports that the patient stopped taking his medication, claiming that they make him feel bad. He was diagnosed with ADHD at the age of 6 years old and has been on and off on medication in managing mood disorders. The patient denies the use of any illicit drug. He complains of worthless feelings and claims that he sometimes hears voices, making it hard for him to sleep. She is withdrawn from friends and even misses school as a result of not wanting to be judged or talked of by friends. She feels lonely and agitated.

O: S.M came in pleasant looking with age-appropriate clothes. He however avoids eye contact despite being cooperative with the examination process. He seems angry and depressed and even cries sometimes during the examination. His effect shows limited variation. His activity levels are reduced and shows signs of restlessness. His speech is age-appropriate, with no pressure, but very argumentative. He also exhibits slowed but coherent thinking. Once in a while, he displays signs of fatigue with poor concentration over a long period. The patient shows no memory deficits as he recalls events appropriately. Orientation in person, time, and the place is intact. The patient displays no evidence of harming himself or others. He denies suicidal ideation, hallucination, or deliria.

A: The patient qualifies for MDD diagnosis according to DSM-V diagnostic guidelines in line with the reported sign and symptoms.

P: Start the patient on Zoloft 25mg orally, once daily at bedtime, and evaluate the patient’s treatment outcome before titrating the dose. Psychotherapeutic interventions such as cognitive group behavioral therapy will help in modifying the behavior of being self-withdrawn and avoiding school.