Week 3: Clinical Hour and Patient Logs PRAC 6645

 

 

           

Week 3: Clinical Hour and Patient Logs PRAC 6645

 

 

 

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College of Nursing

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 Clinical Hour and Patient Logs

1. Substance Use Disorder/PTSD

Name: C.V

Age: 17 years old

Gender: Female

Diagnosis: Substance Use Disorder/PTSD

S: C.V is a 17-year-old female patient who came to the clinic accompanied by her mother with a chief complaint of heroin addiction. She has been taking heroin for the past 2 years, 10-14 stamp bags daily. The patient was recommended to rehab, but she refused. She confirms low self-esteem, low self-worth, depression, hopelessness, helplessness, and poor insight. She has a history of sexual abuse by her uncle from the age of 5 to 12 years. She started taking marijuana to counter the experience, then pain pills before she started taking heroin. She confirms having self-injurious behavior like cutting herself, with a history of PTSD. She also sells sex for drugs and is positive for hep C test. The mother is an alcoholic, while the father died at the age of 30 years from an opioid overdose.

O: The psychiatrist conducted a further psychiatric evaluation and noted that the patient avoids eye contact and gazes around the room when talking about something that makes her uncomfortable like being sexually abused by her uncle. Her thought process is intact and answers questions in a quite tremulous speech. She confirms the feeling of worthless, helplessness, hopelessness, and low self-esteem. She displays poor insight and confirms a history of PTSD and self-injurious behaviors. She however denies hallucination or suicidal ideation.

A: The patient in the provided case study was diagnosed with PTSD and SUD. She has a previous history of PTSD diagnosis, as a result of being sexually abused by her uncle. She currently confirms taking IV heroin, for the past two years.

P: Initiate SC injection (Sublocade) monthly for heroin addiction and sertraline (Zoloft) for PTSD. She was also recommended cognitive-based family therapy, to help with her PTSD, and group therapy for her addiction.

2. Anorexia Nervosa

Name: T.R

Age: 23 years old

Gender: Female

Diagnosis: Anorexia Nervosa

S: T.R is a 23-year-old female who presented to the clinic complaining of recurrent episodes of vomiting and gradual weight loss over the past year. She also reports menstrual irregularities and amenorrhea over the past 6 months. She has been married for about 5 years. Her husband has been consistently criticizing her body weight. She is dull most of the time, with reduced energy levels to go about daily activities. She sometimes has trouble sleeping, as a result of the comments made by her husband concerning her body weight. The patient reports not taking any medication for her current symptoms. She denies a history of any serious present or past medical condition. She has never been hospitalized before. She reports being allergic to amoxicillin. She denies the use of tobacco, alcohol, or any other illicit drug or drug of abuse. She is educated up to the 10^th standard and is currently a homemaker. She is religious and rides bicycles during her leisure time.

O: With symptoms of amenorrhea and weight loss, the patient was evaluated by a physician. Several investigations were carried out in the background of suspected tuberculosis, abdominal tumor, and anemia. All the investigations were however within normal limits except for low hemoglobin levels.

A: The assessment findings reveal an uncooperative character from the patient during the interview. With persistent probing, she displayed apathy, low mood, decreased attention, easy fatigability, and pessimistic ideas about the future. The patient denied suicidal ideation or unusual perceptual experience. The cause of the patient’s symptoms is based on both physical and psychiatric evaluations directed towards anorexia nervosa.

P:  Both phycological and pharmacological interventions were considered. The patient was referred to a psychiatrist for multifamily therapy to help with her weight and appropriate eating habits. She was also given antiemetics and multivitamins to help with her appetite and vomiting.

3. Attention-Deficit Hyperactivity Disorder (ADHD)

Name: B.H

Age: 12 years old

Gender: Female

Diagnosis: ADHD

S: T.K is a 6 years old white male patient with a history of ADHD who was brought to the clinic by his mother for psychiatric evaluation and treatment follow-up. He is well-oriented in-person place and time. The mother reports that the patient’s behavior has been horrific ever since he started taking Trileptal. She confirms that the patient has been angry, restless, argumentative, crying outbursts, and oppositional and even experiences moments of crashing down.

O: The psychiatrist conducted a further psychiatric evaluation and noted that the patient is angry and depressed and even cries sometimes during the examination. His affect 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 place is intact. The patient displays no evidence of harming himself or others. He denies suicidal ideation, hallucination, or deliria.

A: The patient was previously diagnosed with ADHD and was prescribed appropriate medication for the disorder. However, based on the feedback reported by the patient’s mother upon initiation of treatment therapy with Trileptal, the patient’s symptoms worsened, with increased incidences of anger, restlessness, argumentation, crying outbursts, and oppositional and even experiences moments of crashing down.

P: The patient was advised to stop taking Concerta and Ritalin, and started on Vyvanse at 30mg once a day. He was also recommended cognitive-behavioral family therapy to help with her behavior and symptoms.

4. Encopresis Disorder

Name: K.L

Age: 12 years old

Gender: Female

Diagnosis: Encopresis Disorder

S: K.L. is a 12 years old Asian girl who is healthy with no significant intellectual impairments or developmental delays. She however presents as extremely embarrassed and shy as a result of frequent bowel movement accidents. She even had an accident recently, on the bus, during a field trip which led to her peers laughing and teasing her. She was so significantly distressed as a result of this incident and even refused to go to school for the following 2 weeks. She also reports a history of persistent constipation. The patient denies a history of any other health complications. She is not taking any drugs for the current symptoms. She has no history of hospitalization. She confirms consuming a healthy diet and exercising regularly.

O: A comprehensive abdominal examination was carried out to determine the severity of the patient’s fecal impaction and gas accumulation. The perianal area was also inspected to check for changes in skin color, malformations, or irritations. The digital rectal assessment was also done to evaluate the sensory changes in the perianal area and rectum. Finally, the lumbosacral area was inspected to overrule causes such as spina bifida occulta. All other findings were normal except for severe constipation.

A: Based on the patient’s history and examination results, it is quite evident the main cause of her frequent bowel movement accidents is persistent constipation.

P: The treatment plan aimed to treat the underlying cause of the patient’s symptoms and promote the patient’s mental health which was impacted by this disorder. The constipation was managed by osmotic laxatives such as lactulose. The patient was also started on family therapy to promote understanding of her condition and manage the associated negative psychological impact of the disorder.

5. Schizophrenia Spectrum and Other Psychotic Disorders

Name: F.O

Age: 24 years old

Gender: Male

Diagnosis: Schizophrenia Spectrum and Other Psychotic Disorders

S: F.O is a 24 years old male, with past psych history of bipolar, psychiatrically hospitalized due to erratic and high-risk behavior. The patient had a domestic violence charge in November and had gone to court for a hearing day of presentation to the ED. The patient started acting bizarre and ran into traffic, police were able to get him and brought him to the hospital for evaluation. The patient is bizarre, hyperverbal, and grandiose. The patient seems to be responding to internal stimuli. He denies a history of suicide attempts or sib, but per record, he had told the therapist he tried inhaling helium to potentially harm himself. He acknowledges a history of mania and psychosis. Reports being on several medications, but unable to recall their names. He also doesn’t know whether they have been helpful or not. The patient’s father confirms that he has been on medication for about a month.

O: Upon conducting further psychiatric examination it was noticed that the patient looks sad and tragic. He is well oriented in time, person and place. He seems distracted and unable to pay attention. He is well-roomed in age-appropriate clothing. His speech is quite first but in fluent English language. He is in a good mood with a labile affect. His thought process is tangential. Confirms suicidal thoughts and potential harm to self and others. He also confirms signs of hallucination, delusions, paranoia, and grandiosity. Displays poor short-term and long-term memory. Fund of knowledge is appropriate but with poor judgment.

A: The patient was diagnosed with schizophrenia disorder as he displays bizarre behaviors in addition to symptoms such as delusion, hallucination, disorganized speech, and compromised thought process.

P: Initiate schedule Klonopin 1mg orally twice daily for anxiety and Seroquel 100mg at bedtime mood/insomnia/paranoia. She was also advised to sign up for cognitive-behavioral family therapy for appropriate behavior and positive thinking.

6. Bulimia Nervosa

Name: T.Y

Age: 15 years old

Gender: Female

Diagnosis: Bulimia Nervosa

S: T.Y is a 15-year-old female patient who was brought to the clinic by her mother complaining that her daughter has been displaying unusual eating patterns ever since she moved back home about 6 months ago. Her mother claims that the patient has been consuming large amounts of food when alone, and also found food wrappers hidden in her room. She is worried that her daughter might be vomiting after the heavy eating episodes. She also confirms that the patient normally isolates herself in the bathroom after 15-30 minutes after having a large meal. When the patient was asked about her eating habits, she admitted that she had lost control. She claims to feel deep remorse after eating too much, which makes her induce vomiting at the end of the day. She also claims to feel fat and hate herself. She denies any history of other medical conditions. She is not taking any medications at the moment except for contraceptive pills. She reports no allergies. Denies family history of eating disorders.

O: The patient’s vitals were taken, which were all within normal limits. Her abdominal examination revealed no abnormalities. Lab assessment revealed a serum amylase level of 140 Units/L and serum potassium level of 3.8 Meq/L. Other screening tools such as the Eating Attitudes Test (EAT) and SCOFF mnemonic questionnaire were utilized to assess the patients eating disorders.

A: The patient’s subjective data reveal excessive eating, with induced vomiting. The objective results display no significant cause of the patient’s habits. Based on the results of the eating disorder screening tools, the patient was diagnosed with bulimia nervosa.

P: For management of the patient’s symptoms, she was put on antidepressants and therapy. Amitriptyline was considered a once-daily dose, and cognitive-based family therapy to help with promoting self-awareness and adoption of appropriate eating habits.

7. Attention-Deficit Hyperactivity Disorder (ADHD)

Name: B.H

Age: 12 years old

Gender: Female

Diagnosis: ADHD

S: T.K is a 6 years old white male patient with a history of ADHD who was brought to the clinic by his mother for psychiatric evaluation and treatment follow-up. He is well-oriented in-person place and time. The mother reports that the patient’s behavior has been horrific ever since he started taking Trileptal. She confirms that the patient has been angry, restless, argumentative, crying outbursts, and oppositional and even experiences moments of crashing down.

O: The psychiatrist conducted a further psychiatric evaluation and noted that the patient is angry and depressed and even cries sometimes during the examination. His affect 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 place is intact. The patient displays no evidence of harming himself or others. He denies suicidal ideation, hallucination, or deliria.

A: The patient was previously diagnosed with ADHD and was prescribed appropriate medication for the disorder. However, based on the feedback reported by the patient’s mother upon initiation of treatment therapy with Trileptal, the patient’s symptoms worsened, with increased incidences of anger, restlessness, argumentation, crying outbursts, and oppositional and even experiences moments of crashing down.

P: The patient was advised to stop taking Concerta and Ritalin, and started on Vyvanse at 30mg once a day. He was also recommended cognitive-behavioral family therapy to help with her behavior and symptoms.

 

8. Enuresis Disorder

Name: D.H

Age: 5 years old

Gender: Male

Diagnosis: Enuresis Disorder

S: D.H is a 5 years old 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 during the day, he has no problems staying dry. 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 embarrassed that they will turn him down as a result of 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 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 determine 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 family therapy, for family members who had the same condition when young to share their experience.

9. Substance-Induced Psychotic Disorder

Name: K.I

Age: 19 years old

Gender: Female

Diagnosis: Substance-Induced Psychotic Disorder

S: K.I is a 19-year-old patient who was brought to the clinic with her mother for strange behavior. The patient has been taking cocaine and marijuana with his boyfriend with whom they stay together on Campus. She ran away from home about 3 years ago when she was being looked for by the police. Currently, she confirms nightmares and both visual and auditory hallucinations. She seems very clumsy, and quite afraid to communicate. She thinks her boyfriend called the police on her. She however denies suicidal ideation.

O: Upon conducting further psychiatric evaluation, it was noted that the patient is clumsy, and inappropriately dressed for a 19-year-old girl. She avoids eye contact, with an angry and sad facial expression. Her speech is quite tremulous, with a depressed tone. Her self-esteem is low, as she claims that she does not value life anymore. She says that she feels hopeless and helpless. Her thought flow is distorted as she moves from one topic to another. She confirms hallucinations and self-injurious activities.

A: Based on the patient’s history, and lab results, the primary diagnosis is Substance-Induced Psychotic Disorder

P: She was initiated on quetiapine to help with her psychotic disorder. She was also advised to join group therapy for her addiction and family therapy to help with her strange behaviors.

10. Anorexia Nervosa

Name: T.T

Age: 23 years old

Gender: Female

Diagnosis: Anorexia Nervosa

S: P.H 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 the 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 Becoatin for stimulation of her appetite. She was also put on multivitamin supplements. She was also advised to consider family therapy to help with her distress and embarrassment.