PRAC 6645 Clinical Hour And Patient Logs

Sample Answer for PRAC 6645 Clinical Hour And Patient Logs Included After Question

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.

Record your clinical hours and patient encounters in Meditrek.

A Sample Answer For the Assignment: PRAC 6645 Clinical Hour And Patient Logs

Title: PRAC 6645 Clinical Hour And Patient Logs

Persistent Depressive Disorder

Name: K.N

Age: 35 years old

Gender: Male

Diagnosis: Persistent depressive disorder

K.N is a thirty-five-year-old male patient who came to the facility for a visit complaining that he has a problem at work of not doing his things in time and well. He indicates that the problem started after he lost a source of revenue and, therefore, reduced his normal earnings by 30%. He reports feelings of emptiness and sadness, and he has also lost interest in daily activities.

The patient also indicated that he usually feels tired and has low energy levels. The patient believes that this is a problem that can be sorted out at the facility since he longs to be focused again. Recently, he realized that he gets angry and becomes annoyed easily. The patient also confessed that his appetite has greatly reduced in the last week.

O: The patient is well-dressed and groomed. The patient is also well-oriented to place, person and time. The patient has audible speech with a normal volume and speech. He has a sad mood. The patient denies suicidal thoughts, ideation, or actions. The patient also denies delusions or hallucinations.

A: The patient displayed several symptoms that point to a depressive disorder. Since the patient has experienced the symptoms for over three months and persistently, this patient can be diagnosed with a persistent depressive disorder. According to DSM-V criteria, this condition leads to various symptoms such as feelings of sadness and emptiness, loss of interest in activities, low energy levels, a show and anger, and getting annoyed easily, among other symptoms. The patient showed these symptoms.

P: The patient needs to start psychotherapy sessions to help him overcome the symptoms of sadness and emptiness. At least a session per week should help reduce the symptoms. The patient should visit the facility after four weeks for a review and a possible therapy consideration.

Oppositional Defiance Disorder

Name: V.F

Age: 10 years old

Gender: Male

Diagnosis: Oppositional defiance disorder

V.F is a ten-year-old boy who visited the facility accompanied by his mother. The mother reports that her son has been having strange behaviors, which she originally thought were just being emotional, however, various symptoms have persisted, and they discussed as a family that they visit the facility. She reports that the patient often experiences irritable and angry moods, easily loses his temper and is easily annoyed by others.

A few days earlier, he was told by his fifteen-year-old boy to pick a paper he had dropped on the floor and put it in the bin, but he angrily reacted, started crying, and wanted to fight his brother. The boy has also developed a tendency to argue with adults and defies adult requests and rules. He has also shown vindictive behavior. The patient has also been having poor performance in school.

O: The patient is well-dressed and groomed. He is also well-oriented. The patient looks anxious. He has clear speech and talks with a normal tone and volume. The patient asks many questions, sometimes even unnecessarily. The patient denies any delusions or hallucinations. He also denies any suicidal thoughts. The patient’s memory, both current and past, are intact.

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A: According to DSM-V, various symptoms are used in identifying ODD, including vindictiveness, argumentative and defiant behavior, and irritable and angry mood. The patient has shown these symptoms, and therefore, the patient has ODD, therefore, should be offered a treatment and management approach.

P: The patient should start with individual and family therapy to help him with anger management and help in improving communication and relationships. In the course of the plan, cognitive problem-solving training should be used to help the patient with the thought patterns to help impact behavior positively.

Psychosis

Name: C.S

Age: 19 years old

Gender: Female

Diagnosis: psychosis

C.S is a nineteen-year-old white female patient who was brought to the facility with her elder sister. The sister explained that the patient has shown disorganized behavior in the last few weeks and showing repetitive movements. The patient has also shown a worrying behavior of self-harm and hearing imaginary voices. Not long ago, the patient claimed to be hearing some people calling her outside the compound and asking if they could go for a walk together. The sister confirms that she didn’t hear those voices even though she was in the house at the same time. The patient has also continually wanted to be alone, saying she feels better alone.

O: The patient has not dressed appropriately and looks disorganized. She has an incoherent speech with wordiness. She looks nervous. The patient confirms hallucinations, suicidal thoughts, and delusions. She, however, concentrates during the assessment. The patient’s thought process is impaired. The patient has difficulty speaking and keeps on repeating statements. Confirms nightmares

A: The patient displayed symptoms which can be associated with psychosis. Since the patient denies any drug abuse, the condition is not substance or drug-related.

P: The patient has displayed several psychosis symptoms and, therefore, should use a psychotherapeutic approach. Therefore, the patient uses cognitive behavioral therapy. The patient should also be monitored for progress to explore if any adjustments are necessary.

Postpartum Depression

Initials: G.F

Age: 21 years

Gender Female

Diagnosis: Postpartum Depression

G.F is a twenty-one-year-old white female patient who visited the facility, indicating that she needs help with her unpleasant feelings days after delivering her firstborn child. She has been worried and wondering if she is doing things right as a first-time mother to help the child grow well. Such thoughts lead to grief and despair. She suspects that there could be things she is not doing right since the baby keeps crying a lot, especially at night. The baby also wakes up frequently at night only to cry, which disturbs her sleep and makes her fatigued during the day. Even though her partner is responsible, he works in another place and, therefore, can rarely help with the baby. She reports that life after delivery has restricted her activities, and she can no longer enjoy her hobbies.

O: The patient is well-dressed, oriented, and alert. She has a coherent thought process and clear speech. Her mood is sad, and she indicates that she feels like crying sometimes. She denies delusions, hallucinations, obsessions, phobias, or suicidal thoughts. She also denies any intention of harming the baby. The patient’s short-term and long-term memory are both ok.

A: From the symptoms and review, it is evident that the patient is trying to cope with the stress brought about by being a first-time mother. She also experiences sleeping difficulties due to baby cries at night. As such, she is experiencing post-partum depression.

P: The patient can attend psychotherapy sessions to help her improve. The patient can also join support groups that offer support emotional and mental support for first-time mothers.

Post-Traumatic Stress Disorder

Initials: D.W

Age: 38 years       

Gender: Female

Diagnosis: Post-traumatic stress disorder

D.W is a thirty-eight-year-old white female patient who visited the facility. She reported having feelings of disconnection with friends and family members. The patient was involved in an accident a few weeks back, but she came out unharmed. Since then, she has been having thoughts and images of cars rolling due to accidents and people getting injured. She has also been having consistent nightmares of getting killed in a road accident. In the last few weeks, the patient doesn’t want to board cars anymore and avoids it when she can. She also indicates that she doesn’t think she will ever want to drive. She has also lost interest in pleasurable activities.

O: The patient is well-dressed and groomed. The patient has a depressed mood visibly caused by flashbacks of the accident. She has a rushed speech, though the speech is audible. She reported being persistently angry and sad. The patient confirms flashbacks and nightmares due to the car accident experienced earlier. She denies suicidal thoughts, hallucinations, and delusions. She confirms avoiding places and activities which remind her of the past accident.

A: The patient’s symptoms point to Post-traumatic stress disorder due to the accident experienced earlier; therefore, she needs an appropriate management plan.

P: The patient needs to commence cognitive behavioral therapy to help with the symptoms. The plan is to attend at least a session every week and visit the facility after four weeks for review.

Borderline personality disorder

Name: U.T

Age: 33 years

Gender: Male

Diagnosis: Borderline personality disorder

U.T is a thirty-three-year-old male patient who visited the facility, indicating that he has been having an increased frequency of suicidal thoughts. The patient was diagnosed with borderline personality disorder and has been under a treatment and management plan, which he reactivates during a crisis only. He only visits the experts when he feels there is a need. The patient has also been using medications which he stops immediately after he sees an improvement.

The patient confirms suicidal thoughts but has not acted on them and is not planning to act on them as he doesn’t want to leave behind her young family. The patient has also been having various symptoms, such as frequent mood swings, feelings of emptiness, and insomnia. The patient had had a history of violence and had relationship problems before he settled down with his current partner.

O: The patient is appropriately dressed and well-groomed. The patient is also alert and oriented; however, he doesn’t maintain eye contact. He has an intact thought process. The patient has suicidal thoughts but denies ever acting on them. The patient’s mood is distressed. She denies hallucinations and delusions. The patient’s speech is normal, with appropriate volume and tone.

A: The symptoms exhibited by the patient point to a persisting borderline personality disorder hence appropriate management strategy should be used.

P: The patient should commence cognitive behavioral therapy. The patient should attend at least a therapy session a week for four weeks and come back to the facility for a review and further management plans.

Alcohol use disorder

Name: F.W

Age: 34 years

Gender: Male

Diagnosis: Alcohol use disorder

B.T is a thirty-four-year-old male white male patient who was referred to the facility after an attempted detox plan. The patient has been drinking alcohol for the last ten years. At twenty-five years, a rehabilitation plan was started, but it failed as the patient was resistant. Another plan was started one year ago, and therefore, the patient has been referred to the facility, but he is reporting that it is tough living without consuming alcohol.

In the last few months, the patient has been involved in heavy drinking, which has affected both his social life and work life. He sometimes reports to work late, and in other cases, he misses going to work completely. The problem is threatening to run out of control, and the patient is in agreement that he needs help.

O: The patient is well-dressed and groomed. He is also oriented and alert. He, however, looks distressed and sad. His thought process is intact, and he has clear speech. The patient struggles to concentrate and be attentive thought out the process. He denies suicidal thoughts and ideations. He also denies hallucinations and delusions.

A: The patient has shown a willingness to be helped move on from alcohol abuse which is threatening to impair his work and social life. The symptoms point to alcohol abuse disorder.

P: The patient is to commence social and coping mechanism sessions and cognitive behavioral therapy to help him with the symptoms. It is key to monitor the patient’s progress after two weeks to four weeks.

Bipolar Disorder

Name: D.D

Age: 36 years

Gender: Male

Diagnosis: Bipolar Disorder

D.D is a thirty-six-year-old male patient who comes to the facility with reports of unpleasant mood swings. He reports incidences of elevated moods and severely depressed moods. In addition, he explains that sometimes he experiences alternating cases of high moods and low moods. The low moods are usually accompanied by a loss of interest in activities and hobbies he loves engaging himself in. the patient also indicated problems with sleep as he finds it difficult to fall asleep and has challenges making decisions. He also reports finding it easy to participate in dangerous activities, such as driving speedily, and sees nothing wrong with it.

O: The patient is well-groomed but inappropriately dressed. The patient is also alert and well-oriented. He gets distracted easily and struggles to concentrate. His thought process is incoherent, and he shows an excited mood. The patient has impaired judgment. He speaks in increased volume though his speech is audible. He reports delusions but denies hallucinations and suicidal thoughts. The patient’s memory is intact.

A: The patient exhibited symptoms associated with bipolar disorder, especially manic symptoms, and poor judgment.

P: The patient needs psychotherapy sessions, especially cognitive behavioral therapy, which should help with most of the symptoms. The patient should visit the facility in four weeks’ time for review.

Insomnia

Name: T.R

Age: 51 years

Gender: Female

Diagnosis: Insomnia

T.R is a fifty-one-year-old female patient who visited the facility reporting that she has been having a problem with getting sufficient and quality sleep, symptoms which have refused to go even after close to six months. The patient explains that she finds it difficult to fall asleep. In addition, she is easily distracted from sleep and, therefore, frequently wakes up during the night. She finds it challenging to sleep again whenever she wakes up. The result is that she gets tired and sleepy during the day hence impairing her daily functionality and completion of tasks. The patient denies any medication use, medical condition, or substance abuse that could have contributed to the observed symptoms.

O: The patient is appropriately and neatly dressed. She is also well-oriented. She was alert at the start of the assessment session but soon got tired and appeared sleepy. The patient has intact judgment and denies hallucinations, delusions, or illusions. She also denies any suicidal thoughts or mind. The patient’s speech is normal, with no abnormality observed in the tone or volume. She also has intact memory, both short-term and long-term.

A: The symptoms displayed by the patient show that she has insomnia. The frequent sleep disturbances are only worsening the situation.

P: The management plan should be a psychotherapy session and education on how to support effective and quality sleep. For example, removing any potential distractors. The patient needs to visit the clinic for a follow-up after two weeks.

Anorexia Nervosa

Name: N.M

Age: 17-years

Gender: Female

Diagnosis: Anorexia nervosa

N.M is a seventeen-year-old female African woman patient who visited the facility, indicating that she does not want to gain weight since she dreams of modeling in the coming years. As such, she tries to avoid food as much as she can and only eats when necessary to avoid gaining weight and ruining her shape. She confesses to taking only small amounts of food whenever she has to eat. She also indicates that she doesn’t use many fluids as they would make her tummy grow bigger. She also uses some over-the-counter medication to reduce food absorption for minimal intake. She even says that she still needs to work on her weight through physical exercise to further reduce it.

O: The patient is well-dressed and groomed. She is oriented and alert; however, she is anxious and struggles to maintain eye contact. She has audible speech with normal volume, tone, and rate. The patient’s thought process is coherent. She denies suicidal thoughts, delusions, or hallucinations. However, she is obsessed with losing weight and maintaining a model-like body shape. The patient’s judgment and memory are intact.

A: The patient is psychologically disturbed due to body weight and shape leading to her developing anorexia nervosa.

P: The patient should commence cognitive behavioral therapy sessions as well as cognitive remediation therapies. These will help the patient with her thinking pattern and help her develop a positive attitude toward food.