Assignment 1: PRAC 6645 WEEK 10 Clinical Hour and Patient Logs
Assignment 1: PRAC 6645 WEEK 10 Clinical Hour and Patient Logs
Clinical Logs
Major Depression
Name: S.K
Age: 45 years
Diagnosis: Depression
S: S.K is a 45-year-old client that has been undergoing treatment in the unit due to major depression. She was diagnosed with depression six months ago and has been undergoing group psychotherapy sessions and using antidepressants. She was diagnosed with depression after she presented with complaints of feeling sad most of the days almost all the days, feeling worthless and guilty most of the times. She also reported decline in her appetite, as well as becoming socially withdrawn. Her interest in pleasure also declined significantly. The symptoms had affected significantly her ability to perform optimally in her academic and social roles. The symptoms could not be attributed to other causes such as medication use, medical conditions or substance abuse. She was therefore diagnosed with major depression and has been undergoing treatment in the facility.
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O: The patient appeared dressed appropriately for the occasion. She was oriented to self, place, time and events. Her judgment was intact. She denied any suicidal thoughts, attempts or plans as well as illusions, delusions and hallucinations. Her mood was normal.
A: The client has responded well to the treatments. Her mood has improved
P: Psychotherapy sessions were terminated with consent obtained from the client. She was advised to continue with antidepressant therapy. She was scheduled for follow-up visit after two months.
Major Depression
Name: T.M
Age: 28 years
Diagnosis: Depression
S: T.M is a 28-year-old client that was brought to the unit by his relatives for psychiatric review. The client was brought with history of suicide attempt by hanging. The client reported that he wanted to kill himself, as he felt that his life was useless. The client also noted that his mood has been depressed for almost every day. The depressed mood had made it difficult for him to engage in his activities of the daily living. The family also reported that his interest in things had diminished significantly. The client reported suicidal thoughts and attempt. He denied any suicidal plan during the clinical visit. Based on the above complaints the client was diagnosed with depression and initiated on treatment.
O: The client appeared poorly dressed for the occasion. He reported that his mood was depressed. The client was oriented to self, others, time, and events. He denied illusions, delusions, and hallucinations. He reported suicidal thoughts and attempts. He denied current suicidal plans. The client does not have a current suicidal plan. His speech was reduced in terms or rate and volume.
A: The client is experiencing severe symptoms of depression. The client requires treatment to improve his mood and functioning.
P: The client was admitted for further observation. He was prescribed antidepressants to manage the depressive symptoms he was experiencing.
Major Depression
Name: K.U
Age: 36 years
Diagnosis: Depression
S: K.U is a 30-year old client that was brought today to the unit by his family with history of suicidal attempt. The client attempted suicide by getting himself in the highway to be hit by fast moving cars. K.U reported that he wanted to take his life because he always feels depressed and hopeless. He also reported that he lacks interest and pleasure. The family reported that K.U gets easily irritated with things. There was also history of increase in appetite and insomnia. He denied current suicidal plan. Due to the above complaints, the client was diagnosed with major depression and initiated on treatment.
O: The client appears poorly groomed for the occasion. He maintains minimal eye contact during the assessment. His orientation to self, others, place, time and events were intact. K.U denied hallucinations, illusions, and delusions. His speech was normal in rate and volume. He reported recurrent suicidal thoughts with one attempt. He does not have any suicidal plan now. The judgment is intact with thoughts that are future oriented.
A: The assessment findings show that the client is experiencing severe symptoms of depression and is at risk of self-harm.
P: The client was admitted for inpatient monitoring. He was prescribed antidepressants, antibiotics, and wound cleaning. He would be initiated on psychotherapy once stabilized.
Major Depression
Name: M.R
Age: 38 years
Diagnosis: Depression
S: M.R is a 38-year old client that came to the unit for his first follow-up visit for depression. He was diagnosed with depression after being brought in the first visit for admission due to history of self-harm. The client wanted to kill himself, as he felt useless about his life. He had reported that he had suicidal thoughts in almost all the days, as well as depressed mood. He did not want to interact with people and lacked interest in things and pleasure. His level of irritation had also risen, which made it difficult for him to concentrate. The symptoms could not be attributed to any cause such as drug abuse, medication use, or medical conditions. Due to the above complaints, the client was diagnosed with major depression and initiated on treatment.
O: The client appears appropriately groomed for the occasion. He maintains normal eye contact during the assessment. His orientation to self, others, place, time and events are intact. He denies hallucinations, illusions, and delusions. His speech is normal in rate and volume. He denied recent experience of suicidal thought, attempt or plans.
A: The adopted treatments have been effective in reducing the severity of depressive symptoms being experienced by the client.
P: The client was advised to continue with the current treatments. He was scheduled for a follow-up visit after four weeks.
Post-Traumatic Stress Disorder
Name: B.N
Age: 34 years
Diagnosis: Post-traumatic stress disorder
S: BN is a 34-year-old client that came to the unit for her regular follow-up visits after she was diagnosed with post-traumatic stress disorder three months ago. She was diagnosed with the disorder following her experience with a road accident. The client raised complaints during her first visit to the unit that included the persistent recurrence of the distressing memories about the accident. She also reported flashbacks and intense distress following her exposure to stimuli that related to the event. She also avoided any stimuli that related to the traumatic event. The symptoms had a negative effect on the ability of the client engage in her occupational and family roles. As a result, she was diagnosed with post-traumatic stress disorder and has been on treatment in the unit.
O: The client was dressed appropriately for the occasion. She was oriented to self, others, time and events. Her judgment was intact. She denied illusions, delusions, and hallucinations. She also denied suicidal thoughts, attempts, and plans.
A: The adopted treatment interventions have been effective in managing the depressive symptoms of post-traumatic stress disorder. The client reports improved tolerability to the treatment.
P: The client was advised to continue with the current treatments. She was scheduled for a follow up visit after four weeks.
Attention Deficit Hyperactive Disorder
Name: K.T
Age: 8 years
Diagnosis: Attention Deficit Hyperactive Disorder
S: K.T is an 8-year-old boy who was brought to the unit for his regular assessment for ADHD. He was diagnosed with ADHD at the age of 6 years and has been on treatment. The diagnosis was reached after he started experiencing symptoms that included the lack of attention alongside impulsivity and hyperactivity for more than five months after being enrolled in school. The symptoms of impulsivity were reported to affect negatively the social and academic performance of the client. The teacher had reported that the client daydreamed and seemed distant while in class. He also fidgeted and failed to complete her assignments on time. A further assessment of the client showed that the symptoms were not attributable to any cause, hence, the diagnosis with ADHD.
O: The client appeared appropriately dressed. His orientation to self, others, time and space was intact. His attention span was moderate. The client demonstrated flight of ideas. The teacher reported that his social and cognitive functions had improved significantly.
A: The symptoms of ADHD have improved with the currently adopted treatment.
P: The parents of the client were advised to continue with the medications and attend the monthly follow-up visits.
Dementia
Name: T.R
Age: 67 years
Diagnosis: Dementia
S: T.R is a 68-year-old male client who has been on treatment in the unit for dementia after being diagnosed with it three years ago. He was diagnosed with dementia after he started experiencing a significant decline in his memory. The client had started experiencing gradual loss of memory, as he could not remember the names of his family members and his familiar places. The client also reported getting lost in his familiar environments, placing him at risk of harm. There was also the complaints by the family members that the client was easily agitated and irritated by others and events. The symptoms were reported to be worsening on a daily basis, leading to the client being brought to the setting for further assessment. He was diagnosed with dementia and has been on treatment.
O: The patient appeared well groomed for the occasion. His orientation to self, time, others, and events were intact. He reported that his mood was normal for few months. The client denied any suicidal thoughts, illusions, hallucinations, and delusions.
A: The client is responding well to the treatment.
P: The decision to continue with the current treatment modalities was adopted. The client was scheduled for a follow-up visit after four months.
Bipolar Disorder
Name: C.H
Age: 28 years
Diagnosis: Bipolar Disorder
S: C.H is a 28-year-old client that came to the unit for her follow-up after being diagnosed with bipolar disorder five months ago. She was diagnosed with the disorder after she complained of uncontrolled cycles of mood depression and elevation. C.H noted that the elevation in mood was associated with symptoms such as engaging in goal-directed initiatives and over excitement. The mood elevation cycle alternated with depressive episodes where she felt she lacked energy to engage in her daily activities. She also complained about insomnia and lack of interest in things and activities. The depressive symptoms lasted for less than a month, when the patient reported optimal health and wellbeing. The above symptoms had affected significantly the ability of the client to engage in her daily routines. The symptoms were also not associated with drug use, medical problem or substance and alcohol abuse. As a result, she was diagnosed with bipolar disorder and initiated on treatment.
O: The client appeared appropriately dressed for the occasion. She was oriented to self, place, time and events. Her judgment was intact. She denied any recent experience of delusions, hallucinations, illusions, suicidal thoughts, plans, and attempts.
A: The treatment objectives have been achieved. The client tolerates the treatment well.
P: The psychotherapy sessions were terminated due to the realization of the desired treatment objectives. She was advised to continue with the prescribed medications. The client was scheduled for a follow-up visit after four weeks.
Alcohol Use Disorder
Name: H.V
Age: 43 years
Diagnosis: Alcohol Use Disorder
S: H.V is a 43-year-old male who came to the clinic today for his regular follow-up visit after being diagnosed with alcohol abuse disorder and has been on treatment. The client was diagnosed with the disorder after he came to the unit with complaints of binge consumption of alcohol that was beyond his control. The binge consumption of alcohol was despite his efforts such as abstaining from it, which were unsuccessful. He was distressed that the excessive consumption of alcohol was negatively affecting his life and that of the family members. He was however willing to adopt any intervention that could have facilitated the effective management of the problem. Therefore, he was diagnosed with alcohol use disorder and initiated on treatment.
O: The patient was dressed appropriately for the occasion. His orientation to self, others and events were intact. His thought content was intact. He denied any 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: The client is responding positively to the treatment.
P: The client was advised to continue with the treatment and scheduled for a follow-up visit after four weeks.
Schizophrenia
Name: Y.R
Age: 33 years
Diagnosis: Schizophrenia
S: Y.R is a 33-year-old male client that came to the unit for his follow-up visit after being diagnosed with schizophrenia four months ago. He was diagnosed with schizophrenia after he came to the unit with complaints of seeing imaginary things and hearing voices. He also reported that the symptoms had affected severely his level of functioning in areas that included interpersonal relations, work, and self-care. The symptoms had persisted for more than five months. The symptoms could not be attributed to causes such as medication use, substance abuse, and medical conditions. As a result, he was diagnosed with schizophrenia and initiated on treatment.
O: The client appeared well groomed for the occasion. He was oriented to space, time, events, and self. He denied any recent experience of illusions, delusions, and hallucinations. He also denied suicidal thoughts, attempts, and plans. His thought content was future oriented.
A: The adopted treatments are effective in managing the symptoms of schizophrenia.
P: The patient was advised to continue with the current treatments. He was scheduled for the next follow-up visit after four weeks.
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Assignment 1: Clinical Hour and Patient Logs
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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 CLIICAL SITE IS A PRIVATE PRACTICE THEY PROVIDE DIRECT CLINICAL SERVICES SUCH AS PSYCHIATRIC EVALUATION, CRISIS INTERVENTION, PSYCHOMARMACOLOGY TREATMENTS AND REFERALS AS NECESSARY TO PATIENTS WITH DIFFERENT PSCHYTIATRIC DIAGNOSIS.
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