WEEK 7 Assignment 1: Clinical Hour and Patient Logs
WEEK 7 Assignment 1: Clinical Hour and Patient Logs
Clinical Logs
Major Depression
Name: R.W
Age: 34 years
Diagnosis: Major Depression
S: R.W is a 34-year-old client that was brought to the unit by his relatives for psychiatric review. The client was brought with history of suicide attempt. The family reported that the client was found when he was trying to kill himself by hanging. History taking from the client and the family members was done. The client reported that he wanted to kill himself, as he felt that he life was useless. He felt that he had not been successful when compared to his peers. The client also noted that his mood has been depressed for almost everyday. The depressed mood had made it difficult for him to engage in his activities of the daily living, as the family reported him to be socially withdrawn. The family also reported that his interest in things had diminished significantly. The family reported that R.W appeared fatigued in most of the days. R.W reported that he lacked appetite and has been forcing himself to eat. The client reported suicidal thoughts and attempt. He denied any suicidal plan now. Based on the above complaints the client was diagnosed with depression and initiated on treatment.
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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: A.A
Age: 43 years
Diagnosis: Major Depression
S: A.A is a 43-year-old client that came to the unit for her second follow-up visit, after she was diagnosed with depression two months ago. The client recalled that she was diagnosed with depression following a number of symptoms. One of the symptoms is that she was experiencing depressed mood in most of the days for every day. The client was also socially isolated as he lacked interest in things and pleasure. She attributed the lack of pleasure and interest to her depressed mood had made it difficult for her to engage in his activities of the daily living, as the family reported him to be socially withdrawn. A.A also reported that her appetite had increased significantly. She was eating more than normal for the last few weeks. Her ability to make decisions was also significantly affected. He level of irritability was also high, as she found that she was easily irritable. Based on the above, the client was diagnosed with major depression and initiated on psychotherapy and antidepressants.
O: The client appeared appropriately dressed for the occasion. She reported that his mood was not depressed today, as it was last time. The client was oriented to self, others, time, and events. She denied illusions, delusions, and hallucinations. She denied suicidal thoughts and attempts. She denied current suicidal plans. The client does not have a current suicidal plan. Her speech was reduced in terms or rate and volume.
A: The symptoms of depression have improved. The client reports that the treatment has been effective, as she experiences minimal depressive symptoms.
P: The client was advised to continue with the current treatment. She was also advised to come for a follow-up visit after four weeks.
Major Depression
Name: Z.X
Age: 50 years
Diagnosis: Major Depression
S: Z.X is a 50-year-old client that came to the unit for his fifth follow-up visit for depression. The client was diagnosed with depression six months ago after he started becoming suicidal. The client reported that his suicidal symptoms had persisted for over a month, after which he was brought for psychiatric assessment. Some of the symptoms he had during the first hospital visit included suicidal thoughts and attempts and depressed mood. The client also reported that he was experiencing insomnia in most of the days. He also felt worthless. The family had noted that the client was socially withdrawn. He did not have interest in things and lacked pleasure. He was also easily irritated. Based on the above complaints the client was diagnosed with depression and initiated on treatment.
O: The client appeared appropriately dressed for the occasion. His self-reported mood was ‘better.’. The client was oriented to self, others, time, and events. He denied illusions, delusions, and hallucinations. He denied suicidal thoughts, plans and attempts.
A: The client reports continuous improvement in his symptoms of depression. The improvements have been sustained for the last four months. The client denies any adverse or side effects related to the treatment.
P: The client demonstrates sustained improvement in symptoms. Psychotherapy sessions were continued with consent from the client. He was advised to continue with antidepressants. He was scheduled for a follow-up visit after four weeks.
Major Depression
Name: P.A
Age: 38 years
Diagnosis: Major Depression
S: P.A is a 38-year-old client that came to the unit for her third follow-up visit for major depression. The client reported that she was diagnosed with major depression four months ago after she presented to the hospital with a number of symptoms. The symptoms included depressed mood in most of the days. She also reported feeling helpless and having thoughts of committing suicide. The client also noted that she lack interest in pleasurable things or experiences. There was also a significant decline in her appetite and lacked energy. Her ability to make informed decisions had also declined considerably. The client denied suicidal thoughts, plans and attempts. Based on the above complaints the client was diagnosed with depression and initiated on treatment.
O: The client appeared appropriately dressed for the occasion. She reported that her mood was no longer depressed. The client was oriented to self, others, time, and events. She denied illusions, delusions, and hallucinations. She also denied suicidal thoughts, attempts and plans. Her speech was normal in terms of volume and rate.
A: The client is demonstrating continued improvement in symptoms of depression. She is also tolerating the treatment.
P: The client was advised to continue with psychotherapy sessions and antidepressants. She was scheduled for a follow-up visit after four weeks.
Delusional Disorder
Name: R.T
Age: 30 years
Diagnosis: Delusional disorder
S: R.T is a 30-year-old female client that came to the unit as a referral by her family physician for psychiatric assessment. The physician felt that the client had symptoms that were not attributed to a medical condition. The client had persistent thoughts that her supervisor at workplace was deeply in love with her but had not expressed his feelings. The client noted that the client demonstrated his feelings towards her by assigning him simpler task in the organization. When asked whether the supervisor had expressed his feelings or subjected her to any sexual abuse, the client noted that she had a boyfriend as well as the supervisor who was married. The client also reported that her manager was jealous about the fact that the supervisor was in love with her. As a result, she believed that the manager wanted to lay her off from the organization. Further history taking from the client showed that the client has a history of bipolar disorder that has been managed using medications. Based on the above, the client was diagnosed with delusional disorder and initiated on treatment.
O: The client appeared dressed appropriately for the occasion. She was oriented to place, time, and self. She denied illusions and hallucinations. She was delusional. She denied any history of suicidal thoughts, plans, and attempts. Her speech was normal in terms of rate and volume.
A: The client is experiencing symptoms of delusional disorder. In specific, she is suffering from erotomania and grandiose disorders.
P: The client was initiated on individual psychotherapy to address the delusions. The client was scheduled for a follow-up visit after four weeks.
Bipolar Disorder
Name: H.O
Age: 32 years
Diagnosis: Bipolar Disorder
S: H.O is a 32-year-old client that came to the unit for her sixth follow-up visit. She has been undergoing treatment in the unit for bipolar disorder. She was diagnosed with the disorder seven months ago after she presented to the unit with complaints that included periods of elevated mood. She reported that the elevated mood was associated with abnormal behaviors that that included engaging in goal-directed initiatives, excitement and delusions. The symptoms alternated with those of depression such as the lack of energy, insomnia, difficulties in concentrating and feelings of worthlessness. The depressed mood could happen almost every day for a specific period such as one month, followed by elated mood. The client was worried that the above symptoms were affecting significantly her ability to engage in the activities of the daily living, social and occupational roles. 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 client continues to show stabilized improvements in the symptoms of depression. The client notes that she tolerates the treatments 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.
Insomnia
Name: M.O
Age: 32 years
Diagnosis: Insomnia
S: M.O is a 32-year-old male who has been undergoing treatment in the facility due to insomnia. Today, he came to the unit for the fourth follow-up visit. The client recalled that he was diagnosed with insomnia after he presented with symptoms that included the lack of quality and quantity sleep for the last six months prior to the visit to the clinic. He experienced difficulties in sleeping and maintaining sleep. The difficulties in sleeping had affected significantly his ability to engage in activities of the daily living, social, and occupational roles. The client was worried that his productivity would decline further should the symptoms not be controlled. Additional assessment of the client had revealed that the symptoms were not attributed to any factors such as medication use, medical condition or substance abuse. As a result, he was diagnosed with insomnia and initiated on treatment.
O: The patient appeared well groomed for the occasion. His orientation to self, others, time and events were intact. His judgment was also intact, as he denied illusions, delusions and hallucinations. The client also denied suicidal thoughts, attempts and plans. The speech was of normal rate and volume.
A: There is continued improvement in the symptoms of insomnia since the last visit. The client reports that he has been engaging in behavioral interventions that improve the quality and quantity of his sleep.
P: The client was advised to continue with group psychotherapy sessions. He was advised to come for a follow-up visit after four weeks. The treatment would be terminated should the patient demonstrate sustained improvement in symptoms.
Post-traumatic stress disorder
Name: D.D
Age: 28 years
Diagnosis: Post-traumatic stress disorder
S: D.D is a 28-year-old client that came to the unit for her regular follow-up visits after she was diagnosed with post-traumatic stress disorder six months ago. She has been on antidepressant and psychotherapy treatments. She was diagnosed with the disorder following her experience with a road accident. The client raised a number of symptoms that included the persistent recurrence of the distressing memories about the traumatic event. There was also the report of flashbacks and intense distress following the exposure of the patient to the stimuli that related to the event. The client also demonstrated avoidance behaviors of the 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. She also denied avoidance behaviors and distressing emotional experiences associated with the accident.
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: Group psychotherapy sessions were terminated with consent from the client. She was advised to continue with antidepressant treatment. She was scheduled for a follow-up visit after one month.
Alcohol Abuse Disorder
Name: J.H
Age: 47 years
Diagnosis: Alcohol Abuse Disorder
S: J.H is a 47-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 undergoing 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. The client also reported that alcohol abuse had affected his social and occupational functioning adversely. The socioeconomic wellbeing of his family has also been affected adversely. 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 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: 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: E.F
Age: 36 years
Diagnosis: Schizophrenia
S: E.F is a 36-year-old female that came to the unit for her follow-up visit. She was diagnosed with schizophrenia seven months ago and has been undergoing treatment. The diagnosis was reached after she came with complaints of seeing imaginary things and hearing voices. The client reported that the symptoms had affected severely her level of functioning in areas that included interpersonal relations, work, and self-care. The symptoms had persisted for more than four months. The symptoms could not be attributed to other causes such as medication use, medical condition, and substance abuse. As a result, she was diagnosed with schizophrenia and initiated on treatment.
O: The client appeared well groomed for the occasion. She was oriented to space, time, events, and self. She denied any recent experience of illusions, delusions, and hallucinations. She also denied any abnormality in speech content, volume and rate. She denied suicidal thoughts, attempts, and plans. Her thought content was future oriented. She did not demonstrate any abnormal behaviors such as avoidance of eye contact and tics.
A: The treatment objectives have been achieved. The client has demonstrated sustained improvement in symptoms for the last three visits.
P: The participation of the client in psychotherapy sessions was terminated. She was advised to continue with antipsychotics. She was scheduled for the next follow-up visit two months.
Bulimia Nervosa
Name: M.M
Age: 21 years
Diagnosis: Bulimia Nervosa
S: M.M is a 21-year old female that came to the unit for follow-up visit after being diagnosed with bulimia nervosa three months ago. The client was diagnosed with the disorder after she came to the unit with complaints that included eating large amounts of food within short periods. She also reported to lack control over the amount of the food that she was eating. The client also reported engaging in behaviors such as self-induced vomiting, diuretics, and participating in strenuous exercises to reduce weight. Based on the above complaints, the client was diagnosed with bulimia nervosa and has been on psychological treatment.
O: The client appeared well groomed for the occasion. Her orientation to space, time and self was intact. The client had thought process that was future oriented. The client also had normal rate and volume of speech. The client denied any history of hallucinations, delusions, illusions, and suicidal thoughts and ideations.
A: The client reports improvement in symptoms. The client is optimistic that the psychotherapeutic treatments have been effective.
P: The client was advised to continue with psychotherapy sessions, as the symptoms have improved significantly with the adopted interventions.
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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
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