PRAC 6631 CLINICAL HOUR AND PATIENT LOGS
Clinical Hour and Patient Logs
Major Depression
Name: G.O.
Age: 56 years
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Diagnosis: Major Depression
S: G.O. is a 56-year-old client who came to the facility for psychiatric assessment and treatment. He came as a referral by his primary care provider. G.O. came with complaints of being severely depressed on most days and lacking the energy to engage in anything for the past month. He reported that the symptoms started about six months ago after losing his job and worsened over the past month. He also reported that he lacks interest, sleeps more than normal, is easily irritable, and experiences hardships in making decisions. G.O. also reported that he has been feeling guilty over the past two weeks. He denied suicidal thoughts, plans, attempts, or substance abuse and use. He was diagnosed with major depression and started treatment.
O: G.O. was poorly dressed for the occasion. He avoided eye contact during the assessment. He was alert with a grossly intact orientation to himself, others, time, and events. G.O. did not show tics, tremors, or depressed speech. G.O. reported a depressed mood. He had a flat affect. He reported alogia and avolition. G.O. denied illusions, delusions, and hallucinations. He also denied suicidal thoughts, plans, and attempts.
A: G.O. reports symptoms of major depression. He has a depressed mood, which has affected his health and quality of life. Treatment should improve his mood and functioning.
P: The patient was started on oral sertraline 50 mg once daily. He was started on individual psychotherapy. He was scheduled for a follow-up visit after a month.
Constipation
Name: R.Y.
Age: 22 years
Diagnosis: Constipation
S: R.Y. is a 22-year-old client who came to the facility with complaints of constipation for the last three days. The patient reports that he has not had bowel movements for the last two days. He feels bloated, experiences stomachache, and feels that he has not emptied completely his bowels following a movement. The patient is physically active and denies any chest or cardiovascular problems.
O: Vitals: T 37.4, RR 18, BP 124/76, P 90, SPO2 98 room air. The patient is properly groomed, pleasant, alert, and oriented. The abdomen is soft, and non-tender, with normal bowel sounds. There are no organomegaly and abdominal scars.
A: The patient has normal bowel movements. The presenting symptoms are those seen in patients with constipation.
P: The patient was prescribed milk of Magnesia 10 ml daily PRN.
Acute Otitis Media
Name: L.W.
Age: 6 years
Diagnosis: Acute otitis media
S: L.W. is a 6-year-old child whose parents brought her for assessment and treatment. They presented with a chief complain of their child puling her right ear and being irritable. They also report rhinorrhea, low-grade fever, changes in appetite, and crying. The parents deny any known allergies.
O: Vitals: 22 kg, temp 37.9, SPO2 98% room air. The child is pleasant, well-developed, active, and has no signs of distress. Ears: The right tympanic membrane is red and erythematous with loss of light reflex. Nose: Presence of clear nasal drainage. Other systems did not reveal any abnormal findings.
A: The child was started on cefdinir to treat otitis media. Zyrtec 5 ml at night was prescribed for rhinorrhea. The parents were educated about the importance of influenza vaccine. They were advised to bring the child back should the symptoms fail to improve.
P:
Stroke
Name: M.O.
Age: 64 years
Diagnosis: Stroke
S: M.O. is a 64-year-old patient who presented to the facility for his follow-up care. He was hospitalized a month ago for stroke. He reports right-sided weakness, difficulties with walking and balance and speech.
O: The patient has right-sided weakness and reduced sensations on the right side. He has difficulties with balance and walking. He has mildly impaired speech. He does not have cognitive impairments.
A: The patient recently had a stroke. He has symptoms of hemiparesis with gait and balance deficits.
P: The patient was referred to occupational and physical therapy to improve his coordination, strength, and balance. Speech therapy was also recommended to address his communication challenges. The patient is to continue with the medications he was prescribed during his hospitalization. Follow-up was scheduled to be after a month. He was advised to report any abnormal changes such as new symptoms or changes in his overall health status.
Bipolar Disorder
Name: T.T.
Age: 29 years
Diagnosis: Bipolar Disorder
S: T.T. is a 29-year-old client who came to the facility for psychiatric assessment. He came as a referral by his primary care provider for psychiatric assessment and treatment. T.T. came with complaints of repeated cycles of depressed and expansive moods for the last eight months. The last experience of a depressed mood was two weeks ago. The client reported that he experiences symptoms such as low mood, lack of energy, insomnia, difficulties in making decisions and concentrating, and hopelessness during periods of depressed mood. He also noted that he has periods of an expansive mood that lasts up to three weeks. The symptoms experienced during this period include racing thoughts, being too talkative, easy irritability, difficulties concentrating, and engaging in risky activities such as binge alcohol use. T.T. reported that these symptoms usually affect his occupational functioning as a cashier at a local manufacturing firm. He denied substance use, abuse, medication use, and a medical condition that could cause his problem.
O: T.T. was dressed appropriately for the occasion. He appeared of appropriate weight for his age. He was alert and oriented to himself, others, time, and events. T.T. reported a mildly depressed mood. He denied anxiety. His speech was not constricted. He maintained normal eye contact and speech during the assessment. T.T. denied illusions, delusions, hallucinations, suicidal thoughts, and plans.
A: T.T. has mild depression. His complaints align with those seen among patients with bipolar disorder. The treatment should improve his mood and social and occupational functioning.
P: T.T. was prescribed oral Zoloft 50 mg once daily. He was also started on individual psychotherapy. He was scheduled for a follow-up visit after four weeks.
Migraine Headache
Name: L.T.
Age: 28 years
Diagnosis: Migraine headache
S: L.T. is a 28-year-old patient who came to the facility with complaints of severe headaches for the past two days. The patient reports that she has been experiencing unilateral headaches for the past two days. She rated pain as 9/10 with accompanying symptoms such as nausea, photophobia, and vomiting. She denies neck pain, fevers, and hearing loss. She has been using Tylenol for pain relief and resting in a dark room.
O: Vital signs RR 20, P 74, BP 114/78, SPO2 98% room air, pain 9/10, location temporal region. No numbness, tingling, aura, balance, or gait issues.
A: L.T. reports symptoms of migraine headache. Complaints such as unilateral headache, throbbing, photophobia, and nausea are associated with migraine headaches.
P: L.T. was prescribed oral Tylenol 500 mg TDS 3/7, oral sumatriptan 100 mg PRN, oral magnesium 400 mg PO daily, and Melatonin 3 mg PO nightly. The patient was educated about non-pharmacological interventions such as cold compresses on the temporal region, reducing stress, abstaining from caffeine and marijuana, and maintaining good sleep hygiene. She was informed to visit the facility should the symptoms fail to resolve with the above treatments.
Post-Traumatic Stress Disorder
Name: J.N.
Age: 45 years
Diagnosis: Post-Traumatic Stress Disorder
S: J.N. is a 45-year-old female client who came to the facility for her second follow-up visit. She was diagnosed with post-traumatic stress disorder after being involved in a fatal road accident six months ago. The client presented to the facility with complaints of a depressed mood, frequent flashbacks, and distress following the accident. She reported that she has been experiencing recurrent distressing memories about the accident. She also has recurrent dreams related to the accident. She has been also experiencing distressing flashbacks about the accident. She has been avoiding any stimuli or cues that relate to the accident. The symptoms have affected her ability to concentrate and make decisions related to her life and business. She had also developed an intense fear of driving because of fearing her involvement in a similar accident. She denied substance use, abuse, or medication use. She was diagnosed with post-traumatic stress disorder and started treatment.
O: J.N. was dressed appropriately for the occasion and weather. She denied fever, fatigue, and chills. She was pleasant, alert, and oriented. She denied a depressed mood and anxiety. Her affect was normal with no evidence of depressed speech. She responded appropriately to the questions asked during the assessment. She denied illusions, delusions, hallucinations, suicidal thoughts, attempts, and plans. She denied altered cognition, decision-making abilities, and concentration.
A: J.N. reports improved post-traumatic stress disorder symptoms. She reports improved social and occupational functioning. She no longer experiences negative symptoms of post-traumatic stress disorder. She also tolerates the prescribed treatment.
P: J.N. was advised to continue with the current treatments. She was scheduled for a follow-up visit after a month.
Sinusitis
Name: C.L.
Age: 26 years
Diagnosis: Sinusitis
S: C.L. is a 26-year-old client who came to the facility with complaints of facial pain. She was well until the last two weeks when she started experiencing nasal and sinus congestion following the flu. She reports rhinorrhea, nasal congestion, and mild headache. Tylenol helps relieve the pain.
O: Vitals: T 37.5, BP 122/64, P 80, RR 20, SPO2 98% room air, Weight 120. The patient appears fatigued. HEENT: There is left maxillary tenderness with no sinus transillumination. Oral exam shows pink mucus membranes with no postnasal drip or tonsillar exudates. There is rhinorrhea with no nasal flaring or septum deviation. The tympanic membranes are pearly grey with no drainage.
A: The patient has symptoms of acute sinusitis. Allergic rhinitis is the least likely cause due to lack of a history of allergic reactions
P: The patient was prescribed oral amoxicillin 500 mg TDS 5/7 and oral Tylenol 500 mg TDS 3/7. The client was advised to visit the facility should the symptoms fail to resolve.
Anorexia Nervosa
Name: M.M.
Age: 16 years
Diagnosis: Anorexia Nervosa
S: M.M. is a 16-year-old female client who came to the facility for her third follow-up visit. She was diagnosed with anorexia nervosa four months ago and started treatment. The diagnosis was made after her parents brought her to the facility with complaints of an eating disorder. M.M. has a year history of severely restricting dietary intake, which led to considerable weight loss. She was underweight during their first visit. The dietary restriction was attributed to an intense fear of gaining weight and having an undesired appearance. M.M. engaged in other dietary restriction behaviors such as vomiting after eating and the use of laxatives to prevent weight gain. She denied substance use, abuse, and medication use. She was diagnosed with anorexia nervosa and started treatment.
O: M.M. was dressed appropriately for the occasion. She appeared slightly underweight. She denied fatigue, fever, or chills. She was alert and oriented to herself, others, time, and events. She denied anxiety and depressed mood. She had a positive self-identity. M.M. denied illusions, delusions, and hallucinations M.M. denied suicidal thoughts, plans, and attempts.
A: M.M. continues to show improved symptoms. Her dietary intake has significantly improved. She no longer engages in restrictive dietary practices. She has a positive self-identity.
P: M.M. was advised to continue with psychotherapy treatment. The treatment would be terminated should she show continued symptom improvement. She was scheduled for a follow-up visit after a month.
Substance Use Disorder
Name: A.N.
Age: 17 years
Diagnosis: Substance Use Disorder
S: A.N. is a 17-year-old client who came to the facility for his third follow-up visit. He was diagnosed with substance use disorder and has been undergoing treatment. The diagnosis was made after A.N.’s parents brought him with a complaint of abusing alcohol. The parents noted that their son started using alcohol occasionally when he was 15 years old. They have done everything possible to discourage the behavior but have been unsuccessful. A.N.’s alcohol use problem worsened over the last six months when he started taking too much alcohol, which is beyond the normal use by an adult. A.N. also stopped going to school since he spent most of his time looking for alcohol. A.N. has started experiencing withdrawal symptoms whenever he misses taking alcohol. This prompted the parents to bring him to the facility for psychiatric assessment and treatment.
O: A.N. was dressed appropriately for the occasion. He was alert and oriented to himself, others, time, and events. He appeared of normal weight for his age and gender. A.N. did not show tremors or avoidant behaviors during the assessment. He maintained a normal tone and rate of speech during the assessment. He denied suicidal thoughts, plans, or attempts. He also denied illusions, delusions, hallucinations, or alcohol withdrawal symptoms.
A: A.N. shows improvements in symptoms of substance use disorder. He tolerates the current medication. He reports that he attended Alcoholics Anonymous online group and appreciated the support he received. He denied taking alcohol over the last two and a half months. He has also started attending his college classes.
P: A.N. shows improvement in symptoms of alcohol use disorder. Therefore, he was advised to continue with the current dose of naltrexone and his participation in group psychotherapy and virtual Alcoholics Anonymous group.
Attention-Deficit Hyperactive Disorder
Name: T.Y.
Age: 16 years
Diagnosis: Attention Deficit Hyperactive Disorder
S: T.Y. is a 16-year-old child who came to the facility for his regular follow-up visit. He was diagnosed with attention deficit hyperactive disorder at the age of 8 years and has been undergoing treatment. The diagnosis was made after his parents brought him to the facility with complaints of their child being inattentive and hyperactive. The inattention was noted since the child was seven years old. The inattention symptoms included not being keen on details, lacking interest in play activities, being absent-minded, failing to follow through on instructions, and having trouble organizing things. The child was also forgetful and easily distracted when undertaking activities requiring concentration. The symptoms of hyperactivity reported included fidgeting, finding it difficult to sit attentively, and not participating in any leisure activities without interrupting others. The symptoms led to a diagnosis of attention deficit disorder and the client started treatment.
O: T.Y. was dressed appropriately for the occasion. He was alert and oriented to himself, others, time, and events. T.Y. was keen on details. He responded appropriately to questions being asked during the assessment. T.Y. did not show any abnormal behaviors such as fidgeting during the assessment. He denied anxiety and a depressed mood. He also denied illusions, delusions, and hallucinations. T.Y. denied suicidal thoughts, plans, and attempts.
A: T.Y. shows sustained improvement in his social and academic functioning. His parents report improved academic performance, attention, and ability to interact with others. The client also tolerates well the prescribed treatment.
P: T.Y. was advised to continue with oral methylphenidate 20 mg once daily. He was scheduled for his follow-up visit after three months.
Social Anxiety Disorder
Name: K.O.
Age: 16 years
Diagnosis: Social Anxiety Disorder
S: K.O. is a 16-year-old patient who came to the unit for her first follow-up visit. The client was diagnosed with social anxiety disorder and started treatment. She came to the facility with complaints of challenges in interacting with others and expressing herself in social situations. K.O. noted that she always experiences considerable anxiety and fear in social situations with potential scrutiny from others. This included performing in front of others, being observed, and expressing herself in a crowd. She finds it difficult to manage her fear and anxiety. She feels embarrassed by her emotional experiences during these situations. The fear and anxiety often affect her social functioning and academic performance at school. K.O. denied substance use abuse, and medication use. She was diagnosed with social anxiety disorder and started individual psychotherapy.
O: K.O. was dressed appropriately for the occasion. She appeared pleasant, alert, and oriented to herself, others, time, and events. K.O. denied anxiety, distress, or a depressed mood. K.O. did not show any abnormal behaviors such as tremors, tics, and eye avoidance during the assessment. She denied illusions, delusions, and hallucinations. She also denied suicidal thoughts, plans, or attempts.
A: K.O. reports improved social functioning. She can now express herself in front of others without fear of scrutiny. She can also interact with others without fear of being ridiculed.
P: K.O. was advised to continue with individual psychotherapy sessions. The treatment would be terminated should she demonstrate continued symptom improvement.