PRAC 6665 WEEK 3 : Clinical Hour and Patient Logs Assignment 1 Paper

PRAC 6665 WEEK 3 : Clinical Hour and Patient Logs Assignment 1 Paper

PRAC 6665 WEEK 3 : Clinical Hour and Patient Logs Assignment 1 Paper

Clinical Hour and Patient Logs
Major Depression
Patient’s name A.A
Age 57 years
Diagnosis Major Depression
Subjective: The patient is a 57-year-old male that came to the unit as a referral by his primary care provider. The patient came with complains of feeling hopeless and guilty for the last three months. He also reported that he always feels sad about everything in his life. The patient also acknowledged a significant loss of interest in pleasure. He noted that he does not like spending time with his family as he used before. The patient also reported a decrease in his appetite. He affirmed that he has lost some weight over the last three months due to loss of appetite. The patient also noted that he finds it difficult to fall asleep and maintain sleep. These symptoms could not be attributed to any medical condition, medication use, or substance abuse.
Objective: The patient was oriented to self, place, time, and events. His insight was intact. His mood was depressed. His thought process was normal. He had normal speech in terms of tone and rate. The patient thought process was future oriented. He denied anxiety. He denied suicidal thoughts, attempts, or plans. He also denied illusions, delusions, and hallucinations.
Assessment: The patient demonstrates symptoms of major depression. Accordingly, patients with major depression experience symptoms that include having a depressed mood, loss of interest or pleasure, weight loss or gain, insomnia or hyper insomnia, psychomotor retardation or agitation, fatigue, decreased attention span and decision-making abilities, and suicidal thoughts, plans or attempts.

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Plan: The patient was prescribed sertraline oral 50 mg daily for one month. The patient was educated about the expected side effects such as decreased libido, insomnia, and potential weight gain. The patient was scheduled for a follow-up visit after four weeks.
 
Post-Traumatic Stress Disorder (PTSD)
Patient’s name: B.T
Age: 52 years
Diagnosis: Post-traumatic stress disorder (PTSD)
Subjective: The patient is a 52-year-old veteran that came to the unit for his second follow-up visit. The patient was diagnosed with PTSD three months ago. This was after he presented the unit with complaints that included experiencing traumatic memories of his involvement in the Iraqi war. The patient’s complaints included intrusive symptoms such as recurrent distressing memories about the war, recurrent dreams of the experiences, and flashbacks. The patient has also complained of persistent avoidance of any stimuli that reminded him about the experiences. The distress experienced also made him consider himself a bad person as well as being socially isolated. The patient’s complains could not be attributed to other causes such as substance abuse, medical conditions, and medications use.
Objective: The patient was oriented to self, others, time, and place. His thought process was intact. The patient denied illusions, delusions, and hallucinations. The patient’s mood was normal. He denied insomnia or distressing thoughts over the last two months. The patient also denied suicidal thoughts, plans, or attempts.
Assessment: The patient demonstrates sustained improvements in symptoms of post-traumatic stress disorder. The patient reports that he no longer experiences distressing thoughts, flashbacks and dreams about the traumatic encounters. He also tolerates the prescribed medications. Group cognitive behavioral therapy has helped him learn effective coping strategies from other participants.
Plan: The patient’s current dose of sertraline 100 mg per day orally was maintained. The client was advised to continue with group psychotherapy sessions. He was scheduled for a follow-up visit after four weeks.
 
Insomnia
Name: D.R.
Age: 32 years
Diagnosis: Insomnia
Subjective: The patient is a 32-year-old female that came to the unit for her first visit. She came as a referral by her family nurse practitioner for psychiatric evaluation. The patient’s complaints included a considerable decline in the quality and quantity of her sleep over the past one and half months. The patient reported that she finds it difficult falling asleep and maintaining sleep. The patient noted that the number and frequency of night awakenings had increased over the past few weeks. She finds it difficult to fall back to sleep after the awakenings. The patient was worried that the sleep problem was affecting her ability to function optimally in her workplace. She reported that she at times falls asleep during afternoon hours in her workplace. These symptoms could not be attributed to causes such as medication use, mental health problems, or substance abuse.
Objective: The patient was oriented to self, others, time, and place. She maintained normal eye contact during the assessment. Her self-reported mood was “tired.”The patient yawned severally during the assessment. She attributed it to the lack of adequate sleep the previous night. The patient denied illusions, delusions, and hallucinations. She also denied suicidal thoughts, attempts, or plans.
Assessment: The patient experiences the symptoms associated with insomnia. Insomnia is a mental health problem that affects the patients social and occupational functioning and mental health and wellbeing.
Plan: The patient was prescribed Triazolam 0.25 mg at bedtime and educated on safe practices to enhance has quality of sleep. This included avoiding caffeine towards bedtime, avoiding distractors such as bright light and television, and healthy eating habits. The patient was scheduled for a follow-up visit after four weeks.
 
Bipolar Disorder
Name: A.G.
Age: 27 years
Diagnosis: Bipolar Disorder
Subjective: The patient is a 27-year-old male that his family brought him to the facility for assessment. This was after the patient being taken to the emergency department where he was referred for psychiatric review. The patient and his family reported symptoms of mania during the assessment. They included insomnia, racing thoughts, and being easily distracted. The patient also reported difficulties in making decisions and concentrating. The patient and the family reported that these symptoms alternate with those seen in patients suffering from major depression. They included having periods of depressed mood most of the day almost every day, lack of interest and pleasure, weight loss, hopelessness, and fatigue. The patient denied any medication use, medical condition, or substance abuse that could be associated with these symptoms. It was noted from the assessment that the symptoms affected the patient’s quality of life.
Objective: The patient was dressed appropriately for the occasion. He was oriented to self, others, time, and space. His thought process was intact. His self-reported mood was depressed. His affect was flat. He demonstrated flight of ideas. He also demonstrated grandiosity during the assessment. The patient denied illusions, delusions, and hallucinations. He also denied suicidal thoughts, plans, or attempts.
Assessment: The patient experiences symptoms of bipolar disorder. The mania symptoms alternate with those of major depression.
Plan: The patient was prescribed carbamazepine 200 mg BD as a mood stabilizer. He was also enrolled in-group psychotherapy to help him develop effective coping skills for distressing symptoms. The patient was scheduled for a follow-up visit after four weeks.
 
Schizophrenia
Name: R.T.
Age: 41 years
Diagnosis: Schizophrenia
Subjective: The patient is a 41-year-old female that was brought to the unit for psychiatric assessment. The spouse reported that the patient has been showing abnormal behaviors over the last few months. This included her belief that he was the “Messiah” and had been sent to save the world from perishing. The spouse also reported that the patient had demonstrated disorganized speech over the past two weeks. He initially thought the problem would resolve. However, it has persisted prompting him to bring her spouse to the hospital. The additional symptoms that were reported during the assessment included diminished ability to express her needs and impaired social and occupational functioning. The symptoms could not be attributed to causes such as medication use, substance abuse, or medical conditions.
Objective: The patient was dressed appropriately for the occasion. Her oriented to others and events were grossly altered. Her thought process was also altered. She demonstrated illusions and delusions. The patient demonstrated flight of ideas during the assessment. She had difficulties in expressing herself. Her speech was reduced in terms of speed and tone. She maintained normal eye contact during the assessment. She did not demonstrate abnormal behaviors such as tics or tremors. She denied suicidal thoughts, plans, or attempts.
Assessment: The patient experiences symptoms of schizophrenia. The approach to treatment should aim at optimizing symptom management for her health, wellbeing, and functioning.
Plan: The patient was prescribed Clozapine 12.5 mg orally twice a day. She was also enrolled in group psychotherapy sessions to help her cope with her distressing symptoms.
 
Generalized Anxiety Disorder
Name: E.T.
Age: 25 years
Diagnosis: Generalized anxiety disorder
Subjective: The patient is a 25-year-old female that came to the unit as a referral by her primary care provider for psychiatric assessment. The patient raised complaints that included frequent experiences of excessive anxiety and worry of something bad happening to her. She also reported that the management at her workplace is so strict and she constantly fears of losing her job. The patient noted that she finds it difficult to control the worry. She reported that she experiences other symptoms such as restlessness, irritability, muscle tension, and insomnia whenever she develops excess worry. The client denied other potential causes of her problem such as mental disorders, substance abuse, medication use, and medical conditions. The excessive fear and worry was reported to have affected her social and occupational functioning.
Objective: The patient was dressed appropriately for the occasion. Her orientation to self, others, and events were intact. The patient thought process was intact. Her self-reported mood was “anxious.” Her speech was clear and coherent. She maintained normal eye contact during the assessment. She denied illusions, delusions, and hallucinations. She also denied any history of suicidal thoughts, plans, or attempts.
Assessment: The patient demonstrates symptoms of generalized anxiety disorder. This can be seen from her reporting excessive fear and worry that are beyond her control. The symptoms have affected her social and occupational functioning.
Plan: The patient was prescribed Paxil 10 mg orally once a day for four weeks. She was also enrolled into group psychotherapy sessions with the aim of helping her manage her sources of excessive worry and fear. The psychotherapy sessions also aimed at helping her to learn best strategies to manage the distressing triggers of her disorder.
 
Substance Use Disorder
Name: C.H.
Age: 45 years
Diagnosis: Substance use disorder
Subjective: The patient is a 45-year-old male that came to the unit for his first follow-up visit after being diagnosed with substance use disorder. The diagnosis was reached a month ago after the patient was brought to the unit with a range of complaints. They included excessive use of alcohol for more than six months. The spouse noted that the life of the patient depended mainly on alcohol use. The patient reported that he always wanted to stop or cut down on alcohol use but was unsuccessful due to withdrawal symptoms. His family was worried about the manner in which he misused money to acquire alcohol. Alcohol abuse had affected his ability to function optimally at home and his job as an accountant. The amount of alcohol that he needed to achieve his desired effect had been increasing over the last few months. The above symptoms led to him being diagnosed with alcohol use disorder and was initiated on treatment.
Objective: The patient was dressed appropriately for the occasion. He was oriented to self, others, time, and events. He reported that he has not taken alcohol since he started treatment. He did not demonstrate abnormal mannerisms such as tremors or ticks. The client’s mood was normal. His speech was clear and coherent. He denied illusions, delusions, and hallucinations. He also denied suicidal thoughts, attempts, and plans.
Assessment: The patient demonstrates positive response to the prescribed treatments. He also reports tolerance to the treatment.
Plan: The current dosage of naltrexone was maintained. The patient was enrolled in Alcohol Anonymous group to help him learn about effective strategies to optimally manage his health problem.
 
Post-Traumatic Stress Disorder
Name: A.E.
Age: 39 years
Diagnosis: Post-Traumatic Stress Disorder
Subjective: The patient is a 39-year-old female that came to the unit for her first follow-up visit. The patient was diagnosed with post-traumatic stress disorder and initiated on treatment a month ago. The diagnosis was reached after the patient presented the hospital with complaints of persistent distressing memories of a traumatic experience she underwent. Accordingly, she was involved in a road accident where she lost her spouse. The patient noted that she always experienced persistent flashbacks about the accident. She also dreamt about the accident and the events that led to it. She also developed phobia to driving because of the encounter. The client also reported that she avoided any activity of event that reminded her about the traumatic experience. These symptoms had affected significantly her ability to function optimally in her job as evidenced by persistent absenteeism and failing to meet the set targets. The symptoms could not be attributed to any other cause such as medication use, medical condition, mental health problem, or substance abuse. She was diagnosed with post-traumatic stress disorder and initiated on treatment.
Objective: The patient appears dressed appropriately for the occasion. She is oriented to self, others, time, events, and place. Her mood is depressed. Her affect is flat. Her thought processes are intact. She denies illusions, hallucinations, and delusions. She also denied suicidal thoughts, attempts, or plans.
Assessment: The patient demonstrates mild improvement in symptoms of post-traumatic stress disorder.
Plan: The dosage of Zoloft was increased to 50 mg orally once per day. The patient was enrolled in the group psychotherapy sessions. The patient was scheduled for a follow-up visit after four weeks.
 
Anorexia Nervosa
Name: Z.H.
Age: 22 years
Diagnosis: Anorexia Nervosa
Subjective: The patient is a 22-year-old female that came to the unit for her third follow-up visit for anorexia nervosa. The patient was diagnosed with anorexia nervosa four months ago and has been undergoing psychotherapeutic treatment in the facility. The diagnosis was reached after the patient presented the unit with several complains. They included a history of severe dietary restriction with the aim of avoiding weight gain. The patient had been referred to psychiatric support after she was found to be of low body weight as compared to the expected weight of her age, developmental trajectory, and sex. The patient had reported intense fear of gaining weight alongside being disturbed by her body weight and shape. The patient also had some instances of binge eating and engaging in compensatory behaviors such as inducing vomiting because of fearing weight gain. The above symptoms led to the client being diagnosed with anorexia nervosa and was initiated on treatment.
Objective: The patient was dressed appropriately for the occasion. She was oriented to self, time, space, and events. She appeared of less body weight as compared to her age and sex. Her thought processes were intact. She denied illusions, delusions, and hallucinations. She reported that she last engaged in restrictive dieting one and half months ago. She is satisfied with her involvement in individual psychotherapy. She denied suicidal thoughts, attempts, or plans.
Assessment: The patient continues to respond positively to individual psychotherapy sessions. She adheres to the developed plan of care. Her vital signs are also within the normal ranges.
Plan: The client was advised to continue with the psychotherapy sessions. She was also referred to a nutritionist to help her develop an effective and patient-centered nutritional plan. She was scheduled for a follow-up visit after four weeks.
 
Major Depression
Name: T. Y.
Age: 35 years
Diagnosis: Major depression
Subjective: The patient is a 35-year-old female that came to the unit for her third follow-up visit. The patient was diagnosed with major depression four months ago and has been on treatment. The diagnosis was reached after the patient presented the hospital with a range of symptoms. They included experiencing depressed mood almost every day. The patient also reported feeling guilty most of the times. She was also hopeless since she perceived herself a loser in the family. The patient also experience lack of interest and pleasure. She was socially withdrawn. Her appetite had declined over time, leading to her losing more than 20 lbs in less than four months. The client had also raised concerns that she was finding it difficult to fall asleep and maintain sleep. She had attempted to commit suicide at some point, which led her being brought to the psychiatric department for assessment and treatment. The patient was diagnosed with major depression and initiated on antidepressants and group psychotherapy.
Objective: The patient was dressed appropriately for the occasion. She was oriented to self, others, time, and place. Her affect and mood were normal. He thought process was intact. She denied illusions, delusions, and hallucinations. She did not demonstrate abnormal mannerisms such as tremors, mutism, and tics. She denied suicidal thoughts, plans, or attempts.
Assessment: The patient continues to demonstrate improvement in symptoms of major depression. There has been 75% improvement in symptoms. She tolerates the prescribed treatments. She actively participates in the group psychotherapy sessions.
Plan: The patient was advised to continue with the current treatments. They include Zoloft 100 mg orally once daily and group psychotherapy sessions. She was scheduled for a follow-up visit after four weeks.
 
Schizophrenia Disorder
Name: F.A.
Age: 36 years
Diagnosis: Schizophrenia disorder
Subjective: The patient is a 36-year-old male that came to the unit for his monthly follow-up visit. The patient was diagnosed with schizophrenia five months ago and has been on treatment. The diagnosis had been reached after the patient presented the unit with a range of complaints. They included having a history of persistent hallucinations and delusions. The patient also had catatonic behaviors. There was also the history of negative symptoms that included avolution. The symptoms had impaired significantly her level of functioning in areas that included interpersonal relations, self-care, and work. The symptoms were not attributable to causes such as medical conditions, mental health problems, medications use, or substance abuse. The patient was diagnosed with schizophrenia and initiated on antipsychotics and psychotherapy.
Objective: The patient was dressed appropriately for the occasion. She was oriented to self, others, time, place and events. Her insight and judgment were intact. Her mood and affect were normal. She denied delusions, illusions, and hallucinations. The patient also denied suicidal thoughts, plans, and attempts.
Assessment: The patient has demonstrated sustained symptom improvement over the last three months. She also reports tolerance to the prescribed treatments. She notes that psychotherapy sessions have helped her cope effectively with distressing symptoms of schizophrenia.
Plan: The client’s treatment was terminated after obtaining her consent since the treatment objectives had been achieved. She was advised to continue with the current antipsychotics. She was scheduled for a follow-up visit after eight weeks.
Major Depression
Name: M.O.
Age: 33 years
Diagnosis: Major Depression
Subjective: The patient is a 33-year-old male patient that came to the clinic for his first follow-up visit. The client had been diagnosed with major depression a month ago and has been on treatment. The diagnosis was reached after the client presented the hospital with some complains. They included persistently having depressed more for almost every day for three months. The patient had also reported persistent feelings of guilt for most of the days almost every day. There was also the complaint of the patient lacking energy to engage in his daily activities, experiencing insomnia, lacking concentration, and having difficulties in making decisions. The patient also reported suicidal ideations and attempts. The symptoms could not be linked to other causes such as medications use, mental health problems, medical conditions, or substance abuse. As a result, the patient was diagnosed with major depression and initiated on treatment.
Objective: The patient was dressed appropriately for the occasion. He was oriented to self, others, time, and events. The patient denied illusions, delusions, and hallucinations. He also denied suicidal thoughts, plans, or attempts. The mood was normal. The speech was clear and coherent.
Assessment: The patient demonstrates moderate improvement in symptoms. He also reports no side or adverse effects with the prescribed treatments.
Plan: The patient was advised to continue with Zoloft 50 mg orally once daily and group psychotherapy sessions. He was scheduled for a follow-up visit after four weeks.

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Clinical Hour and Patient Logs

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 in order to earn the points associated with this assignment. You may only log hours with Preceptors that are approved in Meditrek.

Students 2018 must complete a minimum of 160 hours of supervised clinical experience. You may not complete your hours sooner than 8 weeks. You will enter your approved preceptor and clinical faculty as part of each time and patient encounter you log.

Your clinical hour log must include the following:

Dates

Course

Clinical Faculty

Approved Preceptor

Total Time (for the day)

Resources

Be sure to review the Learning Resources before completing this activity.

Click the weekly resources link to access the resources.

WEEKLY RESOURCES

Patient Log

Throughout this course, you will also keep a log of patient encounters using Meditrek. You must record at least 80 encounters with patients by the end of this practicum (40 children/adolescents and 40 adult/older adult).

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: You 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 of Week 1

Record your clinical hours and patient encounters in Meditrek.

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Rubric

PRAC_6665_Week1_Assignment3_Rubric

PRAC_6665_Week1_Assignment3_Rubric

Criteria Ratings Pts

This criterion is linked to a Learning Outcome Part 1: Time logs and patient logs are completed within 48 hours of completing clinical time.

5 pts
Excellent

*Time logs are completed within 48 hours of completing clinical time. *Patient logs are completed within 48 hours of completing clinical time.

0 pts
Poor

*Time logs are completed more than 48 hours after completing clinical time. *Patient logs are completed more than 48 hours after completing clinical time.

5 pts

This criterion is linked to a Learning Outcome *Each entry includes Date, Course, Clinical Instructor, Preceptor, Patient number, Client information, Visit information, Practice management, Diagnosis, Procedures (if applicable), Treatment plan and notes, Notes section (Students must include a brief summary/synopsis of the patient visit—this must include enough information to understand how the patient presnted and the student intervention. Do NOT include EMR SOAP notes. *LOGS MUST BE SUBMITTED WITHIN 48 HOURS TO BE ELIGIBLE FOR ANY POINTS

5 pts

Excellent

*Patient logs include all of the required documentation elements.

0 pts
Poor

*Patient logs do NOT include all of the required documentation elements. There are some elements missing or the logs are incomplete. *Patient logs were submitted more than 48 hours after completion of the clinical time.

5 pts

Total Points: 10