Sample Answer for PRAC 6635 WEEK 1 Clinical Hour and Patient Logs Major Depression S: C.L is a 26-year-old male who reports he has had a relapse of a constantly low depressed mood for the last month. He reports a significant appetite increase and has gained over 15 pounds
Sample Answer for PRAC 6635 WEEK 1 Clinical Hour and Patient Logs
Major Depression
S: C.L is a 26-year-old male who reports he has had a relapse of a constantly low depressed mood for the last month. He reports a significant appetite increase and has gained over 15 pounds. Additionally, he reports feeling fatigued most of the day and sleeps more than 12 hours. He also says he is experiencing anhedonia, feels worthless and is unable to go to work.
O: Patient is alert, oriented, and well-groomed. He has a depressed mood, coherent thought, good judgment and insight. There are no hallucinations or delusions.
A: The patient has a relapse of depressive episodes and is concerned about how the symptoms are impacting his life.
P: Zoloft 50 mg oral OD.
Adjustment disorder with anxiety
S: A.D is a 27-year-old female with marked distress after losing her job. She reported having a hard time adjusting to life after job loss and considers the loss a major failure in her life. She reported that in the past four months she has been having excessive worry, anxiety, sleeping difficulties, and is constantly angry. She mentioned that although she got a new job two months later, she feels trapped and isolated and does not like the job. As a result, she has poor concentration levels and has not been performing compared to her previous job.
O: The self-reported mood was anxious and affect appropriate. She demonstrates a coherent thought process. She has a good judgment and abstract reasoning.
A: Problems with adjustment.
P: Paroxetine 20mg orally once daily.
PTSD
S: F.L is a 15-year-old female who presented with complaints of having intrusive thoughts about a fatal road accident she was involved in seven months ago, which left her with a broken femur. She witnessed several people profusely bleeding and two died on the spot. The memories of the accident constantly recollect in her mind, which give her an intense fear and leave her helpless. She reported having flashbacks about the accident. Consequently, she avoids travelling because being in a car reminds her of the traumatic event. She stated that she often gets distressed when in a vehicle, which is accompanied by palpitations and profuse sweating. The client also reported having difficulties sleeping because she often gets nightmares about the accident.
O: Anxious and fidgets a lot. Coherent speech and thought process.
A: Startled reaction and avoidance.
P: Paroxetine 30mg orally once daily.
Obsessive Compulsive Disorder
S: D.C is a 24-year-old female with an obsession of doubt characterized by constantly checking doors and locks in her house and shop. She reported having an abnormal concern about having forgotten to lock the door upon leaving the house and her shop. The doubt causes marked psychological distress, which compels her to frequently check the locks. She reports that she has in many occasions left her house at night to go check if she locked her shop. Besides, she frequently wakes up at night with doubts of having failed to lock the door. The obsession of doubt has contributed to poor concentration levels while at work since she is always concerned that she did not lock the house door.
O: Anxious and fidgets a lot. Coherent speech and thought process.
A: The obsessions and compulsions are time-consuming and interfere extensively with her normal routine.
P: Clomipramine 25 mg PO qDay.
Major Depression
S: W.S is a 16-year-old female who presented with a depressed mood for about six weeks, characterized by feeling sad, empty, and hopeless most of the day and nearly every day. She also reported having a decreased appetite which had caused a weight loss of about 12q pounds. She had low energy levels and would feel fatigued even after sleeping for long hours. She reported having lost interest in most pleasurable activities and decreased ability to concentrate and make decisions.
O: The self-reported mood is sad, and affect is broad. Her speech is clear with normal volume and rate. The thought process is coherent. No delusions, hallucinations, or suicidal/homicidal ideations were noted.
A: PHQ-16. Impaired school and social functioning.
P: Zoloft 50 mg oral OD.
Obsessive-Compulsive Disorder
S: S.D is a 13-year-old female with recurrent and persistent thoughts about being dirty and contracting disease-causing organisms. The obsession with thoughts and ideas that she might have contracted microbes led to marked anxiety and distress. To overcome the obsession, she was compelled to repetitively wash her hands, take a shower about three times a day, and would spend lots of time in the shower than usual. The obsessive symptoms negatively impacted her social life as she avoided public places, shaking hands, and touching surfaces in public.
O: The self-reported mood is nervous, and affect is broad. The client reports that she still feels at risk of contracting infections, especially in public places.
A: Impaired social functioning.
P: Clomipramine 25 mg PO qDay.
Attention Deficit Hyperactive Disorder
S: B.N is a 5-year-old boy who presented with hyperactive, impulsive behavior, and inattention. The child’s mother reported that the behavior started when he was about 4 years. He had temper tantrums and still has problems with anger management. The mother mentioned that the behavior has interfered with his school life since he cannot remain still in class. The teacher reported that it was difficult to contain the child in class since he would move when a class was in session and talk excessively. He was also easily distracted and made impulsive decisions.
O: He is unable to maintain one sitting position throughout the interview and wanders around in the office. The self-reported mood is happy, and the affect is elevated. His speech is clear but loud, and his thought process is coherent.
A: Deficits in attention.
P: Ritalin 5mg OD.
Avoidant Personality Disorder
S: C.H is a 10-year-old girl whose mother reported that she is usually unwilling to get involved with other people. The girl has been socially withdrawn because, which she attributed to having an increased sensitivity to criticism from others. Besides, she avoids social situations due to a yearning to avoid criticism and she disengages from friendships due to the fear of others’ disapproval. The client admitted to having very few friends and has difficulties making friends at school. She stated that her feelings of inadequacy have inhibited her from interpersonal relationships.
O: She appears anxious and tensed and maintains minimal eye contact throughout the interview. The self-reported mood is nervous and affect is constricted. She speaks in low tones and a slow rate.
A: Social avoidance.
P: Behavioral therapy with assertive training.
Postpartum Depression
S: E.Y is a 22-year-old female who presented with uncontrollable worries about her 10-week-old child’s health and well-being. She reported having a feeling of intense sadness and despair four weeks after delivery. She was tearful most of the day with an inability to experience the pleasure of activities she enjoyed before delivery. Besides, she had sleeping difficulties and was always fatigued during the day. She mentions that the sleep disturbances are caused by the baby crying often and having to wake up frequently to breastfeed him. The symptoms had interfered with her ability to function and the PCP was concerned that they would cause risk of harm to the mother and infant.
O: Depressed mood; Broad affect; No suicidal ideations.
P: Zoloft 50 mg oral OD.
Insomnia
S: H.D is a 65-year-old female who reported having trouble sleeping at night, resulting in chronic fatigue. She reported having these symptoms for the last three months and denied taking a lot of caffeine. She reported she often sleeps late at night after having difficulties sleeping, wakes up three to four hours later, and has difficulties going back to sleep later. As a result, she feels fatigued, anxious, and irritable, has difficulties concentrating, and constantly worries about her sleep pattern.
O: Patient is alert, oriented, and anxious. She has a coherent thought process and lacks hallucinations and delusions.
A: The patient has insomnia, causing her to be in severe anxiety.
P: Sleep therapy with sleep hygiene interventions.
