PRAC 6645 WEEK 2 Clinical Hour and Patient Logs Assignment 1
PRAC 6645 WEEK 2 Clinical Hour and Patient Logs Assignment 1
Clinical Logs
Post-Traumatic Stress Disorder
Name: D.S
Age: 34 years
Diagnosis: Post-traumatic stress disorder
S: D.S is a 34-year-old patient who came to the department today for his follow-up visit. He was diagnosed with post-traumatic stress disorder seven months ago, and has been on treatment. The symptoms of post-traumatic stress disorder occurred following his involvement in a sexual assault incident. According to the patient, he experienced the symptoms three months after the incidence. The complaints that led to the diagnosis were varied. They incurred recurrence in distressing memories of the encounter. The recurrence was involuntary and often distressing for the patient. The patient also reported nightmares and flashbacks about the incident, which were emotionally distressing. There was also the complaints of avoidance of any stimuli or conditions that reminded him about the incident. The above symptoms had affected severely the ability of the patient to function optimally in his social and occupational roles. The assessment had further revealed that the symptoms were not attributed to any other cause such as
medication use, medical condition or substance abuse. He was diagnosed with post-traumatic stress disorder and has been using antidepressants and attending group psychotherapy sessions.
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O: The patient appeared well groomed for the visit. He was oriented to self, place, time and events. The mood was normal with speech within the expected range in terms of rate and volume. He denied any recent experience of illusions, delusions, hallucinations, and suicidal thoughts, attempts, and plans.
A: The treatment objectives have been achieved for this client. He has developed the desired knowledge and skills for managing the distressing symptoms of post-traumatic stress disorder.
P: Psychotherapy sessions were terminated with consent from the patient. He was advised to continue using antidepressants. He was scheduled for next follow-up visit after two months.