WEEK 8 Assignment 1: Clinical Hour and Patient Logs
WEEK 8 Assignment 1: Clinical Hour and Patient Logs
Clinical Logs
Insomnia
Name: X.X
Age: 24 years
Diagnosis: Insomnia
S: X.X is a 24-year-old male who came to the clinic for his fifth follow-up visit after being diagnosed with insomnia six months ago. He was diagnosed with insomnia after he presented to the unit with complaints of difficulties in falling asleep and maintaining sleep. He also reported frequent episodes of waking up while asleep and finding it hard to get sleep afterwards. The energy levels of the client during the day were significantly reduced. As a result, he was worried that his productivity was not to the expected level in his organization. The difficulties in sleep could not be attributed to any medical condition, medication, or substance abuse. Due to the above complaints, the patient was diagnosed with insomnia, and has been undergoing group psychotherapy sessions in the unit.
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O: The client appeared appropriately dressed for the occasion. His orientation to self, place, time and events were intact. The self-reported mood of the client was normal. The judgment of the client was intact. He denied any history of delusions, hallucinations, and illusions. He also denied any history of suicidal thoughts, attempts, and plans.
A: The use of group psychotherapy treatment has been effective in improving the symptoms of insomnia being experienced by the client
P: The participation of the client in the group psychotherapy sessions was terminated, as the treatment objectives had been achieved. He was informed to visit the clinic should the symptoms relapse.
Schizophrenia
Name: B.T
Age: 38 years
Diagnosis: Schizophrenia
S: B.T is a 38-year-old female that came to the unit for her sixth follow-up visit after being diagnosed with schizophrenia seven months ago. She recalled that she had come to the unit with complaints that included seeing imaginary things, hearing voices, and having a disorganized speech. The client also reported that the symptoms had affected severely her level of functioning in areas that included interpersonal r
elations, work, and self-care. The symptoms had persisted for more than five months. The symptoms could not be attributed to causes such as medication use, substance abuse, and medical conditions. 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 denied suicidal thoughts, attempts, and plans. Her thought content was future oriented. She did not demonstrate any abnormal behaviors such as tremors and flight of ideas.
A: The treatment objectives have been achieved with the adopted treatment interventions. The client also demonstrates no side effects to the adopted treatments.
P: The psychotherapy session were discontinued with the consent of the client. The discontinuation was because the treatment goals had been achieved. She was advised to continue with the pharmacological treatments. She was scheduled for the next follow-up visit after four weeks.
Attention-Deficit Hyperactive Disorder (ADHD)
Name: K.P
Age: 9 years
Diagnosis: ADHD
S: K.P is a 9-year-old boy who came to the unit for his regular assessment in the company of his parents. He was diagnosed with ADHD at the age of 7 years and has been on treatment. The parents recalled that K.P was diagnosed with the disorder due to symptoms that included the lack of attention alongside impulsivity and hyperactivity for more than six months after being enrolled in school. The symptoms of impulsivity were reported to affect negatively the social and academic performance of the client. The client also demonstrated the above symptoms both in school and at home. The teacher had reported that the client day dreamed and seemed distant while in class. He also fidgeted and failed to complete her assignments on time.. A further assessment of the client showed that the symptoms were not attributable to any cause, hence, the diagnosis with ADHD.
O: The client appeared appropriately dressed. His orientation to self, others, time and space was intact. His attention span was moderate. The client demonstrated flight of ideas. The teacher reported that his daydreaming had stopped with the interests of the client on learning activities improved significantly.
A: The symptoms of ADHD have improved with the currently adopted treatment.
P: The parents of the client were advised to continue with the medications and attend the monthly follow-up visits.