Answer for PRAC 6635 WEEK 3 Clinical Hour and Patient Logs 

1. Bipolar Disorder

Name: H.Y.

Age: 32 years old

Gender: Male

Diagnosis: Bipolar Disorder

S: H.Y., a 32-year-old male with a history of bipolar disorder, has reported a manic episode characterized by increased energy, sleep deprivation, racing thoughts, and impulsive behavior. He also experienced a depressive episode for three weeks, feeling hopeless, low energy, and difficulty concentrating. The patient denies any suicidal ideation during either phase.

O: The male patient’s mental status examination revealed a well-groomed appearance, increased psychomotor activity, rapid speech, a fantastic mood, euphoric affect, flight of ideas, and no suicidal or homicidal ideation. Cognitively alert but impaired, he acknowledges his diagnosis but doesn’t believe he’s currently in a manic episode. His judgment is impaired, with recent impulsive spending and risky behaviors noted.

A: The patient presented with a known diagnosis of bipolar disorder. His present symptoms support this diagnosis based on the DSM-V criteria.

P: The patient was referred to a psychiatrist for pharmacotherapy adjustments and advised to resume cognitive-behavioral therapy for mood stabilization techniques. In two weeks, he is scheduled to return for another therapy session.

2. General Anxiety Disorder

Name: P.F.

Age: 51 years old

Gender: Female

Diagnosis: GAD

S: P.F., a 51-year-old female patient with a history of depression, reported increased anxiety and insomnia. Despite adherence to therapy, her symptoms worsened. She reports that life stressors, including the death of her mother, have overwhelmed her. Despite support from her husband, she is still grieving and has previously sought help from a psychiatrist.

O: The patient is well-groomed and cooperative and maintains good eye contact during an interview. She describes her mood as anxious and overwhelmed, with a tense affect. Her thought process is logical and coherent, with no evidence of delusions or hallucinations. She has good insight into her condition and seeks help.

A: The patient was diagnosed with GAD, supported by the DSM-V criteria.

P: The patient was advised to initiate cognitive-behavioral therapy to help her develop coping strategies and combat maladaptive thought patterns. Follow up in 4 weeks for the next psychotherapy session.

3. Insomnia

Name: T.E.

Age: 38 years old

Gender: Male

Diagnosis: Insomnia

S: T.E. is a 38-year-old male who reported to the clinic today experiencing challenges with both initiating and maintaining sleep. Two months before the current issue, the death of his sister triggered the problem. His inability to achieve sleep occurs at least one hour after he has retired for the night.

O: The patient is alert, well-developed, and nourished, with normal affect, good hygiene, and everyday mood. He maintains sound judgment, insight, and logical thought processes. His computation skills for basic mathematical concepts remain intact. His behavior aligns with expectations.

A: The patient’s diagnosis of insomnia was supported by the DSM-V criteria.

P: The patient was advised to improve sleep hygiene, but due to psychosocial pressures, bereavement symptoms, coping mechanisms, and depressive symptoms, grief counseling was deemed necessary. It was recommended that he attend the subsequent counseling session in two weeks.

4. Anorexia Nervosa

Name: D.D.

Age: 19 years old

Gender: male

Diagnosis: Anorexia Nervosa

S: D.D., a 19-year-old male with a history of anorexia nervosa, has experienced significant weight loss of 30 pounds over the past three months. He has been on and off psychotherapy, restricting food intake and exercising excessively. He expresses fear of weight gain and a distorted body image, believing he is overweight despite being underweight.

O: The patient, thin and appears older than his age, displays cooperative behavior but appears anxious and restless. He has a restricted affect, thoughts of weight, food, and body image, and no delusions or hallucinations. His perception is alert and intact, but he has limited insight into the severity of his condition.

A: The patient’s diagnosis of anorexia nervosa is supported by the DSM-V criteria.

P: The patient was started on cognitive behavioral therapy to promote mindful feeding. He was referred to a nutritionist for dietary interventions. Follow up in 4 weeks.

5. Major Depressive Disorder

Name: T.G.

Age: 21 years old

Gender: Female

Diagnosis: MDD

S: T.G., a 21-year-old female patient, has been experiencing persistent sadness, lack of interest in daily activities, and difficulty concentrating. She has a history of depression and has been on and off antidepressants. She has experienced poor sleep, decreased appetite, and a 12-pound weight loss over the past two months.

O: The patient is disheveled, withdrawn, and minimally engaged during an interview. She describes her mood as sad and empty, with flat affect. Her thought processes are logical but slowed, and she denies suicidal or homicidal ideation. She struggles with concentration and short-term memory. She acknowledges her depression and seeks help with fair insight and judgment.

A: The patient was diagnosed with MDD as per the DSM-V criteria.

P: The patient was advised to initiate cognitive behavioral therapy to combat negative thought patterns and enhance their coping mechanisms. Follow up in 4 weeks for the next psychotherapy session.

6. Separation Anxiety Disorder

Name: J.C.

Age: 10 years old

Gender: Male

Diagnosis: separation anxiety disorder

S: J.C., a 10-year-old boy, has been experiencing anxiety and distress since separating from his mother, significantly when dropped off at school. The issue has worsened over the past few weeks, with frequent nightmares and stomachaches, difficulty sleeping, and cries. His mother brought him to the clinic.

O: The patient is a well-nourished child who appears anxious and fidgety during an interview. He is cooperative but distressed when discussing separation from his mother. His speech is coherent and relevant, but he expresses fear of separation and worries about her safety. His cognitive functioning is alert, but he lacks insight.

A: The patient was diagnosed with separation anxiety disorder as per the DSM-V criteria.

P: The patient was advised to initiate cognitive-behavioral therapy, which would focus on anxiety management techniques, gradual separation exposure, and coping strategies. Follow up in 4 weeks.

7. Enuresis Disorder

Name: T.A.

Age: 8 years old

Gender: Male

Diagnosis: Enuresis Disorder

S: T.A., an 8-year-old boy with bedwetting tendencies, was brought to the clinic by his mother. He has been experiencing nocturnal enuresis, or involuntary urination during sleep, about three times per week for the past seven months. Despite attempts to limit fluid intake before bedtime and wake him up at night, these measures have not been successful.

O: The patients underwent a physical examination, which revealed a well-nourished, well-developed body. The abdomen was soft and non-tender, and the genitalia were normal. The patient was alert and oriented, with normal gait and coordination. The mental status examination revealed cooperative behavior, good eye contact, regular speech, euthymic mood, appropriate affect, logical thought processes, and no delusions or hallucinations.

A: The patient’s diagnosis of enuresis disorder is supported by the DSM-V criteria.

P: The patient’s mother was advised to implement behavioral interventions such as regular bathroom use before bedtime, reward dry nights, and consider a bedwetting alarm if none work after a month. Follow up in 4 weeks.

8. Obsessive-Compulsive Disorder

Name: L.P.

Age: 21 years

Gender: Female

Diagnosis: OCD

S: L.P., a 21-year-old female patient, has been experiencing obsessive thoughts and compulsive behaviors for the past two years. Her symptoms have worsened over the last seven months, and she spends 2 to 3 hours a day washing her hands and checking her locks. These behaviors significantly impact her daily life and work performance, and she feels distressed and exhausted by them.

O: The patient’s mental status examination revealed that she is well-groomed, cooperative, and restless. She has an average speech rate and volume but appears anxious and restless. Her thought process is logical but preoccupied with obsessive thoughts about contamination and safety. She has no hallucinations or delusions and is alert and oriented, with good insight and fair judgment.

A: The patient was diagnosed with OCD supported by the DSM-V criteria.

P: The patient was advised to initiate cognitive behavioral therapy, focusing on exposure and response prevention. Follow up in 4 weeks.

9. Schizophrenia

Name: G.D.

Age: 18 years old

Gender: Female

Diagnosis: Schizophrenia

S: G.D., an 18-year-old woman with a history of schizophrenia, was brought to the clinic by her father for psychotherapeutic options. She has been experiencing an increase in auditory hallucinations, often commanding her to perform distressing tasks. She denies visual hallucinations and has been non-compliant with her medication for the past month due to side effects like weight gain and drowsiness.

O: The patient’s mental status examination revealed poor hygiene, restless behavior, pressured speech, anxious mood, blurred affect, disorganized thought processes, auditory hallucinations, hearing voices, impaired concentration and memory, poor vision, impaired judgment, unable to make safe health decisions due to impaired concentration, memory, and awareness.

A: The patient presented with a known diagnosis of schizophrenia.

P: The patient was advised to initiate cognitive-behavioral therapy to manage hallucinations and enhance coping strategies and was referred to a psychiatrist for medication management. Follow up in 4 weeks.

10. Autism Spectrum Disorder

Name: S.G.

Age: 16 years old

Gender: Male

Diagnosis: Autism Spectrum Disorder

S: S.G., a 16-year-old male diagnosed with Autism Spectrum Disorder, has challenges in social interactions, engages in repetitive activities, and shows limited interests. Although his symptoms are stable, he has difficulties in social relationships, particularly in an academic setting. He has a profound interest in mathematics and dedicates considerable time to learning and resolving challenges. At now, he is not undergoing any pharmacological treatment.

O: The patient is well-groomed and agreeable but has difficulty with eye contact and verbal communication. The mental status evaluation reveals a restricted mood, challenges with social signals, and little verbal content, with no indications of hallucinations or delusions.

A: The patient was diagnosed with ASD as per the DSM-V criteria.

P: The patient was advised to monitor symptoms and social functioning, consider referral to a social skills group, and receive education on the importance of such training. Follow up in 4 weeks for the next psychotherapy session.