Clinical Hour and Patient Logs PRAC 6665

Clinical Hour and Patient Logs PRAC 6665

Logs for Pediatric Clinic

Log 1

Date: Monday, June 12, 2023

Patient Number: PC 23567

Client Information:

Name: S.J.

Age: 16

Gender: Female

Visit Information:

Chief Complaint: S.J. visited the clinic at around 9:25 AM; the reason for the visit was an appointment with the pediatric psychiatrist regarding her monthly mental health check-up related to previously diagnosed pediatric depression. During the visit, S.J. was accompanied by her mother, P.J., and her nanny.

Practice Management:

The visit was to the Pediatric clinic. The overall check-up lasted for 45 minutes.

Diagnosis: Monthly check-up for pediatric depression. The patient scored 16 on the Children’s Depression Inventory-2 scale, indicating improvement.

Treatment Plan and Notes:

S.J., a 16-year-old female patient, presented herself to the clinic at 9:25 AM, accompanied by her mother, P.J., and her nanny. S.J. was diagnosed with pediatric depression four months ago and has been on combined pharmacological and non-pharmacological therapy for the last three months. She had visited the clinic to fulfil her fourth monthly mental health check-up related to the previous diagnosis of pediatric depression and ongoing medication and therapy management. S.J. did not report any concerns with the current treatment regimen; her mother noted that she had made major improvements.

During the visit, S.J.’s vitals, including blood pressure, heart rate, respiratory rate, and body temperature, were checked and noted to be within the normal ranges. She appeared well-groomed and well-dressed. She was also attentive and tried to connect with others in the clinic during her current visit as compared to her previous visits, in which she appeared shy and quite avoidant. She was well-oriented throughout the session and smiled from time to time. S.J. scored 16 on Children’s Depression Inventory-2 (CDI-2) test compared to the previous 28 scores on the CDI-2 scale. This is a notable improvement as compared to her initial assessment and the other preceding visits.

The S.J. will discontinue the fluoxetine dosage after completing the recommended 12-week medication period. However, she will be required to continue with cognitive behaviour therapy (CBT); she and her whole family will also attend five family therapy sessions. The family will also be required to continue providing a supportive environment to support S.J. throughout her recovery. The follow-up sessions will continue with the nanny, and S.J.’s mother will be required to be active in the sessions to provide support and reduce the risk of relapse.

Log 2

Date: Monday, June 12, 2023

Patient No: PC 23576

Client Information:

Name: D.M.

Age: 13

Gender: Male

Visit Information:

M. was brought to the clinic by his parents, Mr and Mrs M.M., at 12:30 PM. with complaints of erratic behaviour and being restless. He was also becoming more hyperactive than before.

Practice Management:

The patient visited the pediatric clinic and was transferred to the mental health clinic. The visit lasted for 65 minutes.

Diagnosis: Attention-deficit/hyperactivity disorder (ADHD)

Treatment Plan and Notes:

The 13-year-old male patient, D.M., was brought to the clinic by his parents, Mr and Mrs. M.M., with the complaint that D.M. had developed some erratic behaviours and became really restless over the one year. The mother reports that, although D.M. has been an active and always busy child, he lately seems to have increased activity, is much more active, and never seems to rest. The patient reports that he always forgets things easily and may sometimes forget his books or an activity that he is doing. He also fidgets a lot and reports that he can spend some time daydreaming of worlds beyond the world we see. The mother reports that she used to drink a lot of alcohol during D.M.’s pregnancy as she was undergoing a period of tremendous change in her life that stressed her significantly.

During the clinical visit, D.M. seemed to try a lot to restrain himself, but he had periods of restlessness and increased motor activity. His vital signs, including blood pressure, respiratory rate, and temperature, were within normal limits. However, he had an increased heart rate. Based on the symptoms presented and his health history, D.M. was preliminarily diagnosed with Attention-deficit/hyperactivity disorder (ADHD).

His treatment plan included a referral to the mental health clinic, as comprehensive evaluation was needed using standardized rating scales to help with the diagnosis and develop a full management plan for the suspected ADHD. An appropriate treatment and care plan will be discussed after a pediatric mental health specialist has confirmed the preliminary ADHD diagnosis. In the meantime, Mr. and Mrs. M.M. were provided information on ADHD and how to manage the child’s hyperactivity. A follow-up appointment was set to review the comprehensive evaluation results and discuss the recommended treatment plan. Top of Form

Log 3

Date: Monday, June 12, 2023

Patient No: PC 23593

Client Information:

Name: E.R.

Age: 12

Gender: Female

Visit Information:

R. was brought to the clinic by her mother after she had been growing more anxious about everything and sometimes had fast heartbeats, which were accompanied by increased sweating than she usually does. Today she had a panic attack which prompted her mother to take her to the clinic.

Practice Management:

The visit was at the pediatric clinic following a panic attack at 2:45 PM. The visit lasted for 40 minutes.

Diagnosis: Panic disorder

Treatment Plan and Notes:

The patient, E.R., a 12-year-old female, was brought to the clinic by her mother due to increased anxiety and symptoms of panic attacks. The mother reports that E.R. has been experiencing growing anxiety and occasionally has episodes of rapid heartbeats accompanied by increased sweating. Today, she had a panic-like attack as she sweat uncontrollably and her heartbeat increased, which led her mother to bring her to the clinic.

Throughout the visit, E.R. appeared visibly anxious and distressed and usually could talk of things that were not in existence in real life, indicating her disconnection with reality. Vital signs were taken and revealed an increased heart rate of 110 beats per minute and mild sweating. E.R. appeared tense and had difficulty maintaining eye contact throughout the evaluation period. She did not have any physical abnormalities as per the concluded examination. The symptoms and the observed signs were consistent with anxiety disorder. After the symptoms, signs, and health history were reviewed against the DSM-5 TR, E.R. was specifically diagnosed with a mild panic disorder.

The available treatment options, including the side effects of each option, were discussed with the parent. The mother gave her consent to proceed with the treatment, and a combined drug therapy, including fluoxetine and olanzapine, was selected. The dosage was started at fluoxetine 20 mg and olanzapine 2.5 mg to be taken orally once daily in the evening. A follow-up is suggested in which observations will be made, and the decision to increase or decrease the dosage will be determined by the symptoms presented after 14 days. E.R. and her mother were educated on anxiety and panic attacks and how these can be managed. E.R. was also referred to a private child psychiatrist for further assessment and management using psychotherapy. Top of Form

Log 4

Date: Tuesday, June 13, 2023

Patient Number: PC 24117

Client Information:

Name: J.S.

Age: 8

Gender: Male

Visit Information:

S. was brought to the clinic by his mother at 2:40 PM after developing severe breathing difficulties.

Practice Management:

The visit was at the pediatric clinic and lasted for 50 minutes.

Diagnosis: Childhood asthma

Treatment Plan and Notes:

J.S., an 8-year-old male, was brought to the clinic by his mother after he developed severe breathing difficulties. The mother reports that J.S. has some dust and smoke-related allergies. She notes that she lives in a flat apartment and recently has a new neighbour who smokes a lot late at night. Since the neighbour moved in a month ago, J.S. began experiencing persistent coughs and sometimes breathing fast. J.S. reports that he feels okay at school but experiences the symptoms after school.

J.S. was visibly distressed and had laboured breathing during the visit. The physical examination of his vitals showed his respiratory rate was elevated, and he exhibited wheezing upon auscultation. Oxygen saturation levels were measured and found to be at 92%, which is lower than normal. J.S. does not have any significant physical abnormalities as per the concluded examination. Based on the symptoms J.S. exhibits and the health history provided by the mother and the patient as well, the patient has been diagnosed with childhood asthma.

J.S.’s mother was provided with information on available treatment options, including the risks and side effects of each option. The mother agreed for the treatment to be started, and Beclomethasone was the agreed-upon medication. For the initial dose, the treatment was started with Beclomethasone with 40 mcg to be delivered orally through inhalation twice daily. A maintenance dose for future asthma management will be provided for two weeks. A follow-up appointment was planned for every week. Once J.S. achieves asthma stability, the dosage will be reduced to the lowest dosage possible and only be used based on need. The new neighbour’s late-night smoking habits seem to be the leading trigger for J.S.’s asthma attacks. It is important to eliminate the trigger on time to reduce J.S.’s exposure. The mother was advised to explain to the neighbour about J.S.’s condition and if he could reduce smoking in the house. The services of a social health worker will be available if needed. J.S.’s mother was also advised on how to manage the patient and how to eliminate possible triggers.

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Log 5

Date: Tuesday, June 13, 2023

Patient Number: PC 24120

Client Information:

Name: C.B.

Age: 7

Gender: Female

Visit Information:

B. was brought to the clinic by both her parents at 4:00 PM. after having difficulties falling asleep as she remained active past her bedtime.

Practice Management:

The visit was at the pediatric clinic and lasted for 40 minutes.

Diagnosis: Childhood insomnia

Treatment Plan and Notes:

7-year-old C.B., a female patient, was brought to the clinic by her father and mother due to the difficulties she has been having with falling asleep. The mother reports that she has difficulties putting C.B. to bed and having her fall asleep as she tends to become more active as her bedtime approaches which is set at 8 PM, and stays active past her bedtime. She notes that C.B. can stay awake and active up to 11 PM.

C.B. appeared alert and active during the visit and evaluation. She had no visible physical abnormalities during the examination. However, the mother notes that her father has been letting her take a sip of her coffee when he gets home at around 7 PM. He also lets her watch some television and funny videos on his phone. She reports that this has gone on for almost the last five months, which she suspects contributes to her difficulty falling asleep. She notes that they have argued over it, but the father insists that it is just a father-daughter thing. Based on the patient’s reported symptoms and the information provided by her parents, C.B. has been diagnosed with childhood insomnia. Coffee and other stimulating activities before bedtime are identified as the underlying factors.

All available options for managing C.B.’s sleeping difficulties were discussed with both parents. The mother notes that a friend had advised her to try using some sedatives she had given her. However, she was concerned about their safety. No medications are prescribed for C.B.’s conditions. The parents are educated on sleep hygiene. Accordingly, the father was advised not to give C.B. any coffee, let her use any electronic devices, or engage in any stimulating activities that interfere with her sleep routine. A strict bedtime routine was drafted, and music therapy was included in the sleep routine. The bedtime routine will include reduced exposure to electronic screens past 6 PM and playing soothing music in the house from 7:30 PM. The father was advised to try to be home early and bond with her daughter with storybooks as an alternative to using the phone. A follow-up appointment will be in two weeks. Medications will be prescribed if C.B.’s sleep does not improve after two weeks with the current intervention.

Top of FormLogs for the Geriatric Clinic

Log 1

Date: Wednesday, June 14, 2023

Patient Number: GC 56752

Client Information:

Name: J.D.

Age: 69

Gender: Male

Visit Information:

D. feels he has yet to do anything meaningful in his life; he feels unworthy of living and has been moody for the last one month. He presented himself to the clinic accompanied by his 25-year-old daughter at 10:00 AM.

Practice Management:

The visit and evaluation of the patient were at the geriatric clinic. The visit lasted for 50 minutes.

Diagnosis:

Major Depressive Disorder (MDD)

Treatment Plan and Notes:

J.D. is a 69-year-old male patient who presented himself to the clinic accompanied by his 25-year-old daughter. J.D. reports that he has been feeling that he has so far done nothing meaningful with his life and has a deep sense of unworthiness. He notes that he easily feels offended and is persistently in low moods. His daughter reports that J.D. has been persistently moody for the past month and has always grumpy for over three months.

J.D. appears openly sad and despondent and has visibly low energy. He had a flat affect, and his speech was quite sluggish. He reports that he is finding it difficult to fall asleep. His daughter reports that J.D. is increasingly refusing to eat, as he notes he has no appetite. Further analysis of the patient’s note shows that his psychomotor capacities are retarding while he is mostly lost in thought and with poor concentration throughout the evaluation. Physical examination did not find any physical abnormalities of concern. A review of J.D.’s symptoms and the health and medical history that was reported against the DSM-5 TR fulfil the diagnostic criteria for Major Depressive Disorder (MDD). The patient was diagnosed with MDD.

J.D.’s treatment will include both pharmacological and non-pharmacological therapy. Sertraline was prescribed. J.D. will take sertraline 50 mg once daily, majorly in the evening. The dosage will be adjusted based on the progress of the symptoms but should not exceed 200 mg per day. A referral to a mental health therapist is made as J.D. will need to be put under cognitive-behavioural therapy (CBT) two times a week for the next four weeks to improve his negative self-thinking and improve his ability to cope. J.D.’s daughter was educated on medication safety, managing her father’s symptoms, and any unintended drug outcome. A safety assessment will also be required to be concluded in the next seven days after J.D. starts using his medications to ensure he has a safe environment for recovery and that he does not pose a threat to himself and the other family members. The next follow-up appointment is scheduled after the next 14 days.

Log 2

Date: Wednesday, June 14, 2023

Patient Number: GC 56800

Client Information:

Name: S.K.

Age: 66 years

Gender: Female

Visit Information:

K. was brought to the clinic at 10:22 by her son and daughter-in-law with complaints that she talks of another person watching her. She also acts like she is living in a dream.

Practice Management:

The visit was at the geriatric clinic after being referred by their family doctor and lasted for 50 minutes.

Diagnosis: Depersonalization-derealization disorder

Treatment Plan and Notes:

S.K. is a 49-year-old female patient who was brought to the clinic by her son and daughter-in-law following concerns about her physical and mental health. The son reports that S.K. has been talking in a very confusing way several times. He notes that his mother has been talking about another person who is like her and has been watching her for a while now. She says that she is usually watching herself like there is a mirror. She has also been acting as if she is living in a dream-like state. She also usually has episodic panic attacks after she gains some bit of herself back.

Although S.K. tried hard to act like herself during the evaluation process, she was openly detached from the event, and major depersonalization and derealization symptoms were identified. She thought they were at a wedding, and she was watching her husband marry another “S.K.” when her son and daughter-in-law were seated across the room. She has no other physical abnormalities of concern besides her diagnosed diabetes which she manages with prescribed medications and diet. As per the DSM-5 TR and the presented symptoms and reported health history, S.K. was diagnosed with Depersonalization-Derealization Disorder.

S.K. was put under a combined medical medication involving Sertraline (Zoloft) and Clonazepam (Klonopin). She will take Zoloft 50 mg once daily, whether in the morning or evening, for the next 14 days. She will also take Clonazepam 0.5 mg as needed in case of a severe panic attack. However, the clonazepam dosage should not be administered more than two times within 24 hours. Additionally, S.K. will be required to attend bi-weekly cognitive-behavioural therapy (CBT) in addition to her medication to improve the depersonalization and derealization symptoms. Besides these, the family members were educated on how to reduce triggers for related symptoms and manage her conditions to recover. The next appointment is scheduled after the next 14 days or in between as needed.

Log 3

Date: Wednesday, June 14, 2023

Patient Number: GC 56893

Client Information:

Name: K.A.C.

Age: 67 years

Gender: Male

Visit Information: Top of Form

A.C. visited the clinic at 3:35 PM after having almost life-like dreams and experiences that left him feeling afraid. His two sons accompanied him.

Practice Management:

The case was at the geriatric clinic but referred to the geriatric mental health unit. The visit lasted for 50 minutes.

Diagnosis: Posttraumatic stress disorder (PTSD)

Treatment Plan and Notes:

K.A.C. is a 67-year-old male patient who was presented to the clinic accompanied by his two sons. K.A.C. reports that he has been experiencing some strange dreams and experiences for a while. However, of late, these dreams and experiences are almost life-like and leave him feeling afraid. His sons note that he sometimes shouts and begs for his life in his sleep. Small knocks shock him, and sometimes he is ready to fight. K.A.C. is a former U.S. Army officer deployed six times during his service years. He notes that he was captured and held as a prisoner of war post-Gulf War between 1991 and 1993. The current symptoms have been severe since they were attacked by armed robbers at their house two months ago, and K.A.C. was held at gunpoint.

K.A.C. was openly anxious and distressed throughout the evaluation. He said he feels his old nightmares are back and real this time. He notes that there are some people out to detain him. He is majorly hypervigilant. Besides his previously diagnosed high blood pressure (HBP) and type 2 diabetes mellitus (T2DM), K.A.C. has no other health or mental concerns. From the symptoms presented and reports on health history, with reference to the DSM-5 TR, K.A.C. is diagnosed with posttraumatic stress disorder (PTSD).

After a review of his current health status and medication, Sertraline (Zoloft) and prazosin were prescribed to help K.A.C. manage his PTSD episodes. K.A.C. is put on Zoloft 50 mg to be taken orally once daily. The medication will be titrated based on how the symptoms respond to the current dosage as well as how K.A.C. tolerates the medication alongside his current hypertension and T2DM medication plan. He will also use prazosin 1 mg taken orally once daily before bedtime to help with his blood pressure. The prazosin dosage can be gradually increased to 4-12 mg dosage based on how K.A.C.’s blood pressure responds to the medication and how well he tolerates the dosage. K.A.C. will be required to adhere to the T2DM treatment plan. His sons were educated on how to manage and care for their father and were informed of the right medication administration strategies to avoid cases of reactions and adverse unintended outcomes. All related medication risks and side effects were also clearly explained while emphasizing the need to report any reactions to the dosages. For all dosage increases or reductions, the family will be required to consult a specialist and report the progression of the symptoms. K.A.C.’s next appointment is scheduled in the next 14 days at the Geriatric Mental Health Unit.

Log 4

Date: Wednesday, June 14, 2023

Patient Number: GC 56902

Client Information:

Name: D.J.

Age: 63 years

Gender: Male

Visit Information: Top of Form

J. presented himself to the clinic at 4:45 PM with complaints of not living his sex life as desired.

Practice Management:

The visit was at the geriatric clinic and lasted for 30 minutes.

Diagnosis: Erectile dysfunction (ED)

Treatment Plan and Notes:

D.J., a 63-year-old male client, presented himself to the clinic with concerns regarding his current sex life. He notes that he got married to a 48-year-old lady two years ago, six years after his first wife died in a car accident. D.J. reports that he has been having a good sex life for the last year. However, he complains that he no longer performs as he used to in the last five months as his penis fails to harden enough for an erection. He notes he has tried some herbals he bought at a farmer’s market he had been advised by his male friend, but these also failed to maintain his erection.

D.J. appears anxious and distressed while discussing his sexual health and sex life concerns. He reports his major concern is failing to satisfy his wife and her looking for pleasure in other young men. His vitals are a bit elevated, and he is currently under high blood pressure treatment. He had been drinking a lot of alcohol before he met his current wife though he is working on his alcohol consumption. From the presented symptoms and D.J.’s health history, he has been diagnosed with erectile dysfunction (ED).

Sildenafil (Viagra) was diagnosed for D.J.’s ED. He will be required to take the medication at 50 mg an hour before he engages in any sexual activity with his wife. He should not take the medication unless he wants to have sex. The drug dosage will be adjusted as needed and as his ED symptoms progress, as well as how well he tolerates the drugs after a couple of times of use. D.J. was also educated on erectile dysfunction and how age and HBP can lead to ED. He was also educated on the risks of using Sildenafil at his age and with his current HBP status. He is required to cut on the alcohol further and tell his wife that he will be using Sildenafil for sex. He will also be required to remain active daily. He clearly expressed his understanding of the treatment plan. D.J.’s next appointment is earlier advised on Tuesday, June 20, 2023, at 11:00 AM. He is required to report any unintended symptoms and experiences with the use of Sildenafil within the next two uses. Top of Form

Log 5

Date: Thursday, June 15, 2023

Patient Number: GC 56911

Client Information:

Name: C.B.J.

Age: 73 years

Gender: Female

Visit Information: Top of Form

B.J. visited the clinic at 9:00 AM. accompanied by her daughter and grandson, complaining that the medications prescribed five days ago were ineffective in managing her sleep issues.

Practice Management:

The visit was at the geriatric clinic and lasted for 20 minutes.

Diagnosis: No diagnosis was made.

Treatment Plan and Notes:

C.B.J., a 73-year-old female, was presented to the clinic by her daughter and grandson with complaints that C.B.J. feels that the medications she was using were not effective enough. C.B.J. had a Flurazepam prescription five days ago to help her manage her diagnosed insomnia. She is currently using Metformin and diet therapy to help manage her Type 2 Diabetes.

C.B.J. appeared a bit fatigued during the examination and reported that she still found it hard to fall asleep for the most part of the night. She feels frustrated and concerned that the medications she was prescribed do not work and wants a replacement. She has no other concerns as of this day of examination. Despite C.B.J.’s symptoms and concerns, no new diagnosis was made during this visit.

For the treatment plan, C.B.J. will remain under the current medications for insomnia as well as the non-medical interventions that were previously discussed, including remaining active, taking the medications correctly and at the right time, as well as observing her lunch and dinner times and the times she takes her diabetes medications. The current regimen for insomnia will not be reviewed, and she will continue with the Flurazepam 15 mg taken orally once a day shortly before her bedtime. In case her symptoms do not improve, the medications will be reviewed, and the dosage will be increased to 30 mg only if need be. Her next appointment will be at the geriatric clinic on Thursday, June 29, 2023, at 9:30 AM. However, if there are other concerns over the efficacy of the current medications, she will be required to visit the clinic as needed

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You must record at least 80 patients by the end of this practicum. You must record at least 80 patients by the end of this practicum. You must see at least 5 pediatric/adolescent patients and 5 adult/older adult patients.

The patient log must include the following:

Date
Course
Clinical Faculty
Approved Preceptor
Patient Number
Client Information
Visit Information
Practice Management
Diagnosis
Treatment Plan and Notes — Students 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.