Patient Logs Discussion Paper

  1. A 14 year old female presents to the clinic accompanied by her mother. She shows signs of restlessness and a sluggish movement response. The mother complains that the patient “has been unwilling to talk and appears very sad.” She seems restless and winces in her seat on a regular basis. Occasionally refuses to speak for many hours. Diagnosis: 1- Catatonia. Treatment plan: electroconvulsive therapy and lorazepam (30mg per day).
  2. A 34-year-old woman comes to the clinic with her spouse. The husband reports “my wife has been having suicidal thoughts and has lost appetite in the last week.” She was prescribed Tylenol 650 mg PO Q6 PRN and cognitive behavioral treatment after being diagnosed with F41. 9- Anxiety disorder. Patient Logs Discussion Paper

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  1. An 18-year-old female with an eating disorder arrives at the clinic. She reports “I have become much concerned about my looks and I have been trying to lose weight.” She has a range of alarming delusional thoughts regarding food, her physical attractiveness, and how others view her. Her inner voice constantly reminds her that she is “big” and that losing weight will make her life so much better. Diagnosis: F50.00 Anorexia nervosa. Treatment plan: Family-based therapy and nutritional education Patient Logs Discussion Paper
  2. A 29-year-old man accompanied by his sister presents with psychotic symptoms. The sister claims the patient “has been having hallucinations and looks sad all the time.” The patient was bullied at school in the past. Patient had anxiety and sadness prior to the delusions and hallucinations. The patient had echopraxia, expressive aphasia, and body swaying throughout the session. In addition, the patient is indifferent and has delusory allusions. His arms and legs have bruises and wounds. The patient grew hostile and belligerent throughout the session. Diagnosis: 9- Schizophrenia. TX plan: Clozapine and risperodine medications.
  3. A 48-year-old female comes to the clinic. She works as an office clerk and is a mother of four children. She just quit using conjugated estrogens and has had no trouble dealing with the withdrawal symptoms. She claims “I am always tired almost all the time and I have lost interest in my usual activities.” She has started overeating as a result of boredom. She has lately added weight due to these changes. Diagnosis: F33. 0- Major depressive disorder. TX: Cognitive behavioral therapy and mood stabilizers.
  4. A 34-year-old man with complaints of “I have been losing weight and having sleeping problems.” He also reports being isolated and inactive. His symptoms began last year when his spouse was diagnosed with cancer and worsened when she passed away two months later. The emphasis of the conversation was on what he liked about his spouse and his memories of her. Diagnosis: F43. 10- PTSD. TX plan: Zoloft and CBT.
  5. A 32-year-old female comes to the facility with a history of neurocognitive disorder. She was brought in by her friend, claiming that “she has been unable to care for her since she tends to forget things and is incapable of performing daily activities”. Diagnosis: 81- Major Neurocognitive disorder: TX plan: cognitive behavioral therapy.
  6. A 27-year-old man who is sleep deprived and overweight presents to the hospital. He claims “I gamble too much and it’s affecting my life.” Client had a history of smoking and substance abuse, but had stopped two years earlier. When the client loses a game, he is reported of violently abusing his wife and kids. Diagnosis: 0-Compulsive Gambling Disorder. TX plan: distractions and techniques for dealing with and managing his irrepressible drive to gamble as well as his rage problems Patient Logs Discussion Paper
  7. A 35-year-old male with anger issues is accompanied by his wife to the clinic. His wife reports “my husband has been getting easily angry over petty stuff.” He was diagnosed with  9- Impulse control disorder. Supportive psychotherapy was used to talk about the family issues. Anger management programs for the patient were recommended, and also open communication, and avoidance of distress triggers.
  8. A 20-year-old female visited the facility following her parents’ divorce. Her mother joined her on the visit and mentioned “my daughter has been worrying too much.”  Diagnosis: 9- Anxiety disorder. TX plan: CBT and Zoloft 25mg per day.
  9. A 57-year-old man is presented to the clinic by his son. The son states “my dad’s mental abilities have been deteriorate over the last month.” These alterations have been gradual, but they seem to be becoming worse.  Sometimes, he appears alert, but at times, he appears confused, unhappy, and sad. Diabetes and heart disease are discovered in his medical information. He was diagnosed with 81- Neurocognitive disorder. The patient began CBT.
  10. The patient is a 42-year-old man with complaints of “I have been drinking too much because of stress.” He has had anxiety problem and sadness in the past. Diagnosis: F10.10- alcohol abuse disorder. The session focused on stress and anxiety coping techniques with the aims of boosting mood, limiting outbursts, and minimizing drug abuse.
  11. A 27-year-old woman comes to the clinic. She reports “I have become constantly worried of saying or doing anything that may embarrass me.” She went to the doctor who referred her to a specialist, who prescribed anti-anxiety medication. She has just begun taking higher doses than instructed, and she intends to gradually increase the amount each week since she may not feel well on lower doses.  Diagnosis: 280- Medical Induced Anxiety Disorder. The patient was prescribed sertraline and told to return to the clinic in two weeks Patient Logs Discussion Paper
  12. A 38-year-old female reported to the clinic with a 7-month experience of anxiety symptoms such as restlessness, weariness, reduced attention, sleep disruptions, fatigue, vomiting, nausea, and joint pain. She reports “I’m worried my fiancé might fall ill or have an accident while going to work.” Her health issues prompted her to miss a lot of work, which generated a lot of problems.  She was diagnosed with F41.1- Generalized Anxiety Disorder and placed on talk therapy.
  13. A 30-year-old woman comes to the facility complaining of “I am stressed all of the time and worry about everything.”  She considers herself as a “worrier” who has always been anxious, but her worry has become considerably worse in the last year since her parent’s illness and she no longer controls her thoughts. When she’s anxious, she becomes tense in her legs, stomach, and shoulders, her heart accelerates, and she has trouble breathing. She has trouble falling asleep and many awakenings owing to anxiety. She appears irritated and exhausted. She does not consume any alcoholic drinks. She was diagnosed with F41.1- Generalized Anxiety Disorder. TX plan: Carry on with CBT.
  14. A 32-year-old female presents with complaints of “I have been battling deep sadness, sleep difficulties, and weight gain.” The patient is diabetic and takes metformin on a regular basis. She has had suicidal ideation, drug abuse, and hospitalizations in the past. HgbA1c and a renal panel were ordered. Diagnosis: 9- Major Depressive Disorder. TX plan: CBT and Zoloft
  15. A 26-year-old male presents to the clinic accompanied by his brother. The brother claims that the patient “has been horrifying instances involving individuals falling from the World Trade Center, since the 9/11 attack. Since then, he’s experienced nightmares. He feels obliged to evacuate to a safe location when an airplane flies above. He is considering relocating from New York since he keeps reliving the events of 9/11 every time he sees the attack scene. He was diagnosed with F43. 10- PTSD and began group therapy.
  16. A concerned roommate brings a 17-year-old male to the facility, reporting “my friend recently been hiding in his bedroom.” The patient informed his roommate that the authorities had the ability to listen in on everything he says in any place other than his bedroom. His roommate also noted that the patient has been unable to work because he is depressed and anxious. He also mentioned that he has been smoking a lot of marijuana than normal. He was diagnosed with 94- Substance-Induced Depressive Disorder and began talking therapy immediately.
  17. A 23-year-old college student is presented by a roommate who reports the client “has begun wrapping the room with aluminum foil.” He suspects that the neighbors have been eavesdropping in on his phone conversations and uses that cover to prevent them from doing so. He has stopped going to classes and interacting with his colleagues. Diagnosis: 9- Schizophrenia. TX plan: group therapy Patient Logs Discussion Paper
  18. A 31-year-old woman presents with sleeplessness, tiredness, and an irregular heartbeat. The patient suffers from anorexia. When her spouse left her, she developed anorexia. “Not eating helps me appear better…and so I won’t become envious of his new partner, I’m insecure,” the patient claims. Hospitalization due to severe dehydration and low blood pressure in the past. A blood test was conducted, and the results were abnormal. Diagnosis: Diagnosis: F50.00 Anorexia nervosa. Treatment plan: Family-based therapy and nutritional education.

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  19. A 28-year-old woman comes to the facility reporting; “I have knee pain and low back discomfort occasionally”. The patient seems unable to recall the cause of the pain. She reports she has trouble falling asleep and is unable to get a full night’s rest. She sometimes refers to herself as “restless,” which she attributes to a lack of sleep. She states she is always worried about her educational outcomes, profession, and her sister’s well-being, who was just diagnosed with Leukemia. The patient complains of getting up in the middle of the night with a twitchy headache that lasts a few hours. She is tense and uptight for the majority of the day. Diagnosis: F41.1- Generalized Anxiety Disorder. TX plan: CBT and Lexapro.
  20. A 22-year-old woman was diagnosed with nymphomania by her former psychiatrist last year presents to the facility. Childhood background of rape and abuse. The patient’s condition did not improve as a result of her medication, and she said that her “my sexual cravings are stronger every day.” The client is single and lives alone in a flat. She has past drug overdose admissions.  The purpose of the session was to define the patient’s sexual urges and devise distraction activities to assist her shift her focus when her sexual wants surfaced. Diagnosis: F32.9- Depression. TX Plan: Psychotherapy and enhanced antidepressant and antipsychotic drug dosages Patient Logs Discussion Paper
  21. A 29-year-old female comes to the clinic accompanied by her spouse, who is concerned about her drinking. He reports “I noticed she is always carrying a drink, and when I ask what it is, she says lemon juice or soda, but I fears she’s combined alcohol with those beverages”. She just had a DUI, and he confronted her about her drinking, after which she promised to abstain. He discovered she was still frightened, tense, and irritable when she eventually stopped drinking. Diagnosis: 2- Alcohol dependence. TX plan: She was advised to consult a therapist and to quit engaging in actions that trigger the desire to drink.
  22. A 19-year-old visits the clinic stating; “I experience manic episodes that has resulted in me sleeping less”. He has developed a number of high-risk behaviors, including binge drinking and engaging in sexual relations in a manner he has never been before. Diagnosis: 9- Major Depressive Disorder. TX plan: CBT and Zoloft
  23. A 25-year-old woman comes to the facility stating that; “I frequently feel pain in my knees and the lower back”. The patient seems unable to recall the cause of the pain. She reports she has trouble falling asleep and is unable to get a full night’s rest. She sometimes refers to herself as “restless,” which she attributes to a lack of sleep. She states she is always worried about her educational outcomes, profession, and her sister’s well-being, who was just diagnosed with Leukemia. The patient complains of getting up in the middle of the night with a twitchy headache that lasts a few hours. She is tense and uptight for the majority of the day. Diagnosis: F41.1- Generalized Anxiety Disorder. TX plan: CBT and Lexapro.
  24. A 24-year-old female presents to the facility with her friend with a history of non-suicidal self-injury, predominantly scratching her arms and legs, dating back to puberty. The friend states; “She tried suicide twice, first as an adolescent and again 6 months ago through overdose of prescription pills, but she still has suicidal ideation and claims that thinking about death as a remedy gives her solace”. Diagnosis: 3- Borderline personality disorder. TX plan: behavioral therapy Patient Logs Discussion Paper
  25. A 37-year-old woman comes in with a history of anxiety. She states; I have been incapable of working for the last 4 years due to severe anxiety”. She has pursued non-facilitated self-help and had many consultations with a family practice psychiatrist, all of which he believes were ineffective. Diagnosis: F41.1- Generalized Anxiety Disorder. TX plan: CBT
  26. An 18-year-old male presents to the clinic with concerns that; “The campus security and local policemen are following me and spying on me”. His internet connection is occasionally slowed, which he believes is evidence that surveillance systems are interfering with his gadgets. His anxiety is interfering with his capacity to do his academic work, and his classmates are concerned. Diagnosis: 9- Schizophrenia. TX plan: Cognitive Behavioral Therapy.
  27. A 27-year-old woman presents with weariness, melancholy, and malaise. The patient states; “I have trauma memories have caused me to struggle with a new relationship”. Abuse history. There is a manifestation of paranoia. Diagnosis: 10- PTSD. The purpose of this session was to characterize and explore the definitions, implications, and aims of healthy relationships, as well as psychoeducation. Weekly counseling and pharmacological therapy to manage paranoia, sadness, and persistent memories are part of the treatment regimen.
  28. A 29-year-old presents to the clinic with complaints of; “I continuously feel nervous and fatigued, I rarely sleep, have hallucinations on a daily basis, and am worried about my employment”. He describes himself as someone has been “easily stressed” in the past. He saw a psychiatrist at college for a few appointments when he was worried about his exams and found it helpful. Apart from that, he has never been prescribed medicines for mental illness. He was diagnosed with F41.1- Generalized Anxiety Disorder. TX plan: CBT.
  29. A 23-year-old male with a smoking habit came to the clinic. He claims; “My friends and I have been smoking since they were teenagers. Following an examination and review, CBT was suggested. The patient was also advised to attend a weekly smoking cessation community counseling program. Diagnosis: Z72.0- Tobacco Use. TX Plan: CBT
  30. A 21-year-old female comes to the office, reporting; “I always feel worried”. She claims the problem started while she was studying for her final examinations and was incapable of coping because of nervousness. Despite her ambition to continue her education, she was afraid she would not be able to handle the workload and dropped out at the age of 17, disappointing her family. She claims she cannot make decisions as she is afraid of what would happen if she makes an improper decision. She admits to feel irritated as well, but she does not have suicide thoughts. She was diagnosed with F41.1- GAD and TX Plan; Relaxation techniques and CBT.
  31. A 58-year-old man who is a heavy drinker and a smoker presents to the facility. 7 months ago, the client developed end-stage renal illness, and 4 months ago, pneumonia and asthma. He is on a three-times-a-week dialysis schedule. Two unsuccessful marriages and a company that went bankrupt in the past. The patient lives alone in the residence and has no close relations. “When I feel lonely,” the patient said, “drinking and smoking are my comforting techniques.” Diagnosis: F32.9- Depression TX Plan: Counseling and medication treatment to address loneliness and change coping mechanisms  Patient Logs Discussion Paper
  32. A 22-year-old female states that; “I feel weary, I have gained weight, I have sleep issues, and a lack of desire in activities”. She says she has never had any suicidal ideation. Diagnosis 00- Insomnia, TX Plan: She was prescribed Lunesta 1mg once day at night. She was told to come back in a week.
  33. A 24-year-old female complains; “I feel fatigued all of the time and have put on weight because of eating due to loneliness”.  She reports sleeping problems, a loss of happiness in her life, and a belief that her existence has no meaning. Denies having had any suicidal thoughts. Diagnosis: F32.9- Depression TX Plan: Counseling and medication treatment to address loneliness and change coping mechanisms.
  34. A 35-year-old woman presents to the clinic with constant fidgeting. She seemed to have a short attention duration and kept talking. She claims; “I have regular masturbation and am always concerned about vaginal cleanliness. Diagnosis: 1- obsessive compulsive disorder. TX plan: propranolol 40 mg per and exposure and response prevention (ERP).
  35. An 18-year-old male reported to be vivacious and talkative. He said that; “I only sleep two hours every day and am not weary throughout the day”. He stated he was depressed after a breakup two years ago. He has had several sexual partners and has been an alcoholic for the last two years. Diagnosis: F32.9- Depression. TX Plan: He was prescribed drugs to help him control his manic episodes, as well as cognitive behavioral therapy Patient Logs Discussion Paper
  36. A 36-year-old man reported “I hear voices and have lost my appetite for the previous ten months”. Her younger brother stated that their mother and sister were occasionally physically abused by the patient. Patient additionally said that he got the impression that others around him were trying to harm him. He was once observed wandering about town for two days without returning home. There is no history of mental illness in his family. Diagnosis: 9- Schizophrenia. TX plan: olanzapine, ketamine, and diazepam.
  37. A 21-year-old woman reported; “I feel irritated and unable to control my thoughts”. She says she has trouble sleeping and has regular dreams about the attack she had a month ago. She also experienced disturbing dreams of her attacker on a regular basis. Diagnosis 00- Insomnia. TX Plan: The patient will need cognitive processing psychotherapy for 14 weeks, including 70-minute weekly meetings.
  38. A 37-year-old woman complains;” I constantly worry and it is interfering with her ability to operate”. She had earlier been diagnosed with 1- Generalized Anxiety Disorder TX Plan: Synthroid, Buspirone, Ambien, and Paxil among other psychiatric drugs. The objective is to change drug doses while evaluating side effects each week for one month, as suitable for anxiety disorder.
  • 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.

USE THIS FORMAT

Your BRIEF Meditrek Documentation should include the following information:

Chief complaint ( in patient or parent’s words) Patient Logs Discussion Paper

-HPI or Visit Information- start by identifying the patient, for example: ” 8 y/o white boy … reason for visit..

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-Diagnosis: to include the ICD 10 code. For example, DMDD- F34.31

-Treatment plan to include pharmacological and non-pharmacological interventions.

Please include 4-5 patients per page just short and simple . you can turn in at different intervals, don’t need all at the same time. Just turn in pages as they are completed.

Please log more children and young adults

You can use psych disorders from this list

Adjustment disorder

Anxiety disorder

Dissociative disorder

Eating disorder

Impulse control disorder

Mood disorder

Neurocognitive disorder

Neurodevelopmental disorder

Personality disorder

Psychotic disorder

Sexual disorder

Sleep disorder

Somatoform disorder

Substance Related and Addictive disorder

Trauma and stress related disorder Patient Logs Discussion Paper