Clinical Hour and Patient Logs


Name: F.D

Age: 16 years old

Gender: Female

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Diagnosis: Schizophrenia

S: F.D. is a 16-year-old female who is being treated for schizophrenia. She was diagnosed with the disease five months ago and has been treated with medication and psychotherapy. She came to the facility today with her mother for her normal follow-up visits. The patient recounted being diagnosed with schizophrenia after exhibiting symptoms such as seeing imagined objects, hearing voices, and having disordered speech. The client also stated that the symptoms have adversely impacted her level of functioning in areas such as interpersonal relationships, schoolwork, and self-care. For more than five months, the symptoms continued. The patient denies using drugs or any other substance that may cause similar symptoms.

O: The patient was well-dressed for the occasion. She was focused on space, time, events, and herself. She denied having had any recent experiences with illusions, delusions, or hallucinations. She also denied any abnormalities in the content, volume, or tempo of her speech. She denied having suicidal ideas, intentions, or attempts. Her idea content was forward-thinking. She exhibited no aberrant habits such as avoidance of eye contact or tics.

A: The evaluation results suggest that the client’s symptoms have stabilized after improving. In addition, the client tolerates the pharmaceutical and psychological therapies employed to address her health issue. 

P: Recommend group therapy. Sessions of cognitive behavioral group therapy that focus on real-life plans, problems, relationships, and coping skills are advised.

Post-Traumatic Stress Disorder

Name: S.K

Age: 37 years old

Gender: Male

Diagnosis: Post-traumatic stress disorder (PTSD)

S: The 37-year-old patient arrived at the clinic with his girlfriend, complaining of nightmares and recurring recollections of the accident they had two years earlier. According to his partner, the patient has been angry and anxious since the accident. He did not seek medical assistance, however, until yesterday, when he was poised to fall from the rooftop of a towering building. Sleep deprivation, acute anxiety, aggression, social isolation, and emotional detachment are all symptoms. The patient denies having a family history of mental illnesses. He also denies experiencing hallucinations or delirium. He is not presently using any medicine to treat the symptoms.

O: The patient entered the room looking well-dressed. He appeared slightly preoccupied yet alert to person, time, and location. His mental process is sound, and he has enough short and long-term memory. He, on the other hand, fidgets a lot and shows indications of intense nervousness. He admits to having suicidal thoughts, although he has only attempted suicide once. He, on the other hand, denies delirium or hallucination.

A: According to DSM-V diagnostic standards, the patient qualifies for PTSD after a traumatic occurrence such as a vehicle accident.

P: Advise the patient to consider group cognitive behavioral therapy. Prolonged exposure therapy, as well as eye movement desensitization and reprocessing therapy, are also recommended to help regulate the patient’s PTSD symptoms.


Name: I.S.

Age: 18 years old

Gender: Male

Diagnosis: Insomnia

S: I.S. is an 18-year-old male patient who visited the psychiatric unit for a routine check-up. He had been diagnosed with sleeplessness around 8 months before the current appointment. He has been receiving individual psychotherapy to help him sleep. His difficulty falling and remaining asleep is the primary cause of his insomnia diagnosis. This has had a significant impact on his schoolwork since he is unable to concentrate for extended periods and appears to daydream the majority of the time. Therapy has not been beneficial, and he believes he requires medication to sleep better. He denies any previous history of mental illness. He denies having suicidal thoughts or intending to hurt himself or others.


O: The client appeared to be aware of time, location, and person. He demonstrates sound judgment. He, on the other hand, appears lethargic and has a short attention span. He makes an effort to keep eye contact. His short-term and long-term memory are both intact. Denies hallucination, delusion, and illusion. He does, however, admit to being melancholy recently, because his lack of sleep is impacting his career.

A: He is eligible for the diagnosis of MDD, which he has previously handled, according to the DSM-V diagnostic criteria. The main focus of this consultation, however, is on regulating the patient’s insomnia.

P: Propose cognitive behavioral group treatment, which teaches sleep hygiene and relaxation strategies to improve the patient’s sleep quality and duration.

Major Depressive Disorder

Name: M.S

Age: 31 years old

Gender: Female

Diagnosis: MDD

S: M.S., a 31-year-old African-American woman, was admitted to the psychiatric unit for examination. The patient believes she has PTSD because most military veterans are diagnosed with the same disease both during and after duty. She does, however, describe a history of depression in her early childhood, which she managed with antidepressant medication. She, on the other hand, stopped taking her medicine when she entered the army, fearing that she would not be enrolled. She, on the other hand, denies having nightmares. During the mental examination, the patient revealed symptoms such as difficulty sleeping, decreased appetite, crying bouts, decreased focus, decreased interest, social anxiety, and poor energy levels. The patient denies experiencing hallucinations or delirium.

O: The patient enters the examination room dressed sharply in age-appropriate casual wear. Her eye contact is great, and she answered questions well during the interview. She has a strong sense of location, person, and time. She talks clearly and with a typical tone and volume. Her understanding is consistent. She believed the method was acceptable for her age, with unremarkable judgment. Her long-term and short-term memories are both intact. She, on the other hand, is depressed and appears to be preoccupied most of the time. She admits to feeling useless but denies suicide intentions. She claims to be terrified to leave the house. Denies experiencing nightmares, hallucinations, or delusions.

A: According to the DSM-V criteria, the patient is diagnosed with MDD because he has dramatically diminished energy levels and interest in formerly fascinating activities. Sleeping difficulties, weight fluctuations, worthlessness, weariness, psychomotor agitation, and decreased attention are other symptoms.

P: Suggest to the patient that she try group cognitive behavioral treatment.  The patient will be able to adopt appropriate resilient skills to cope with depressive symptoms.

Conduct Disorder

Name: R.G

Age: 15 years old

Gender: male

Diagnosis: C.D.

S: R.G. is a 15-year-old Caucasian teenager who came to the clinic with her father after the school suggested that she undergo a mental examination. According to her father, she was taken home by her school principal after assaulting her class teacher, and she had to be assessed before returning to class. She said that her instructor had made an improper remark to her and that she wanted to retaliate against her for failing to complete her assignment. According to her father, she has been suspended four times in the previous 13 months for bringing a knife to school, hitting other pupils, and taking money away from other children’s backpacks. Her school performance has also dropped in the last year. When confronted about her behavior, she said that her stepmother irritates her at home and that she periodically leaves for several days as a consequence.  She was said to have bad interpersonal interactions, although she denied having suicidal thoughts, self-harming activities, substance misuse, or damage to herself or others.

O: R.G. is a young Caucasian girl whose appearance and age are consistent. She is clean and well-kempt, dressed suitably for the weather, and her nutritional state is normal. She has strong communication abilities, but she cannot maintain long-term eye contact, and she has somewhat diminished cooperation and concentration. She stated that she is in a pleasant mood, but her affect is limited and she is quickly upset. She has a rational thought process, and her speech was delivered at the appropriate level and tone, and it was readily understood. She denies hearing weird sounds or seeing things, and having suicidal/homicidal ideas, and there is no indication that she has delusional thinking. She has medium intellect, acceptable abstraction, intact memory, global intelligence, and a poor understanding of her circumstances.

A: The patient in the case study reported hitting her instructor, harassing her friends, constantly getting into physical confrontations, taking money from several other student lockers, bringing a knife to class, and having terrible interpersonal interactions which suggests the diagnosis of conduct disorder.

P: Group psychotherapy, like cognitive behavioral group therapy, focuses on problem-solving abilities, relationship development via conflict resolution, and learning techniques to reduce negative effects in their environment.

Bipolar Disorder

Name: D.R.

Age: 25 years old

Gender: Female

Diagnosis: Bipolar Disorder

S: D.R., a 25-year-old female patient, presented to the psychiatric clinic with a history of mood swings. She claims to have missed her dosages owing to forgetfulness. She has a history of hypertension and takes Trandate 100mg twice a day to control it. She denies any past suicidal thoughts.

O: The patient was well-dressed and dressed appropriately for his age. Throughout the interview, the patient maintains eye contact and proper facial expressions. Communicates clearly, with a regular tone and velocity of speech. Her mental process is reasonable and coherent. She denies having delusions, hallucinations, or suicidal thoughts. She admits to forgetfulness, but her long-term memory is intact. Her understanding is lacking. The patient’s capacity to recognize the repercussions of her behavior is restricted. Denies having suicidal thoughts or having a history of suicide attempts.

A: To qualify for BD diagnosis, the patient must exhibit at least three of the following symptoms: racing thoughts, talkativeness, loss of sleep, inflated self-esteem, easily distracted, and psychomotor agitation, among others. The patient demonstrated the majority of these symptoms, which met the criteria for a diagnosis of bipolar disorder.

P: Suggest talk therapy or cognitive behavioral group therapy. Discuss with patients how to overcome their troublesome feelings, attitudes, and behaviors during therapy sessions.

Anorexia Nervosa

Name: S.H

Age: 12 years old

Gender: Female

Diagnosis: Anorexia Nervosa

S: S.H. is a 12-year-old Caucasian female who was brought to the clinic because she had lost her appetite during the previous week. The patient states that he or she is unable to eat. When she attempts to eat, she complains of nausea and vomiting. She also claims to have lost weight in recent months as a result of her inability to eat. Fatigue, as well as pale and dry skin, are other symptoms. The patient has already taken multivitamins, which she believes are unhelpful. She has denied taking any other over-the-counter medicine to treat her present problems.

O: When the patient arrived at the clinic, she was well-dressed and dressed appropriately for his age. She is aware and focused on person, place, and time. Her mother’s activities are routine. During the interview, she is cooperative and talked in a clear and regular tone. Her disposition is depressed. She has a restricted appearance and exceptional perception and judgment. Her memory is intact, and her mental process is ordinary. Her functional condition, on the other hand, is somewhat degraded.

A: Based on the patient’s history, it is apparent that she has anorexia nervosa. She has pale and dry skin, indicating dehydration. She has also been unable to eat for the previous week, indicating that she has anorexia nervosa.

P: Assist the patient in developing healthy eating habits, identifying emotions, and developing coping strategies. Family counseling is often advised for support and to aid in the reduction of the patient’s guilt and despair caused by the eating problem.

Name: S.F

Age: 11 years old

Gender: Female

Diagnosis: Encopresis Disorder

S: S.F. is a healthy 11-year-old Asian girl with no noticeable intellectual disabilities or developmental delays. She, on the other hand, appears exceedingly humiliated and bashful as a result of her regular bowel movement accidents. She also had an accident on the bus recently on a field trip, which resulted in her friends laughing and ridiculing her. She was so upset as a result of this occurrence that she refused to attend school for the next two weeks. She also mentions a history of constipation. The patient denies having any additional health problems. She is not using any medications to treat her present problems. She had no prior hospitalizations. She admits to eating a portion of healthy food and exercising regularly.

O: A thorough abdominal examination was performed to assess the severity of the patient’s fecal impaction and gas buildup. The perianal region was also examined for changes in skin tone, deformities, or irritations. The sensory alterations in the perianal region and rectum were also evaluated using the digital rectal examination. Finally, the lumbosacral region was examined to rule out potential reasons such as spina bifida occulta. Except for severe constipation, all other results were normal.

A: Based on the patient’s narrative and physical findings, it is clear that chronic constipation is the root cause of her frequent bowel movements.

P: The treatment plan aimed to treat the underlying cause of the patient’s symptoms and promote the patient’s mental health which was impacted by this disorder. Family and group therapy are indicated to assist the kid to overcome encopresis-related shame, guilt, despair, and poor self-esteem.

Name: K.L

Age: 22 years old

Gender: Female

Diagnosis: GAD

S: K.L., a 22-year-old female, arrived at the department complaining of overwhelming worry and anxiety about the unknown. She had been suffering from severe anxiety and terror for some months. She was afraid she might die from an unknown source, and that her life was in jeopardy. Her overwhelming worry had made it impossible for her to focus on her studies. She also complained that she was often weary and that she lacked control over her excessive stress and anxieties. Extreme dread and anxiety were not caused by any medical ailment, medicine, or substance use or misuse. During her anxiety attacks, the client also reported experiencing chest aches and palpitations on occasion.

O: The patient appeared to be well-groomed. She was focused on location, time, and herself. The pace and volume of speaking were both normal. The patient’s mood was normal, with some anxiousness. The client denied having ever had hallucinations, delusions, or illusions. The client’s recollection was intact.

A: The findings of the mental state evaluation and the Generalized Anxiety Disorder 7-item scale (GAD-7) support a mild anxiety diagnosis.

P: Group Applied Behavior Analysis (ABA) is recommended to encourage desired behaviors and discourage unwanted ones to develop a range of talents.

Name: H.T

Age: 36 years old

Gender: Male

Diagnosis: Sexual Dysfunction

S: H.T. is a 36-year-old African-American male patient who came to the clinic with the primary complaint of sexual dysfunction. The patient has had this issue for some time and has been hesitant to take medicine. However, based on the advice of his primary care physician. He says he’d want to test Cialis to assist boost his erectile function. He claims that his sexual dysfunction has deteriorated over time and that he has been unable to acquire or sustain an erection half of the time he has engaged in sexual activity. Denies any history of testicular infection or groin injury.

O: The patient seemed healthy and uninjured on physical examination. The testicles drop bilaterally, with no signs of masses or inguinal hernias, according to a genitourinary examination.

A: The findings of the physical examination show normal testicles with no history of infertility or genital diseases. As a result, the patient was diagnosed with sexual dysfunction.

P: Sex therapy and cognitive behavioral group therapy can both assist with the psychological reasons for sexual dysfunction. Counselors can assist patients in overcoming fears, stress, anxiety, previous trauma, body image difficulties, and other factors that might prevent them from having a meaningful sex life.

Name: M.K

Age: 41 years old

Gender: Male

Diagnosis: AUD

S: M.K. is a 41-year-old Caucasian male patient sent by his supervisor to the clinic. The patient has a history of alcohol use problems and had been clean for quite some time until a gaming establishment opened in her area. His manager states that the patient even reports working inebriated and making a lot of noise, which disrupts other employees. He has not consumed alcohol in ten years. However, with the opening of a gaming establishment in the area, he has been unable to quit gambling, which promotes his drinking. He feels depressed and wants things might return to normal. He has also gained weight since resuming his drinking. He is concerned about losing his work but does not want to return to treatment. He denies any other comorbidities. He seldom exercises and consumes largely fast food. Denies suicidal thoughts or self-harming conduct.

O: The patient was dressed correctly for the visit. His orientation in terms of person, place, and time is complete. He did not exhibit any odd behaviors such as tics. His thought process and substance were suitable. He denied having had any recent hallucinations, illusions, or delusions. He also denied any homicidal thoughts or efforts.

A: The patient fits the diagnostic criteria for alcohol use disorder and gambling disorder as defined by the DSM-V.

P: Suggest to the patient that he or she try group cognitive behavioral treatment. Substance abuse support group sessions can also be beneficial to the patient. When the patient is ready, consider rehabilitation.

Attention-Deficit Hyperactivity Disorder (ADHD)

Name: D.M

Age: 12 years old

Gender: male

Diagnosis: ADHD

S: D.M. is a 12-year-old white male patient with a history of ADHD who was brought to the clinic by his mother for psychiatric evaluation and treatment continuation. He is well-versed in physical locations and times. The patient’s conduct has been horrible, according to his mother, since he began taking Trileptal. She verifies that the patient was furious, restless, argumentative, had sobbing outbursts, was oppositional, and even had periods of tumbling down.

O: A further mental evaluation was performed by the psychiatrist, who discovered that the patient is furious and despondent, and even cries at times throughout the examination. His influence varies just slightly. His energy level has decreased and he appears restless. His speech is age-appropriate, relaxed, and combative. He also thinks slowly but coherently. He occasionally shows indications of weariness with poor attention for a lengthy period. The patient has no memory problems since he recalls events correctly. Person, time, and place orientation are all intact. The patient shows no signs of causing harm to himself or others. He denies having suicidal thoughts, hallucinations, or deliria.

A: The patient had previously been diagnosed with ADHD and was given the necessary medication to treat the condition. However, based on input from the patient’s mother, the patient’s symptoms deteriorated, with higher occurrences of rage, restlessness, arguments, sobbing outbursts, and oppositional behavior, as well as experiencing times of falling.

P: Both pharmaceutical regimes and group psychotherapy will assist the patient. During group therapy, the patient will participate in a variety of activities that will help reduce ADHD behaviors while also increasing social skills using Cognitive Behavioral Therapy strategies.

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