Sample Answer for PRAC 6635 WEEK 9 Clinical Hour and Patient Logs Somatic Symptom disorder S: S.E is a 35-year-old A.A female whose health record shows that she has had a chronic history of numerous physical complaints since her early 20s

Sample Answer for PRAC 6635 WEEK 9 Clinical Hour and Patient Logs

1. Somatic Symptom disorder

S: S.E is a 35-year-old A.A female whose health record shows that she has had a chronic history of numerous physical complaints since her early 20s. She has sought frequent medical treatment for the various physical complaints affecting multiple body systems. In the last five years, she has presented to her PCP with various vague symptoms such as muscle, joint, and back pains, abdominal pain, headache, altered bowel patterns, food intolerance, sore throat, and heavy menstruation. The client states that the physical symptoms have significantly impaired occupational and social areas of functioning.

O: The client is neat and appropriately dressed for the weather. She appears mildly anxious and maintains minimal eye contact. The self-reported mood is depressed,’ and affect is full range and appropriate.

A: Psychological distress with comorbid depression.

P: Continue with weekly CBT sessions.

1. Generalized Anxiety Disorder

S: W.D is a 34-year-old male client on follow-up for GAD. He was diagnosed with GAD after presenting with symptoms of excessive worry about his job. The excessive worry began after he got a job promotion to the editor-in-chief in a media company six months ago. He reports having immense pressure to perform and meet the job’s expectations. The client reported that she has been unable to control her worries for the past six months.

O: The client is neat and appropriately groomed. He is alert and oriented. He maintains adequate eye contact throughout the session. His speech is clear and he demonstrates a coherent thought process. GAD-7 score: 11

A:  Improved anxiety symptoms compared to the previous session.

P: Initiate Prozac 20 mg PO once daily.

1. Illness Anxiety Disorder

S: A.B is a 77-year-old client who presented with persistent preoccupation with having a severe illness that the PCP has not diagnosed. The PCP could not persuade her that she had no major illness even after conducting numerous diagnostic studies. The client’s preoccupation with having a severe illness began when she was diagnosed with PUD 7 months ago. She was prescribed Omeprazole, which has alleviated the symptoms. However, the client believes that the epigastric pain was due to stomach cancer since her father had the same condition.

O: The client is alert, oriented, and maintains adequate eye contact. The self-reported mood is nervous, and the affect is blunt. She is preoccupied with thoughts of having stomach cancer and beliefs that it might spread to her lungs.

A: The client has abnormal illness behavior. She has high anxiety levels.

P: Refer for psychotherapy for possible CBT and cognitive and exposure therapy.

1. Adjustment Disorder with anxiety

S: O.H is a 35-year-old female client referred for assessment after developing marked distress after losing her job in an insurance firm eight weeks ago. She reports facing difficulties adjusting to life after the job loss and considers it a major failure in her life. She also feels guilty for disappointing her employer, who had put much trust in her to do the job as expected. The client stated that in the past four months, she has had an excessive worry, anxiety, sleeping difficulties, and is constantly angry.

O: The self-reported mood is anxious, and affect is appropriate. She demonstrates a coherent thought process. No obvious obsessions, phobias, hallucinations, delusions, or suicidal ideations.

A: Disruption in social functioning. Occupational impairment.

P: Fluoxetine 10 mg PO OD.

1. Insomnia

S: A.D is a 42-year-old male who reports he has been having difficulty falling asleep at night for the last two months. He reports he stays awake almost throughout the night and denies sleeping during the day, being stressed, and taking drinks with caffeine. He reports he wakes up too early and does not feel well-rested after a night’s sleep. Additionally, he reports having daytime tiredness, making it difficult to pay attention and remember. He says that the symptoms have made him more irritable and anxious, with an increased propensity to errors.

O: The patient is alert, anxious and well-groomed. He is irritable and has a coherent thought process. His memory and judgment are intact.

A: The patient has insomnia and worries about his sleep pattern.

P: Initiate Fluoxetine 10 mg PO OD.