Psychotherapy

1

Subjective:

CC (chief complain): ADHD

HPI: The patient is a 48-year old female who has difficulties concentrating and sleeping. The patient holds a degree in law and works in a law firm. The patient is also a member of the LGBTQ, often goes for casual dates, and he has no children. The patient has a good appetite and often sleeps for four to six hours. The patient also reports having difficulties with attention and delayed recall. However, she denies having a history of drug use but enjoys smoking and taking scotch drinks over the weekends. The patient has no fever. she has a history of HTN blood pressure which is often controlled by losartan.

Reflections

The patient is calm and able to answer most of the questions accordingly. However, I noticed that the patient became nervous and hypersensitive, which hindered the in-depth collection of information, especially about her family. Indeed, I faced some communication barriers which hindered the adequate collection of information. Being my first time collecting patient data from this patient, I didn't know how to approach a patient who was restless. When presented with a similar situation in future, I will employ therapeutic communication strategies to make the patient feel safer, confident and comfortable. Therapeutic communication strategies will aid in calming hypersensitive patients hence making them comfortable to engage fully in the conversation (Donovan & Mullen, 2019).

2

Subjective:

CC (chief complain): Schizoaffective disorder

HPI: P.T is a 26-year-old male patient who presents psychiatric evaluation for Schizoaffective disorder. The patient mother is concerned about her son’s lack of sleep and A/H.The patient stays up all night once a week though he reports that he enjoys staying up all night. Pt has been skipping his medication and whenever he has a seizure and bangs his head on the floor. This trend has had a detrimental impact on patient well-being The patient also reports having aurora before seizures. The patient often hears voices, and he is currently placed on medication to treat the condition. However, He is not comfortable with IM DM medication.

Reflections:

When presented with a similar situation, I will employ therapeutic communication to comfort and create an environment that will enable the patient to share their vulnerabilities and fears. I will gather sufficient information about the patient family, including the history of the disease in the family since schizophrenia tends to run in families. Considering the social determinants of health that impact mental health, such as socioeconomic factors and social support networks, I will recommend the patient connects with friends and peers in their social support networks. This can help their ability to cope with stressful situations and alleviate the impact of mental illnesses (Reitz & Scaffa, 2020). I will also teach about self-help strategies such as maintaining a balanced diet, relaxation techniques, and daily exercises, which help improve overall health outcomes.

3

Subjective:

· CC (chief complain): Schizoaffective disorder

· HPI: A,L is a 35-year-old male who presents Schizoaffective disorder depressive type, Post tramatic stress syndrome (PTSD). The client notes that his medication is working and has no psychological concerns or issues. He is compliant with his medication regime and reports no adverse side effects. However, he is delusional at this time. “My medications are working. I don’t have any psychological questions or issues. I’m doing good. I was doing some research and I found out that modern western philosophy it came from allegorical alchemy that came from the kabala. I found that interesting about how the world works. You Know?”

Reflections:

When presented with this scenario, therapeutic communication was used to help comfort the client and create an environment enabling the client to share vulnerabilities and experiences (Siregar et al., 2021). Furthermore, the client was calm and oriented to the situation. The client revealed his delusions in great detail. However, the doctor did not have any difficulty gathering much of the required information to inform the diagnosis. The DSM-5 diagnostic criteria for schizoaffective disorder include delusional thinking. Thus, given a similar situation, the focus will be to create an environment that encourages the patient to share their thoughts as much as possible. In this assessment, adequate client data was collected including the client’s psychiatric history and his family psychiatric history. The lack of adequate client data can skew the accuracy of the diagnosis. Gathering sufficient data can improve the precision of diagnosis and inform the suitable treatment intervention. The client’s current mental state is possibly as close to his baseline as he will achieve. However, He currently has no domestic issues or problems with law enforcement.

References

Donovan, L. M., & Mullen, L. K. (2019). Expanding nursing simulation programs with a standardized patient protocol on therapeutic communication. Nurse education in practice, 38, 126-131.

Reitz, S. M., & Scaffa, M. E. (2020). Occupational Therapy in the Promotion of Health and Well-Being. AJOT: American Journal of Occupational Therapy, 74(3), 7403420010-14.

Siregar, I., Rahmadiyah, F., & Siregar, A. F. Q. (2021). Therapeutic Communication Strategies in Nursing Process of Angry, Anxious, and Fearful Schizophrenic Patients. British Journal of Nursing Studies, 1(1), 13-19.