Assignment 2: Practicum – Week 1 Journal Entry

Week 4 Journal Entry
Select a client that you observed or counseled this week. Then, address the following in your Practicum Journal:
• Describe the client (without violating HIPAA regulations) and identify any pertinent history or medical information, including prescribed medications. Assignment 2: Practicum – Week 1 Journal Entry
• Using the DSM-5, explain and justify your diagnosis for this client.
• Explain whether cognitive behavioral therapy would be effective with this client. Include expected outcomes based on this therapeutic approach. Support your approach with evidence-based literature.
• Explain any legal and/or ethical implications related to counseling this client.
Note: Be sure to use the Practicum Journal Template, located in the Learning Resources.
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Patient name: Martha tow

sex: female

date of birth: 10/18/45

Age: 72

G

date: 09/18/18

start time: 22:51

referral source: Laurel Wood

legal status: involuntary

Preferred language: English

vital signs completed at: 22:51

B/P: 151/84

P: 97

R:17

Pulse ox: 99

height: 5’1

weight: 128

Presenting problem

Patient is a 72 year old female who has brought to ER by family due to increased confusion and paranoia as well as increasing AVH. Patient has been seeing her deceased son‘s and Joking to schedule her funeral. Patient has been attempting to leave the house stating she is following her deceased son. Patient attempted to answer questions but answers were not always related or were nonsequential at times. Patient did report something ver joking to schedule her funeral. Patient has been attempting to leave the house stating she is following her deceased son. Patient attempted to answer questions but answers were not always related or were non-sequential at times. Patient did report sometimes Feeling sad, but did deny s7/h7 and aggression Assignment 2: Practicum – Week 1 Journal Entry

Currently employed/in school: no, details: retired

Medicaion

Zoloft 5 mg po daily

Abilify 150 mg po two times daily

Ativan 1 mg po every 6 hours prn for anxiety

Vistaril 25 mg po q6hrs prn for anxiety

Motrin 600 mg q8 hrs prn for pain

Assignment 2: Practicum – Week 1 Journal Entry

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