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: A , S

Unit #: L000297016

Room/bed:

Age: 62

Sex: M

Adm DT:

Rep srv DT: 08/21/18

Rep srv Tm: 0633

History of Present Illness

Chief Compliant: Abnormal Behavior

Pcp: No Primary or family physician

Hpi: 62 yo CM who presented on a 1013 for abnormal, behavior, homicidal ideations, danger to self and others was consulted for admission for elevated lipase. Pt was unable to be placed by psych, 2/2 lipase elevation-therefore medicine was consulted for admission. Patient is bizarre on examination, consistent with patient narration of cocaine use and utox positive multiple drugs. Apparently, on previous admission the patient acted inappropriately with staff and would require a 1-1 ratio when admitted to this facility. He is a very poor historian, mumbling something or another, rather than answering any of the questions. Assignment 2: Practicum – Week 1 Journal Entry

History

Past medical history: reports: COPD, schizophrenia

Additional medical history: cocaine use disorder

Additional surgical history: denies any past surgical history

Additional family history: denies any FH of mental illness

alcohol use: alcohol use

drug use: cocaine

Smoking status for patients 13 years old or older: current every day smoker

Medications/allergy-vaccine HX

Medications: haloperidol 2 mg po daily

Haloperidol 5mg po bedtime

Quetiapine (seroquel) 50 mg po bid 9a 5p

Quetiapine (seroquel) 400 mg po bedtime

Trazodone pamoate (vistaril) 50 mg po q6h prn prn agitation pr anxiety

Cyanocobalamin (vitamin b-12) 1000 mcg po qam

Allergies:

Coded allergies:

No known drug allergies (08/20/18)

Review or systems Assignment 2: Practicum – Week 1 Journal Entry

Additional notes:

12 pt ROS was attempted, however he didnt answer

Physical Exam

VS/i&O

General appearance: agitated, chronically ill appearing, alert, awake

head/eyes: A BNL conjunctiva/sclera, a traumatic

ENT: Dry mucosal membrane

Neck: no JVD

Cardiovascular: normal heart sounds respiratory: clear to auscultation , no distress

Abdomen/G.I.: active bowel sounds, soft , non-tender

Extremities: moves all

musculoskeletal: normal inspection

Neuron/CNS: abnormal speech (pressured) , Altered mental status, alert

Skin: dry, intact

Psychiatry: aBNL judgment/insights, auditory hallucinations, unable to evaluate Assignment 2: Practicum – Week 1 Journal Entry

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