Patient logs for individual psychotherapy.

Patient logs for individual psychotherapy, this is a very short note that summarizes a soap note, one paragraph per patient. examples will be provided in file, no reference or in-text citation needed. just a short note for psychiatric diagnosis. 5 patients per page for a total of 15 (again this is a short note with a few sentences stating the reason for visit, history, medication therapy if any, treatment plan, etc). please contact me if any questions or concerns. Patient logs for individual psychotherapy.

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Patient Logs

1

A 39 year old American female presented with complaints of difficulty in sleeping, sadness, fatigue, and loneliness. Patient had a history of 3 failed relationships and is paranoid that she will never get married, have a family, and carry her own baby. Patient had history of hospitalization due to her suicide attempt. She states that she is taking her antidepressants on a daily basis. The session focused on proper management of emotions and dreams, and exploration of the future possibilities. Initial diagnosis: Anxiety disorder. Tx plan: Continue psychotherapy and medication therapy.Patient logs for individual psychotherapy.

2

A 29 year old Latin man characterized to have low-esteem, avoidance of full range of emotions, and extreme sensitivity. The patient and his brother had a history of car accident 3 months ago which resulted to his brother’s death. He takes blame for it and showed excessive guilt since then. The patient is thin since he his anxiety affected his eating routine. Since then, the patient became uneasy, too cautious, and overly organized and clean. Diagnosis: Guilt, depression, and Obsessive Compulsive Disorder (OCD). Treatment plan: pyschotherapy sessions twice a week, and antidepressants.Patient logs for individual psychotherapy.

3

A 30 year old Japanese female presented mood swings, anxiety, and trouble sleeping weeks which started three days after she gave birth to her 2nd child. The patient noted that she is always irritable and her concentration span has been reduced. She also noted that sometimes, she is crying even for no reason. Diagnosis: Postpartum depression. Treatment plan: Continuation of psychotherapy and antidepressants.Patient logs for individual psychotherapy.

4

A 16 year old Chinese boy has been seen with a primary diagnosis of depression. He had history of suicidal attempts which is still evident in his cuts and bruises in his arms. He had a history of losing in a national mathematics tournament which resulted his extreme sadness and regrets. The patient always preferred to be alone. His eating routine has been affected from his isolation. Diagnosis: Depression. Treatment: 1) Psychotherapy twice a week and increase dosage of antidepressants and anti-anxiety medications. 2) Refer him to a dietitian so a specialist can monitor his eating routine.Patient logs for individual psychotherapy.

5

An 18 year old Filipino man has been hospitalized last month due to sleep deprivation. He presented drowsiness, difficulty in breathing, and impaired memory. He noted that he is playing video games and computer games for almost 18 hours a day for most days. He stated that “whenever I am not playing games, I feel empty”. He dropped out from school since he noted that his classmates are not also supportive in his gaming career and his grades are failing anyway.Patient logs for individual psychotherapy. The patient presented symptoms of fatigue, malaise, and low-self esteem. He also noted that no one can understand him, even his parents. He also noted that he knows and acknowledge that he maybe have a mental disorder and is willing to be cured or treated. Diagnosis: Video game addiction/ gaming disorder and depression. Treatment plan: 1) thrice a week psychotherapy and counselling 2) antidepressants and anti-anxiety medications 3) Enter a support group with other patients of this condition 4) If symptoms got worse or the patient does not change at all, I would refer him to a rehabilitation center.Patient logs for individual psychotherapy.

6

A 25 year old female was examined to be irritable with poor concentration of thoughts. She reports difficulty of sleeping and frequent nightmares about the assault she experienced one month ago. She also had recurrent intrusive visions of her assailant. Patient will undergo cognitive processing psychotherapy for 12 weeks with weekly sessions of 60-90 minutes.Patient logs for individual psychotherapy.

7

A 40 year old male complained of hearing voices for the past 10 months and loss of appetite. Her accompanying brother claimed patient sometimes physically abused their mother and sister. Patient also reported that he sometimes had a sense that people around want to hurt him. He was once seen roaming around town and did not go home for 2 days. No family history of any mental illness. He was diagnosed with Schizophrenia and started with medications upon admission after showing aggressiveness, including IV diazepam, IM haloperidol, IV Ketamine and olanzapine tablets.Patient logs for individual psychotherapy.

8

A 19 year old male patient presented to be highly energetic and talkative. He reported he only sleeps 2 hours per day without getting exhausted during the day. He claimed he experienced depression after a break up 3 years ago. He has multiple sexual partners and an alcoholic drinker for 2 years. He was given medications to stabilize his manic episodes and was scheduled for cognitive therapy sessions.Patient logs for individual psychotherapy.

9

29 year old female presented with complaints of fatigue, sadness, and malaise. Patient is reported to be struggling with a new relationship because of trauma flashbacks. History of abuse. Paranoia is exhibited. Session focused on characterizing and exploring definitions, meanings, and goals of a healthy relationships including psychoeducation. Tx plan: weekly counselling and medication therapy to address paranoia, depression, and recurring flashbacks.Patient logs for individual psychotherapy.

10

62 year old male, extreme alcoholic and smoker. The patient developed an end-stage renal disease 9 months ago, and bronchitis and emphysema 4 months ago. On a routine dialysis three times a week. History of 2 failed marriages and bankrupt businesses. The patient does not have any close relatives and is alone in the house. Patient stated that “smoking and drinking are my coping mechanisms whenever I feel alone”. Tx plan: psychotherapy and medication therapy to address loneliness and alter coping mechanism.Patient logs for individual psychotherapy.

11

37 year old male presented with symptoms of Schizophrenia. The patient has history of being bullied in school. Before the delusions and hallucinations, patient presented anxiety and depression. During the session, patient exhibited echopraxia, echolalia, and body rocking. The patient is also apathetic and has delusional references. Bruises and cuts on her arms and legs. During the session, patient became aggressive and violent. Antipsychotic drugs clozapine and risperodine were administered. Session got interrupted. Next session, next week. Tx plan: psychotherapy and medication therapy.Patient logs for individual psychotherapy.

12

25 year old female presenting with complains of insomnia, fatigue, and arrhythmia. Patient is anorexic. Anorexia started when she was left by her partner. Patient indicated that “not eating makes me look good better…and so I won’t get jealous of his new girlfriend, I’m insecure”. History of hospitalization from extreme dehydration and low blood pressure. Blood test was ordered which turned to be abnormal. Tx plan: medication therapy and sessions that would tackle anxiety and self-worth.Patient logs for individual psychotherapy.

13

45 year old male presented extreme weight loss, loneliness, apathy, and difficulty in sleeping. His symptoms started when his wife was diagnosed with stage 2 breast cancer last year and got worse when she died 2 months ago. Session focused on talking about what he like about his wife and his memories of her. Tx plan: Next session would center on identifying and reconstructing his new life. A support group was recommended.Patient logs for individual psychotherapy.

14

35 year old male characterized as sleep deprived and obese. He is seen with a primary diagnosis of compulsive gambling disorder. Patient had history of smoking and drug abuse but quit 2 years ago. The patient is also noted to be physically hurting his wife and children whenever he loses from the game. Session focused on diversions and mechanisms to address and manage his uncontrollable desire to gamble and his anger issues.Patient logs for individual psychotherapy.

15

20 year old female, clinically diagnosed with nymphomania last year by her previous psychiatrist. History of molestation and rape during childhood. Patient did not improve from her maintenance medicine and based from her, “sexual desires are more intense now”. The patient is living alone in an apartment. previous hospitalizations for drug overdose. Session goal was to characterize the patient’s sexual desires and came up with distraction exercises to help her divert her attention when sexual desires attack. Tx plan: psychotherapy and increase dosage of antidepressants and antipsychotic medications.Patient logs for individual psychotherapy.