Patient logs for individual psychotherapy.

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 individu