Sample Clinical Assessment Report

In the end he took chances and faced stress often but could assess and handle it better now that he learned these skills.(“Anxiety: Challenge by Another Name”

He was feeling suffocated and the previous year before he was on the verge of quitting. He felt overwhelmed a lot in his life and for most of his life when he felt like that he would just run away, and would end up giving up.

A displayed feelings of apprehension and became less co-operative during the initial clinical interview. She additionally displayed thoughts of inadequacy . She moved back to her parent’s house when she began getting panic attacks and was housebound through fear of inducing a panic attack. As a result of this, she became overly reliant and attached to her parents, who provided emotional, financial, and decision making support.

The impact of Mrs. Smith’s anxiety and panic attacks takes a heavy toll on the family. Mrs. Smith has been the family member that maintains equilibrium for the family. Without her calming influence, Mr. Smith and Junior have lost their stability. Mrs. Smith provided the steady emotional balance in the family.

You are working in the internal medicine clinic of a large teaching hospital. Today your first patient is 70-year-old J.M, a man who has been coming to the clinic for several years for management of CAD and HTN. A cardiac catheterization done a year ago showed 50% stenosis of the circumflex coronary artery. He has had episodes of dizziness for the past 6 months and orthostatic hypotension, shoulder discomfort, and decreased exercise tolerance for the past 2 months. On his last clinic visit 3 weeks ago, a CXR showed cardiomegaly and a 12-lead ECG showed sinus tachycardia with left bundle branch block. You review his morning blood work and initial assessment.

Journey’s intake unit completes all initial assessment to assess client for different level of care and accurately assign them to the most appropriate unit. The different level of care ranged from intensive inpatient care unit to medication only. As a practicum student, I worked in the outpatient services unit. The assessment was completed via an online program with an intake staff and the client, usually a week or two before the first scheduled appointment with a clinician. Therefore, once a client is assigned to me, I have access to review their file. The assessment are usually completed in a brief model format, and as the clinician assigned to work with a client, I am expected to use the first two sessions of therapy

The patient tells me that she is unsure when her last menstrual cycle was. Her periods are very irregular and she had not been keeping track of it. She and her husband have been attempting pregnancy for the last year and a half and she tells me that as of Thursday, August 27th, she and her husband had gone through the procedures for adoption. She said that she knows she ovulated on August 18th. She was using an ovulation kit. She took a home pregnancy test on the 28th, which was positive, repeated with a different brand of test on the 29th and that was also positive. She has a regular gynecologist with York Gynecology, Robert Cervenka, MD, that she uses regularly, and she already has an appointment with him

When I initially started planning this paper I was ecstatic to learn what the literature had proven effective for the Native American community and possibly my own people, the Navajo Nation. Since I was a little girl I pledged that I was going to help my people, in any way that I could when I grew up. My main drive behind my profession of choice isn’t for the money obviously, I grew up on the Navajo Reservation, and I have witnessed first hand the detrimental effects of alcohol abuse. My father was an alcoholic he died

With a severe trauma, and experiencing symptoms daily for a number of years, it is questionable that she struggled to identify the triggers of her panic attacks as documented in the CE.

His quality of life worsened because his friends were making fun of him. The text states when he found that out “I feel sick inside” (line 330, pg 200). The day after he found out they were bullying him, the text states “Still didn’t go to the factory.” Pg 201, line 358. “When I left afterwords, I found myself trembling” pg 203, line 468.

Maria is a caregiver at Peppermint Tree Daycare in Edison, New Jersey. Maria has known me for all of my life, although I don’t remember her as a child. When I was a young girl I attended this facility where she took good care of me and watched me grow until I was four years of age. My mother and she grew such a tight bond that she would babysit my sister and I on weekends when my mom needed to work overtime. As years went by, my mom and Maria lost touch. Two years ago, I ended up getting a job at Peppermint Tree Daycare. I now work in the baby room with Maria five days a week and look at her as a second mother. Because of my close relationship with her, I felt interviewing her would be perfect. I asked Maria if she would be willing to do this interview and in a heartbeat she considered my request.

The fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) divides the substance-related disorders (SRDs) into two sub-categories, namely, substance-induced disorders (SIDs) and substance use disorders (SUDs) (McCarron, Xiong, & Bourgeois, 2009). SIDs relates to the medical conditions that are caused by the use of substances. These conditions include intoxication and withdrawal syndromes. SUDs are defined as a patient’s recurrent behavior to use alcohol and/or drugs that cause clinical and functional impairment, for example, malfunction at school, work, home, and health problems (McCarron, Xiong, & Bourgeois, 2009).

If my supervisor told me that she thinks the patient I chose was misdiagnosed and that the problem is something else entirely, I would defend my diagnosis using this case study. Paula presents herself as a woman who “get(s) dizzy” with “chest pains…short of breath” as well as she “feel(s) like (she’s) dying and the world is ending” (Getzfeld, 2004)1. When she visits the emergency room, the doctors tell her the cause is not physical – therefore they must be psychological. Key symptoms of panic attacks include heart attack-like symptoms, as well as raised heart rate, sweating, and dizziness, all of which Paula experienced. Another key of diagnosing panic disorder (PD) is that a lot of random panic attacks occur and these attacks bring on at least 1 month of fear that more attacks will occur which Paula experienced. PD involves avoiding situations due to the fear of a difficult escape should a panic attack occur and that they will be embarrassed; Paula had said she did not go to work as

He adds that a panic attack can sometimes serve as a warning that a person might be “living too fast, too hassled, and too stressed-out (p. 5).”

With the continuous changes in healthcare, evaluation of students’ clinical knowledge and skills relies on the need for continuous evaluation. Evaluation is the process of using data to make judgements about students’ individual performance. Evaluation of clinical performance provides data from which educators use to judge the extent to which students have acquired specific learning outcomes (Billings & Halstead, 2016). With the use of best practice evaluation methods, clinical performance can be evaluated to ensure quality patient care. Educators face a challenging task when providing evaluation that is fair and reasonable. Tasked with evaluating students in the clinical setting, educators can evaluate how students integrate theory and apply it to real-life situations. Observations of performance in the clinical setting should focus on the outcomes to be met and competencies to be developed (Oermann & Gaberson, 2014). Developing a clinical evaluation tool to determine whether students can think critically, prioritize problems, and complete patient care procedures correctly is essential. There are a variety of evaluation methods to use in nursing education. Depending on the learning outcomes to be measured will determine which tool best evaluates the students’ performance. Clinical practice is an essential and highly significant component of nursing education. Education programs are obligated to respond to government requests for well-educated healthcare professionals.