Practicum Journal Entry
Student’s Name
Practicum Addresses
Institutional Affiliation
Practicum Journal
Introduction
The Journal entry seeks to assess a patient that I am currently serving by making the descriptions about the client and keeping the HIPAA guidelines. Through the journal, relevant history, medical report, and current medications are identified. This assessment will help in the process of diagnosis using the “Diagnostic and Statistical Manual of Mental Health Disorders (DSM-5)”. The journal concludes she summarizes by describing legal as well as ethical insinuations related to the process of counselling the client.
Client Description
Demographics Population: Mrs. Y is a 34-year-old Caucasian woman. She has one child.
Presenting Problem: “I have been experiencing anxiety and depression for the past one week, I feel hopeless.”
Chief Complaint: From the report by Mrs. Y, the chief complaint is depression and anxiety.
History of Present Illness: From her report, Mrs. Y has been under depression and anxiety for the past one week. She appears to panic and not able to sit down. She spends most of her time sleeping and experiencing weight loss and experiencing a low level of mood. Symptoms have been there for five months.
Physical Assessment
From my observation, Mrs. Y appears groomed as well as hygienic. Mrs. Y is not attentive. She is depressed and looks sad. She is hopeless, and her movement depicts depression. The facial expression describes the anxiety in her.
Current Medications: Mrs. Y is currently taking 75mg of Mirtazapine every 12 hours.
Diagnosis of the client using “Diagnostic and Statistical Manual of Mental Health Disorders, 5th edition (DSM-5)”
Axis I: The depressive disorder. I will consider depressive disorder as a major diagnosis for the patient. “As defined by Diagnostic and Statistical Manual (DSM), the criteria for major depressive disorder are that there should be the presence of five or more symptoms” (Straussner, 2013). She exhibits five common symptoms of depression disorder (Marrag et al., 2015).
Axis II: Anxiety disorders. “The second diagnosis of the client is anxiety disorder. The client appeared to be panicking, fearful, and uneasiness” (Straussner, 2013). The client could not sustain calmness (Regier, Kuhl & Kupfer, 2013).
Legal and or Ethical Implications Related to Counselling of the Client
“There is a ten-section code of conduct that a mental health care provider should observe when dealing with clients having mental disorders” (American Psychological Association, 2017). Mental care provider should avoid any kind of harm. I must, therefore, obtained a knowledgeable consent before the intervention.
Reference
Marrag, I., Chebbi, W., HAJJI, K., Mansouri, A., Zarrouk, L., Younes, S., & Nasr, M. (March 28, 2015). Risk Factors of Recurrence in Major Depressive Disorders. European Psychiatry, 30, 720.
Regier, D. A., Kuhl, E. A., & Kupfer, D. J. (June 01, 2013). The DSM-5: Classification and criteria changes. World Psychiatry, 12, 2, 92-98.
American Psychological Association. (2017). Ethical Principles of Psychologists and Code of Conduct. Retrieved from http://www.apa.org/ethics/code/index.aspx.
Straussner, S. L. A. (January 01, 2013). The DSM-5 Diagnostic Criteria: What’s New?. Journal of Social Work Practice in the Addictions, 13, 4, 448-453.