I need to do 24 clinical logs. They do not need references. The logs should include the following: Date, patient, age, gender, race, time spent with patient. Diagnosis/Reason for Visit (1-2 brief paragraphs) Chief Complaint/ Reason for Visit Hx of Present Illness – Provide enough information that you can convey the complexity and scope of the problem. Note any significant pre-existing or concomitant clinical signs and symptomology. Focused Diagnosis/Assessment Focused Plan (must include diagnostic tests, medication dosages, psychotherapeutic interventions, referrals, etc.) This is a sample of how the log should be written. A.H. is a 28-year-old Caucasian female who was evaluated for the first time for complaints of hypersomnia and severe fatigue beginning four months ago. She appears disheveled in a t-shirt and sweatpants with stains. Her hygiene is poor, and she has an unpleasant body odor. There is no eye contact during the interview and she is shy and withdrawn. She answers questions appropriately with flat affect. She stated, “I’m stressed out by my family, and I want to sleep all the time.” She has been sleeping between 10-14 hours a day. Her symptoms have gradually worsened after losing her job as an accountant when the pandemic began. She has been experiencing severe fatigue and is unable to cook meals and clean her home. She reports not wanting to leave her home anymore because “it’s just not worth the effort.” She has no motivation to look for a job. “I’m really stressed about money and paying my rent.” She reports that her family tells her to “just get over it and move on,” which makes her feel guilty and even more isolated. She reports feelings of loneliness, worthlessness, and has low self-esteem. The only activity that relieves her symptoms is sleep. She states that she has considered suicide but cannot do that to her family. She denies previous psychiatric diagnoses. She is not married and denies substance use, smoking, and alcohol consumption. Denies hallucinations, delusions, and paranoia. Screening Tests: PHQ-9 Depression Questionnaire: Scored 19—moderately severe depression Alcohol Use Disorders Identification Test (AUDIT): Scored 0. Diagnosis: Major Depressive Disorder Treatment: Paroxetine 20 mg PO Qam Therapy: Referred for individual and group cognitive-behavioral therapy. Follow-Up: 4 weeks for clinical monitoring and medication management
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