20 y/o African American, female Follow up on my mood? S: Patient is being seen for a follow up visit. Patient has a history of depression, bipola
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20 y/o African American, female
“Follow up on my mood”
S: Patient is being seen for a follow up visit. Patient has a history of depression, bipolar, gender identity crisis and cannabis use. Patient recently changed her name stating her birth name wasn't “identifiable”. Patient has complaints of feeling mentally drained and overworked. She states she's tired and is considering going to an inpatient mental health facility for a few days. Patient who lives at home with her parents has decided that it would be best if she went to live with her grandmother. She states her parents does not understand her identity. She has resorted to excessive alcohol and marijuana use to “ease the pain”. Patient has exhibited symptoms of impulsive behaviors by going on shopping sprees, only using her credit cards. Patient is currently taking Abilify 20mg PO daily, Sertraline 50mg PO daily and Concerta 27mg PO daily. NKDA
O: Temp 97.9, BP 1/22/80, HR 70, O2 sats 99%
A: Bipolar disorder- Bipolar I Disorder – F31.13
Substance Use Disorder (Alcohol and Marijuana) – F10.20, F12.10
P: Increase Abilify to 30mg PO daily. Continue all other psychiatric medications as prescribed and monitored for changes in behavior and/or adverse reactions. Education provided to patient. Reviewed medication side effects and adherence importance. Keep tracks of physical symptoms of mood and depression and triggers associated. Discussed worsening signs and symptoms and when to contact office or report to ED. Patient advised to continue with outpatient counseling. Referred to substance abuse treatment program. Follow up in four weeks or sooner if symptoms worsen.
Patient is a 65 year old Hispanic Female
“I’ve been feeling down lately”
S: Patient states she has been doing fairly well with her anxiety symptoms. Patient states medications have been effective. The patient admits to feeling down a few times a week for no obvious reasons. She states she is sleeping better, achieving approximately 6-7 hours of restful sleep each night. Crisis issues: she states she has no suicidal plan nor does she have any homicidal plans. She states she has no access to prescription medications other than her prescribed meds. Patient believes that her weekly therapy sessions and journaling has helped with coping mechanisms.
Reviewed allergies: NKA
Current medications: Lorazepam 1mg PO QD, Seroquel 100mg PO QHS and 100mg PO BID, Trazodone 75mg PO QHS, Oxcarbazepine 150mg PO BID, Buspirone 10mg PO TID.
ROS: no complaints
O- Vitals: T 97.8, P 89, R 18, BP 129/79
A: Generalized anxiety disorder – F41.1
Major depressive disorder, recurrent, severe with psychotic symptoms – F33.3
Psychotic disorder with delusions due to known physiological condition – F06.2
P: Increase Seroquel to 200mg PO QHS. Continue all other meds as prescribed. Monitor for side effects to meds or any other concerns. Hold for sedation. Medication education provided. Continue outpatient counseling. Keep track of physical symptoms of anxiety or depression and triggers associated. Follow-up: in one week or earlier if any depressive or anxiety symptoms worsen.
Patient 61 year of AA female
"I’m here for my follow up"
S: Patient states she has a history of depression and anxiety x10 years. She recently moved to FL and feels as if she has been doing generally well with her anxiety and depression symptoms. She states her current medication regimen has been effective. Patient states her appetite is good. She has been sleeping 6-8 hrs every night. Denies suicidal or homicidal ideations. Patient states she has no access to medications outside her prescribed meds. She has been going to church and has made new friends and feels this has been helpful with coping mechanisms.
Allergies: PCN
Current Medications: Buspirone 7.5mg PO qhs, Fluoxetine 40mg PO daily.
O: Temp – 97.9 BP – 143/70 HR – 72 RR – 21 02 Sat – 98%
A: Major depressive disorder, recurrent, mild – F33.0
Generalized anxiety disorder – F41.1
P: Continue medications as prescribed. Notify office of any changes in mood or depression. Continue journaling and attending church as means of coping with symptoms. Continue outpatient counseling and current medications as prescribed at current dosages and monitor for changes in behavior and/or adverse reactions. Keep track of physical symptoms of depression and triggers associated. Follow-up: in 1 week or earlier if symptoms worsen.
Referrals: None at this time
64 y/o M with PMH of depression, suicide attempt 6 years ago
Follow up appt 90213, 90836
S: The patient reports that lately, he has been feeling increasingly nervous and frustrated. He denies the presence of depressive symptoms. He can't pinpoint what's making him feel frustrated and anxious. After reading about the potential adverse effects of Gabapentin online, he is a little concerned. He states he is experiencing hallucinations in which he sees visions of recent events in his sleep and in his thoughts. He denies ever experiencing night terrors. He denies suicidal or homicidal ideation.
Allergies: PCN
Current Medications: Gabapentin 300mg PO BID, Ziprasidone PO 80mg daily, Divalproex 125mg BID, Escitalopram 30mg PO daily, Gedeon 80mg PO daily
O: Temp: 98.6 BP: 122/68 HR: 92
A: Generalized anxiety disorder – F41.1
Post-traumatic stress disorder, chronic – F43.12
Major depressive disorder, recurrent, mild – F33.0
Bipolar disorder, in partial remission, most recent episode depressed – F31.75
P: Continue medications as prescribed and monitor for behavioral changes and/or adverse effects. Keep track of physical symptoms of anxiety or depression and triggers associated. Follow-up: in 2 weeks or earlier if any depressive symptoms worsen. Outpatient counseling sessions to continue bi-weekly until further notice. No referrals at this time
51 y/o F
"Initial psych appt" 90213, 90836
S: Patient’s son present during visit and states that patient was evaluated by her PCP last month for depression and recommendation was made to start her on Sertraline or Citalopram. Patient reports that she took Sertraline years ago but it did not seem to help. No signs of depression, anxiety or mood instability noted, good appetite and is sleeping well. Crisis Issues: Patient denies suicidal and homicidal ideation. She states she has no other medications at home other than her prescribed meds.
Reviewed Allergies: NKA
Current Medications: Melatonin 3mg qHS,
ROS: No complaints
O- Temp – 97.4 BP – 130-60 HR – 70 RR – 20 02 Sat – 97 Weight – 114lbs
A: Adjustment disorder with depressed mood – F43.21
P: Start Escitalopram 5 mg PO QD for depression. Staff to monitor, document and report any changes in behavior. Continue outpatient counseling. Keep track of physical symptoms of depression and triggers associated. Follow-up: in 2 weeks or earlier if symptoms worsen.5
92 y/o M Hispanic
"My first visit"
S: Patient is being seen today for initial psychiatric evaluation, psychotropic medication review, and to rule out symptoms of depression and anxiety given recent medical hospitalization, current physical functioning, and reduced mobility. Patient is currently at Encompass Health Altamonte for rehab and psych has been consulted to evaluate patient for increased agitation/yelling. Patient is seen sitting in gym. He is alert and oriented to self. He reports that he is at the VA hospital and does not know the current year. Patient is hard of hearing. Patient is a poor historian; no family is present during visit. Patient reports that he lives with his son and grandson but per chart review, patient lives at Brookdale ALF. Writer attempted to contact son Scott but did not get an answer. Patient denies any anxiety or depression. He reports that he is participating in therapy. Patient denies any difficulty sleeping, sleeping 7-8 hours at night. Patient states his appetite is good. Nurse on shift reports that patient has been cooperative with care this morning with no behavioral issues.
O: Temp – 97.8 BP – 108-59 HR – 70 02 Sat – 98
A: Adjustment disorder with anxiety – F43.22
P: Start Trazodone 25mg PO QHS for anxiety. Continue outpatient therapy as scheduled. Follow up appt in 2 weeks or sooner if symptoms worsen. Keep track of physical symptoms of depression and anxiety and triggers associated.
81 y/o AA male
“ New patient visit”
S: Patient reports that he had a down day on yesterday but is feeling much better today. He reports that he was feeling disappointed in himself on yesterday when he thought about his injury from falling but states that he is generally a positive person. He notes a history of anxiety and was started on Sertraline 1 month ago by his PCP. He reports that his anxiety has been controlled with this medication. Patient is motivated and is participating in therapy. He lives alone and endorses good social support from his friends and neighbors. He reports having some difficulty sleeping last night. He states he is sleeping about 5 hours a night. Patient states appetite has been good. Patient denies any suicidal ideation or hallucinations.
Current medications: Sertraline 50 mg PO daily and Trazodone 150 mg PO qHS.
Allergies: NKDA
O: Vitals: Temp – 98.3 BP – 171-74 HR – 62 02 Sat – 94.
A: Generalized anxiety disorder – F41.1
Insomnia- F51.01
P: Start Melatonin 5 mg PO QHS for sleep. Continue all other current psychiatric medications at current dosages and monitor for changes in behavior and/or adverse reactions. Keep track of physical symptoms of depression and anxiety and triggers associated. Follow-up: in 2 weeks or earlier if symptoms worsen.
72 y/o W Male
"Follow up after medication changes" 99214
S: Patient reports that he is having some anxiety due to his health issues. He also worries about his living situation as he has been living in a hotel. He reports that he does not have any family but has a friend that is trying to help him get a mobile home. He has difficulty sleeping and has taken OTC sleep aids at home. He states he is sleeping an average of 5 hours at night. He states his appetite has been good. He reports that he is motivated and hopeful. Patient is participating in therapy and is cooperative with care in the rehab facility. He denies any suicidal ideation or hallucinations. Patient is tolerating current psych meds without complications noted or reported. NKDA
Current Medications: Buspirone 10mg PO TID, Sertraline 100mg PO daily, Alprazolam 0.5mg PO BID prn for anxiety and Melatonin 5mg PO QHS prn for insomnia.
O: Vitals: Temp – 97.5 BP – 105-67 HR – 81 RR – 18 02 Sat – 100.
A: Insomnia- F51.01
Adjustment disorder with anxiety – F43.22
P: Continue all current psychotropic medications at current dosages and monitor for changes in behavior and/or adverse reactions. Continue journaling as coping mechanisms as patient states it helps with anxiety symptoms. Continue outpatient counseling. Keep track of physical symptoms of anxiety and triggers associated. Follow-up: in 2 weeks or earlier if symptoms worsen.
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