Description
SUBJECTIVE:Chief Complaint:New patient Telepsychiatry audio/video History Of Present Illness:20 year old male presented with Medical History:Patient Denies any Negative Cardiac Hx, Negative Respiratory Hx, Negative Seizures Hx, Negative Head Trauma Hx, and Negative Family Cardiac History. Psychiatric/Mental Health History: Patient denies any previous suicidal attempts. Patient reports positive previous psychiatric hospitalization/admissions after being held in Jail. Patient was brought to Hospital (July 20) for detox by his girlfriend and mother in which he stayed for approximately 2 days to flush drug out of the system. Was not discharged with psyhatric medications as per patient and girlfriend. Family History:Maternal: Positive for Psychiatric (Bipolar Disorder), Negative for Substance, and Negative for Alcohol. Paternal: Negative for Psychiatric, Negative for Substance, and Positive for Alcohol. *(Died when patient was 9 year old)*Social History:Marital Status: Single Children: Denies Living Situation: Single Occupation: Non Employed (Recently fired from HomeDepot and charged with Grand Theft) / Adult Student (Full-time) Tallahassee state college for sports medicine. Current Income: Public Assistance scholarship money and looking for a job. Substance Abuse History: Yes Drug type: Edible THC gummies ( 3x times the potency) Patient is socially appropriate for age. Legal Status: Positive for Grand Theft after stealing from Homedepot July 31 and Criminal Trespassing on Hotel grounds July 19. Functional Status: Denies physical limitations. HIV-STD prevention: In a monogamous relationship. Safe sex education provided to reduce transmission. Seat belt safety: Discussed to wear always. Skin Cancer Prevention: Avoids the sun, tanning beds. Smoking cessation: Educated on prevention. Patient advised to reduce exposure to second hand smoke whenever possible.Smoking Status: Never SmokedReview of System:Constitutional: Negative for activity change, appetite change and fatigue.Cardiovascular: Negative for chest pain, palpitations and leg swelling.Psychiatric: Positive for agitation, Positive for behavioral problems and negative confusion at present time. Negative for passive suicidal thoughts, intent or plan at present time. Negative for active suicidal thoughts, intent or plan at present time.OBJECTIVE:Vital Signs:Height: 73.00 inWeight: 163.00 lbsBMI: 21.50Resp. Rate: 18Physical Exam:Constitutional: Oriented to person, place, and time. Appears well-developed and well-nourished. No distress. Neurological/Psychiatric: General/Orientation: Awake, alert and oriented x3. No acute distress. Appearance, general attitude and behavior: Appears stated age. Combed hair. Fair hygiene. Casually dressed. Hyperactive, talkative, and disorganized. Fair eye contact. Abnormal Movements/Gait: Psychomotor agitation noted. Fidgeting and inability to sit still. Stable gait. Characteristic and/or quality of speech: Pressured speech especially when speaking about his hallucinations while under the Edible THC. Mood and Affect: Irritability with low frustration tolerance. labile. Thought Process: Flight of ideas and easily distracted. Thought Content: Ruminations about his hallucinations while under the Edible THC. Perceptual Disturbances: Paranoid features “I feel like someone is following me” and “I always have to look over my shoulder”. “It has gotten worst after the THC edible”. Suicidal ideations/Homicidal ideations: Denied active suicidal/homicidal ideations, intent or plan at present time. Memory: Grossly intact. Attention/Concentration: Poor/Poor Insight and Judgement: Poor/Poor Medication Side Effects: Patient denied. None observed.ASSESSMENT:Diagnosis:ICD-10 Codes:1)F3162; Bipolar disorder, current episode mixed, moderate2)F19151; Other psychoactive substance abuse with psychoactive substance-induced psychotic disorder with hallucinations3)Z630; Problems in relationship with spouse or partner4)Z9149; Other personal history of psychological trauma, not elsewhere classified5)F5105; Insomnia due to other mental disorder6)F1210; Cannabis abuse, uncomplicated7)Z653; Problems related to other legal circumstancesPLAN:Procedures:1) 99205; E&M of a new patient, mod to high severity (60min)2) 90838; Psychotherapy (at least 53 minutes) with E&M codeProcedure Notes:I reviewed patients GAD7: & PHQ9: Mood Questionnaire: Pos Anxiety/Mood Disorders psychotherapy: Provided modalities of cognitive behavioral therapy and interpersonal psychotherapy while helping to express and clarify thoughts, feelings, and concerns. Discussed at length achievable Goals including but not limited to: Improving problem solving/coping/insight, increase distress tolerance, improve interpersonal skills, reduced symptom induced distress, maintaining a consistent routine, schedule, and anticipating stressful situations. Creating a plan and allowing extra time to work with your plan. Practicing stress management or self-calming techniques Diaphragmatic Breathing that you have learned from your mental health care provider. Exercise regularly and spend time outdoors. Eat a healthy diet that includes plenty of vegetables, fruits, whole grains, low-fat dairy products, and lean protein. Do not eat a lot of foods that are high in fat, added sugar, or salt (sodium). Drinking plenty of water. Avoiding alcohol and illicit substances which can increase anxiety. Avoid caffeine and certain over-the-counter cold medicines as these may make you feel worse. Understanding that you are likely to have setbacks. Accept this and be kind to yourself as you persist in taking better care of yourself. Recognize and accept your accomplishments, even if you judge them as small. Spending time with people who care about you and keeping all follow-up visits for optimal mental health benefit and wellbeing. We discussed working towards these Goals to achieve improvement and eventual resolution in symptoms if attainable depending on clinical presentation and medical condition. A total of 70 minutes of supportive psychotherapy was spent along with coordination of care. Instructions provided regarding diagnosis, recommendations, and treatment plan. Questions were welcomed and answered.Orders:1) 005009; CBC With Differential/Platelet (lab order)2) 058867; CMP12+8AC (lab order)3) 000620; Thyroid Panel With TSH (lab order)4) 081950; Vitamin D, 25-Hydroxy (lab order)5) 000810; Vitamin B12 and Folate (lab order)6) 700841; Drug Screen 10 w/Conf, Serum (lab order)Medications:lamoTRIgine 25 MG Oral Tablet Disintegrating; Place 1 tablet orally daily; Qty: 14; Refills: 0OLANZapine 10 MG Oral Tablet Disintegrating; Place 1 tablet orally at bedtime; Qty: 30; Refills: 0Care Plan:Patient Education: Antipsychotics: These agents include the “typical” or first-generation antipsychotics and the “atypical” or second-generation antipsychotics. First-generation antipsychotics include chlorpromazine, fluphenazine, haloperidol, and perphenazine. —Although these drugs are effective, their long-term use can result in a muscle movement disorder known as tardive dyskinesia, which consists of fine tremor, muscle spasms, and rigidity. **** Second-generation antipsychotics include aripiprazole, olanzapine, paliperidone, quetiapine, risperidone, and ziprasidone. —These medications, though less likely to cause movement disorders, have a unique set of side effects, including weight gain, high cholesterol, and an increased risk of diabetes. —Anyone taking either type of antipsychotic should be monitored routinely for side effects. —Antipsychotics should not be stopped abruptly but should always be tapered off slowly or replaced with another drug according to a medical provider direction. Antipsychotics often improve many of the symptoms of schizophrenia within a few weeks of therapy. —It is critical that antipsychotics be continued even after symptoms have improved in order to avoid relapse. —If one antipsychotic does not relieve symptoms, it is possible another agent will work. —Patients should always tell their medical provider and pharmacist about any other prescription drugs, OTC products, vitamins, or supplements they are taking to avoid serious drug interactions. Patient verbilized understanding and accepts risks and complications. -Start on Olanzapine 10 mg PO daily at HS.Care Plan Continuation:Patient Education: Mood Stabilizers (Lamictal) A serious, life-threatening skin rash (also known as Stevens–Johnson Syndrome) may occur with the use of lamotrigine. **Contact your health care provider immediately, call 911, and/or go to local ER if you have any of the following: a skin rash, blistering or peeling of your skin, hives, shortness of breath, or painful sores in your mouth or around your eyes.*** –Studies have found that individuals who take antiepileptic medications including lamotrigine have suicidal thoughts or behaviors up to twice as often than individuals who take placebo (inactive medication). These thoughts or behaviors occurred in approximately 1 in 500 patients taking the antiepileptic class of medications. If you experience any thoughts or impulses to hurt yourself, you should contact your doctor immediately, call 911, and or go to your local ER. –Aseptic meningitis, a serious inflammation of the protective membrane that covers the brain and spinal cord has been identified as a very rare but serious side effect of lamotrigine. Patient instructed to contact your health care provider immediately, call 911, and/or go to local ER if you experience headache, fever, nausea, vomiting, stiff neck, rash, unusual sensitivity to light, muscle pains, chills, confusion, or drowsiness while taking lamotrigine. -Start on Lamictal 25 mg PO QD for two weeks then 50 mg for two weeks.Care Plan Continuation:Insomnia: Discussed with patient methods to ensure adequate sleep hygiene:-Including keeping regular sleeping and waking times -spending less than 8 hours in bed maintaining nutrition and exercise -avoiding sleep altering substances such as caffeine and alcohol. -Start on Olanzapine 10 mg PO daily at HS.Patient Instructions/FU:Patient instructed to call 911 or visit local ER for any acute life threatening symptoms including but not limited to: chest pain, palpitations (abnormal heart beat), low blood pressure (<115/70), elevated blood pressure (>160/100), shortness of breath, difficulty breathing, fever above 101.5, seizures, muscle weakness or rigidity, abnormal skin rash (SJS), numbness of extremity, difficulty speaking, falls, and uncontrollable bleeding. All questions answered to patient satisfaction. Follow up: 2-4 weeks, 1 months if chronic condition such as but not limited to Depression, Anxiety, and schizophrenia. Labs: TSH; B12; Folate; CBC, CMP to rule out medical cause for psychiatric symptoms. ***Patient instructed to take all medications as prescribed and Follow up with Therapist as scheduled. ***Follow up with appropriate medical providers as needed. ***Abstain from all illicit drugs, alcohol or mind altering substances. ***Risks, benefits, alternative to treatment and side effects of medication discussed with patient who verbalized understanding and agreement with this treatment plan. ***Safety plan discussed with patient: Tell a friend;Tell a family member; call the office; call 911 or go to nearest ER if you develop thoughts of harming self or others or develop symptoms of psychosis; call crisis line at 988 Suicide & Crisis Lifeline https://988lifeline.org/.