Emmanuel Denis
Registered Nurse
Brooklyn-One/ Interfaith Medical Center
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Academic ServiceUpdated: 03-09-23
Admitting & Consulting PrivilegesUpdated: No ContentAffiliations (Universities & Colleges)Updated: No ContentClinicals / Clerkships / ExternshipsUpdated: 10-17-22
PMHNP Case Log
| Date: | 02/15/2023 |
| Rotation Type: | NL 812 Family Psychiatric Nursing III |
| Comments: | |
| Patient Age: | 21 Years |
| SOAP Note: | Chief Complaint/Reason for Encounter: Ms. V reports that she had a miscarriage in January. Currently denies any pain or active bleeding. Reports non-command auditory hallucinations the voice tells her "Bad stuff about herself 3 voices saying crazy stuff". Denies SI/HI or self-harm thoughts. Reports feeling sad and depressed. Energy level is low, reports interrupted sleep. Feels worthless and stated her appetite fluctuates and she also feels restless. This patient reports pain in her back/leg, reporting 8 out of 10 pain scale, stated she is in pain mgt. Patients has a follow up appt with her OBGYN next week. Patient request to have CBD as part of her medication regimen. Patient was educated on the side effects and drug drug interaction possibility of CBD. Ms. V. agrees and verbalize understanding. HPI: The patient was c/o still having trouble sleeping. "Paranoid" that someone is going to break into her home while she is sleeping. Always locking windows and doors. Denied SIB/SI/HI. She complains of depression and anxiety, fatigued, and not wanting to get up and do anything, laying in bed all day. She also has periods of time when she is impulsive, has racing thoughts, has excess energy and stays up all night cleaning. Feels people are trying to use her or don't really care what she goes through. Has low self esteem, as she is unable to do what she wants to because she is too nervous to go out into the public. Feels helpless but not hopeless. Having racing thoughts, ruminates about something bad happening. She is impulsive, paranoid and sleeping only 2-3 hours a night. Sometimes she doesn't sleep at all. Has irritability and getting annoyed easily. Has been having symptoms for 2-3 years. Denies AH/VH. Denies access to weapons. Reports for medication management and supportive care via telehealth. She is calm, AAOx3. She states that she has been taking her Abilify for 3 weeks and has noticed some restlessness. She states that she has also noticed that she sometimes gets tired after taking her medication. Patient encouraged to continue her medication as it is possible that these side effects will subside. She continues to have nightmares about people trying to hurt her. Also states she is having strange dreams such as, "sunflower seeds coming out of my legs." She does report a slight decrease in auditory hallucinations. She denies visual hallucinations. Denies SI/HI. Reports being able to sleep through the night. She states that she is concerned about her weight gain of 40 pounds over the last 4 months. CW 240lbs, Ht 5'3". |
| Age: | 18-49 yrs: |
| Gender: | Female |
| Race: | White Non-Hispanic |
| Insurance: | Other |
| Referral: | None |
| Client Presentation: | Mood and Affect: Patient reported sadness and denied SI or self-harm thoughts. Alertness & Orientations: Alert and oriented to all spheres. Speech: Check all that are normal, use following box for information Speech abnormalities: note abnormalities; e.g. perseveration, paucity of language Thought processes: Check if normal Additional information: delusions, preoccupations with violence, homicidal or suicidal ideation, obsessions Thought Content & Perception: Denied A/V hallucination but admits to paranoia. No delusional or obsessional content voiced/elicited. Suicidal ideation: Pt denied Homicidal ideation: Pt denied Violent ideation: Pt denied Memory (Recent/Remote): Immediate 3/3, Recent 3/3. Long term is spotty. Attention/Concentration: Able to state months backwards from Dec.-Jan. Laughing inappropriately while completing this. Language: Fluent English. Language to not a barrier to care. Fund of Knowledge: Judgment and Insight: Insight and judgement are fair. |
| DSM 5 Identifiers: | 21 year old Caucasian female with history of depression: hx bullying in school for being over wt. Denied other issue in school. denied suicidal homicidal ideation plan/intent ever. Denied specific phobia, A/V hallucinations but admits to paranoia, impulsivity, irritability, racing thoughts, mind won't stop, excessive energy at times. Anxiety: worries someone may break into house at night. Hx break-ins at grand parents' house when she was child. Nightmares occur weekly. Denied nightmares r/t trauma |
| Formulation of Plan (i.e. Treatment/ Interventions, Differential diagnosis, Medications, Non-pharmacological treatment, Follow-up): | Intervention/Psychotherapy: Supportive counseling, psychoeducational therapy and motivational interview provided. Encouraged to continue use coping skills and natural support system to manage her problems when able. Encouraged her to ask for help when needed. Counseled metabolic risks and life style options. Encouraged healthy life style. In case of suicidal ideation, pt was instructed to call 911 and go to ED. Medication: Discussed use of Abilify for bipolar symptoms and she agrees to take Abilify. She has never taken psychiatric medications before; she has been afraid of the side effects. Medication education including risks, benefits and side effects discussed. Patient was emailed patient information sheet for Abilify. She provided informed verbal consent, and her medication treatment plan was initiated. INCREASE ARIPIRAZOLE (Abilify) to 15mg 1 tablet once daily. D/C ARIPIRAZOLE (ABILIFY) 10MG. START MINIPRESS (PRAZOSIN) 1MG 1 TABLET AT BEDTIME FOR NIGHTMARES. PLAN TO ADD COGENTIN 0.5MG AT HER NEXT VISIT IF RESTLESSNESS PERSISTS. Encouraged patient to use one pharmacy for all prescription medications to reduce risk of drug to drug interaction. Encouraged to maintain sobriety to optimize the therapeutic effects of her medications. Labs/Radiology/Tests/Consultation Counseled benefit to health care. Encouraged patient see PCP and other healthcare providers as recommended. Other: Follow up appointment 2/15/23 @3:30 pm Counseled access to office services schedule emergency services. Patient agreed to call office if problem arises before scheduled return |
| Time with patients (in minutes): | 30 |
| Consult with preceptor (in minutes): | 60 |
| Patient Interaction: | In Person |
PMHNP Case Log
| Date: | 02/22/2023 |
| Rotation Type: | NL 812 Family Psychiatric Nursing III |
| Comments: | |
| Patient Age: | 26 Years |
| SOAP Note: | Chief Complaint/Reason for Encounter: This is a 26 y/o American male. Mr. B. was seen via telehealth for medication management and patient care. The patient reports he has difficulty to fall sleep. As per Mr. B. said when he goes to his bed it takes a while to fall sleep. He denies issues with focusing and concentration. This patient reports a normal energy. He denies feeling sad or depressed' denies lack of energies or feeling worthless. The patient denies suicide and homicidal ideations. No Psychotics symptoms reported or noticed during the interview. No recent falls re[ported. As per this patient, he denies use of alcohol. Mr. Burns reports he smokes cannabis ( up to about 4 gm) daily; and, he smokes cigarettes 15-25 a day. (NR) discussed and recommended but declined by patient. Patient reports medication adherence; denies any side effects and ADRs. Encouraged to continue current psychotropics as prescribed . As per patient stated he is compliance with medication, but he complains of nauseas related to heat/humidity. |
| Age: | 18-49 yrs: |
| Gender: | Male |
| Race: | Black |
| Insurance: | Other |
| Referral: | None |
| Client Presentation: | Mentally stable. Recently stated a new full-time job as a Machine operator, reports he is enjoying it and feels proud of himself. Mr. Burns said the job environment is very good, he only works with men and there`re not drama or conflicts at work. The patient reports he is sleeping better since he started to take melatonin at night. His appetite is good. He denies issues with focusing and concentration. This patient reports a normal energy. He denies feeling sad or depressed, lack of energies or feeling worthless. The patient denies suicide and homicidal ideations. No Psychotics symptoms reported or noticed during the interview. |
| DSM 5 Identifiers: | The DSM-5 defines insomnia as dissatisfaction with sleep quantity or quality, associated with one (or more) of the following symptoms: Difficulty initiating sleep. Difficulty maintaining sleep, characterized by frequent awakenings or problems returning to sleep after awakenings. Name: Insomnia Disorder Disorder Class: Sleep Disorders Disorder Class: Sleep-Wake Disorders A. The predominant complaint is difficulty initiating or maintaining sleep, or nonrestorative sleep, for at least 1 month. B. The sleep disturbance causes clinically significant distress or impairment in social, occupational, educational, academic, behavioral, or other important areas of functioning. C. The sleep disturbance does not occur exclusively during the course of narcolepsy, breathing-related sleep disorder, circadian rhythm sleep disorder, or a parasomnia. F. The insomnia is not better explained by and does not occur exclusively during the course of another sleep-wake disorder (e.g., narcolepsy, a breathing-related sleep disorder, a circadian rhythm sleep-wake disorder, a parasomnia). D. The disturbance does not occur exclusively during the course of another mental disorder (e.g., major depressive disorder, generalized anxiety disorder, a delirium). H. Coexisting mental disorders and medical conditions do not adequately explain the predominant complaint of insomnia. E. The disturbance is not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition. G. The insomnia is not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication). Specify if: With nonsleep disorder mental comorbidity, including substance use disorders With other medical comorbidity With other sleep disorder Specify if: Episodic: Symptoms last at least 1 month but less than 3 months. Persistent: Symptoms last 3 months or longer. Recurrent: Two (or more) episodes within the space of 1 year. Note: Acute and short-term insomnia (i.e., symptoms lasting less than 3 months but otherwise meeting all criteria with regard to frequency, intensity, distress, and/or impairment) should be coded as another specified insomnia disorder reference: Abuse, S., & Administration, M. H. S. (2016). Impact of the DSM-IV to DSM-5 Changes on the National Survey on Drug Use and Health. |
| Formulation of Plan (i.e. Treatment/ Interventions, Differential diagnosis, Medications, Non-pharmacological treatment, Follow-up): | Treatment Plan Medication: #1)Continue Melatonin 3 mg 1 tablet for insomnia #2)Continue Sertraline (Zoloft) 50 mg 1 tablet for anxiety and depressive symptoms. Other: Follow up appt: 2 months |
| Time with patients (in minutes): | 30 |
| Consult with preceptor (in minutes): | 30 |
| Patient Interaction: | Telemedicine |
| Clinical Notes: | Intervention/Psychotherapy: This session the therapeutic focus was on helping the patient improve ability to cope. This session the therapeutic focus was on stabilizing the patient. The focus of today's session was on symptom reduction. The main therapeutic techniques used today were supportive. Stress reduction techniques were also discussed. PATIENT was counseled and educated regarding the risks and benefits of treatment. |
PMHNP Case Log
| Date: | 02/18/2023 |
| Rotation Type: | NL 812 Family Psychiatric Nursing III |
| Comments: | |
| Patient Age: | 48 Years |
| SOAP Note: | Mr. Clemente was seen today via telehealth for medication management. Appears anxious and irritable. The patient describes self as doing Ok on medication but has some issue with sleep for the past few months. The patient states that he only sleeps for two hours a day stated his sleep is very bad. denies daytime naps. The admits to compliance with medication. The patient is requesting for his Klonopin 0.5 mg to be increased to 1mg to improve his sleep. The patient was informed that the Klonopin can be habit forming and it is always advisable to look for alternatives. Verbalized understanding and agreed to try a different medication . The was complaining of feeling worried because he will start a new part time job next week and he want to be able to get good sleep so the he can perform at work. The patient was educated on sleep hygiene. |
| Age: | 18-49 yrs: |
| Gender: | Male |
| Race: | White Non-Hispanic |
| Insurance: | Other |
| Referral: | None |
| Client Presentation: | Mr. Clemente presents awake, alert, oriented x4, casually groomed, and dressed. He us attentive, but looks unhappy. He exhibits speech that is normal in rate, volume, and coherent . Language skills are intact. His affect is flat. Suicidal ideas or intent are denied. There are no apparent signs of hallucinations, delusions, or indicators of psychotic process. Associations are intact, thinking is logical, and thought content appears appropriate. Homicidal ideas or intentions are denied. Insight into problems appears fair. Judgment appears intact. There are and anxiousness and irritability. There are no signs of hyperactive or attentional difficulties. Mr. Clemente's behavior in the session was cooperative. |
| DSM 5 Identifiers: | Bipolar disorder, current episode manic without psychotic features, moderate, F31.12 (ICD-10) (Active) Generalized anxiety disorder, F41.1 (ICD-10) (Active) Major depressive disorder, recurrent, moderate, F33.1 (ICD-10) (Activ |
| Formulation of Plan (i.e. Treatment/ Interventions, Differential diagnosis, Medications, Non-pharmacological treatment, Follow-up): | Instructions / Recommendations / Plan: #1) The patient to continue with current plan of care. #2) Discontinue : hydroxyzine pamoate (hydroxyzine pamoate) 25 mg, capsule #3) STAT Doxepine 25 mg Take one table HS #4) Follow up March 18, 2023. #1) hydroxyzine pamoate (hydroxyzine pamoate) 25 mg, capsule, TAKE 1 CAPSULE BY MOUTH EVERY 12 HOURS, Qty: 60, Refills: 1, Duration: 30, Issued: 1/14/2023 #2) melatonin (melatonin) 10 mg, tablet extended release, Take 1 tablet by mouth at bedtime as directed, Qty: 30, Refills: 1, Duration: 30, Issued: 1/14/2023, USE Rx DISCOUNT CARD: $5.2, BIN:019876, PCN:CHIPPO, Group:EMR, ID:DF409B37F0 #3) Rexulti (brexpiprazole) 2 mg, tablet, Take 1 tablet by mouth once a day D/C 1mg, Qty: 30, Refills: 1, Duration: 30, Issued: 1/14/2023 #4) Vraylar (cariprazine) 4.5 mg, capsule, Take 1 capsule by mouth once a day as directed, Qty: 30, Refills: 2, Duration: 30, Issued: 1/14/2023, USE Rx DISCOUNT CARD: $1458.36, BIN:019876, PCN:CHIPPO, Group:EMR, ID:DF3FF4FD50 |
| Time with patients (in minutes): | 60 |
| Consult with preceptor (in minutes): | 30 |
| Patient Interaction: | In Person |
| Clinical Notes: | his session the patient's focus was on feelings of anxiety. Coping with depression was also discussed. The problem of non compliance was also discussed in today's session. The focus of today's session was on educating the patient about symptoms. Mr. Clemente was counseled and educated regarding recent diagnostic results. Mr. Clemente was counseled and educated regarding the importance and scheduling of all follow up instructions. Mr. Clemente was counseled regarding the need for compliance with all medical instructions, particularly having to do with medication. Mr. Clemente was given medication instructions and education. Mr. Clemente was counseled and educated in ways to reduce risk factors. Mr. Clemente was counseled and educated regarding the risks and benefits of treatment. Mr. Clemente was counseled and educated regarding the risks and benefits of the recommended procedure. |
PMHNP Case Log
| Date: | 02/18/2023 |
| Rotation Type: | NL 812 Family Psychiatric Nursing III |
| Comments: | |
| Patient Age: | 28 Years |
| Patient Sex: | M |
| Patient Ethnicity: | Black or African American |
| SOAP Note: | History: Mr. Perry is a unmarried, unemployed African-American male, age 28-year-old who presents to this practice today to established care. His chief complaint is, " I want to find inner peace". He was escorted by his mother today to establish care. The patient walk-in, alert and oriented in no sign of acute mental disturbances. On assessment, the patient states that he is experiencing lack of interest in activities that he once used to enjoy. The patient states that all he does is sleeping " I love my sleep" he continued jokingly. Mr. Perry was complaining of lack of interest daily activities and his frustration about how he is being alienated by society rules and he is nor ready to abide to any rules. The patient states that he is always feeling that way. As per mother, she notices changes in patient behaviors since returning from Michigan after leaving a relationship with boyfriend that did not go well. Reportedly, the patient refused to go to work, spent most time in bed sleeping, not taking care of self. The patient not eating and not taking care of self. He is alert and oriented to all spheres; pleasant and was laughing during encounter. Patient is well articulated with good eye contact and fair insight. He denies allergy to food and medication. The patient states that his goal for treatment to find his inner self and peace. Denies any suicidal and homicidal ideation; plan or intent to hurt self or others. Support therapy rendered. Past Psychiatric History: As far as can be determined Mr. Perry's psychiatric history is entirely negative. There have been no psychiatric hospitalizations, no prior psychiatric treatment, and no history of assaultive or suicidal behavior. There is no history of depressions, anxiety attacks, or other common psychiatric symptoms. No psycho tropic medications have ever been taken. There is no history of non compliance with medication or treatment. Information Received From: *The family -mother Psychiatric Hospitalization: Mr. Perry has never been psychiatrically hospitalized. Outpatient Treatment: Has never received outpatient mental health treatment. Suicidal/Self Injurious: Patient reports history of suicide attempt during his childhood, stated three times. "I attempted to jump in front of a bus around age 14 and there was a time, I wanted to jump out of a car. However, this patient reports at this time, even though he denied history of inpatient psychiatric hospitalization and previously denied past history of psychiatric mental illness. He reports he was hospitalized at Newark Beth Israel for about two days when he attempted to end his life. Mother was called into the office with patient's consent. Noteworthy, mother id not accept the fact that Darrell was depressed and wanted to kill himself at age 14. Mother reported history of sexual abuse towards Darrell by his cousins. Darrell reported it wasn't a sexual abuse. Patient denies any intrusive thoughts nor flashbacks regarding the incident. Addiction/Use History: Marijuana use x 5 years, get it from his partner who buys it from the dispensary, smokes daily. Alcohol reports as "once in a blue". He reports occasional tobacco use which he said he mixes with weed. Social/Developmental History: Mr. Perry, is a 28 year old Black male, unmarried, identified self as Bisexual man who was born in Brooklyn and raised in Jersey by both parents. The patient has completed high school and attended one full semester of college. He joined the police force and resigned after almost 4 years of service. He decided to leave his job because because he wanted to move to Michigan to stay with his boy friend. Patient left Michigan and back to jersey because the relationship did not work out. Childhood History: Mr. Perry was born in NY, moved to NJ in 2002, raised by both parents but father left when he was age 16. Patient's and father still communicates. Abuse/Neglect: Patient's mother reports he was molested by his paternal cousins. Barriers to Treatment: None Children: Mr. Perry has no children. Community Providers: PCP Dr Lecant @ 92 Nothfield Rd, West Orange. Criminal Justice History: Mr. Perry has never been arrested or incarcerated, has no history of violence, and is not currently under any kind of court supervision. Cultural and Religious Considerations: "I am spiritual and not religious". Educational History: Mr. Perry attended college for one full semester , but did not graduate. Employment History: Patient has not been working for 5 years. Denies desire to go work. Gender/Sexual Identity: Current Gender identity: *Male Sexual Orientation: *Bisexual Housing Status: Lives with mother and maternal grandma (Nana). Patient has an older brother whom he does not get along with. Military History: Mr. Perry never served in the military. But was in the Police force for almost 3 years until resigned. Personal Goal(s): Mr. Perry's goal(s) are as follows: Reports his goal for treatment as "inner peace" Relationship/Marriage: Patient is currently in relationship with a Caucasian male guy" ( David) Family History: Grandmother (maternal) was diagnosed with Depression. Uncle (maternal) diagnosed with Depression. Medical History: Medical history is negative and Mr. Perry has no history of serious illness, injury, operation, or hospitalization. Does not have a history of asthma, seizure disorder, head injury, concussion or heart problems. No medications are currently taken. |
| Age: | 18-49 yrs: |
| Gender: | Male |
| Race: | Black |
| Insurance: | Other |
| Referral: | None |
| Client Presentation: | Mr. Perry presents as friendly, attentive, disheveled, uncommunicative, normal weight, Weight: 160 LBS Height 5 "7". His speech is normal in rate, volume, and articulation, and is spontaneous. with normal volume. There is no difficulty naming objects or repeating phrases. Demeanor is sad. Wishes to be dead have been occurring but suicidal intentions are denied. Signs of moderate depression are present. There are no apparent signs of hallucinations, delusions, bizarre behaviors, or other indicators of psychotic process. Associations are intact, thinking is logical, and thought content appears appropriate. He wishes to be dead but denies any suicidal ideas or intentions. Denial is convincing. Homicidal ideas or intentions are denied. Insight into problems appears to be poor. Judgment appears poor. There are no signs of anxiety. There are no signs of hyperactive or attentional difficulties. No signs of withdrawal or intoxication are in evidence. |
| DSM 5 Identifiers: | Major depressive disorder, recurrent, moderate, F33.1 (ICD-10) (Active) |
| Formulation of Plan (i.e. Treatment/ Interventions, Differential diagnosis, Medications, Non-pharmacological treatment, Follow-up): | Instructions / Recommendations / Plan: START AUVELITY (DEXTROMETHORPHAN-BUPROPION) 45-105MG ONCE DAILY. #1)Patient and mother agreed to resume therapist services. #12 Auvelity (dextromethorphan-bupropion) 45-105 mg, tablet, IR and ER, biphasic, Take 1 tablet by mouth once a day, Qty: 30, Refills: None, Duration: 30, Issued: 2/18/202 #3) Follow up Marc 18, 2023 |
| Time with patients (in minutes): | 90 |
| Consult with preceptor (in minutes): | 90 |
| Patient Interaction: | In Person |
PMHNP Case Log
| Date: | 11/16/2022 |
| Rotation Type: | NL 812 Family Psychiatric Nursing III |
| Comments: | |
| Patient Age: | 20 Years |
| Patient Sex: | M |
| Patient Ethnicity: | Black or African American |
| SOAP Note: | Mr. BA is a 20-year-old male. His chief complaint is" pt has depression an anxiety since 13 y/o. Patient stated he is doing much better. Over the last 2 weeks he denied lack of motivation or lack of energy, Pt reported sadness sometimes, denied concentration issues, denied mood swings. Patient denied SI/HI/VH. Patient stated he started dating a boy last week and the relationship is been ok. As per patient when he started taking the Lexapro he was having stomach pain but he denied any current pain or other side effects from the medication. Pt educated to take the medication after eat and instructed to get an appt with the PCP for evaluation and treatment if the stomach pain came back. He verbalized understanding. Patient expressed he has plan in the future to go back to the school to improve his English and start technical career. |
| Age: | 18-49 yrs: |
| Gender: | Male |
| Race: | Black |
| Insurance: | Other |
| Referral: | None |
| Client Presentation: | Mr. BA. presents as calm, Mr. BA. presents as friendly, attentive, communicative, casually groomed, normal weight, and relaxed. He exhibits speech that is normal in rate, volume, and articulation and is coherent and spontaneous. Language skills are intact. Mood presents as normal with no signs of either depression or mood elevation. There are no apparent signs of hallucinations, delusions, bizarre behaviors, or other indicators of psychotic process. Associations are intact, thinking is logical, and thought content appears appropriate. Suicidal ideas or intent are denied. Homicidal ideas or intentions are denied. Cognitive functioning and fund of knowledge are intact and age appropriate. Short- and long-term memory are intact, as is ability to abstract and do arithmetic calculations. This patient is fully oriented. Insight into problems appears normal. Judgment appears intact. There are no signs of anxiety. There are no signs of hyperactive or attentional difficulties. Mr. BA's behavior in the session was cooperative and attentive with no gross behavioral abnormalities. No signs of withdrawal or intoxication are in evidence. |
| DSM 5 Identifiers: | Major depressive disorder, recurrent, moderate, F33.1 (ICD-10) (Active) Cyclothymic disorder, F34.0 (ICD-10) (Active) |
| Formulation of Plan (i.e. Treatment/ Interventions, Differential diagnosis, Medications, Non-pharmacological treatment, Follow-up): | Instructions / Recommendations / Plan: #1 Continue #2) Lexapro (escitalopram oxalate) 5 mg, tablet, Take 1 tablet by mouth once a day, Qty: 30, Refills: None, Duration: 30. #2) 11/2/2022 Started Lexapro 10mg PO 1/2 tab QHS |
| Time with patients (in minutes): | 60 |
| Consult with preceptor (in minutes): | 60 |
| Patient Interaction: | In Person |
| Clinical Notes: | This session the patient's focus was on feelings of sadness. This session the therapeutic focus was on helping the patient improve ability to cope. Mr. B was counseled regarding the need for compliance with all medical instructions, particularly having to do with medication. Mr. B was given medication instructions and education. Mr. B was counseled and educated in ways to reduce risk factors. Mr. B was counseled and educated regarding the risks and benefits of treatment. |
PMHNP Case Log
| Date: | 01/27/2023 |
| Rotation Type: | NL 812 Family Psychiatric Nursing III |
| Comments: | |
| Patient Age: | 24 Years |
| Patient Sex: | M |
| Patient Ethnicity: | White |
| SOAP Note: | M.C. is a 23 year old male who arrived to the office today for a follow up appointment. He was last seen on 12/9/22 and reports doing better since. Patient reports he is in school to become a history teacher. Verbalized he still experiences anxiety symptoms when thinking about school and his family. Reports feeling like a failure when his father compares him to his other siblings. Verbalized his coping skills include talking to friends. States he attends therapy weekly and has been helpful. Appetite normal, sleep varies between 5-10 hours at night. Sates he feels well rested in the morning. Patient encouraged to have a night time routine. Patient reports he has a strong support system consisting of his close friends. Patient reports he has been experiencing difficulty concentrating in school, easily distracted, verbalized leaving tasks incomplete. Denies thoughts of hurting himself, suicide, or hallucinations. Current weight 140lbs, Height 5'10. |
| Age: | 18-49 yrs: |
| Gender: | Male |
| Race: | White Non-Hispanic |
| Insurance: | Other |
| Referral: | None |
| Client Presentation: | Mr. C. presents as calm, Mr. C. presents as friendly, Mr. C. appears happy, attentive, communicative, and relaxed. He exhibits speech that is normal in rate, volume, and articulation and is coherent and spontaneous. Language skills are intact. Mood presents as normal with no signs of either depression or mood elevation. Affect is appropriate, full range, and congruent with mood. Associations are intact and logical. Suicidal ideas or intent are denied. Homicidal ideas or intentions are denied. Insight into problems appears normal. Judgment appears intact. There are no signs of anxiety. There are no signs of hyperactive or attentional difficulties. Mr. C's behavior in the session was cooperative and attentive with no gross behavioral abnormalities. |
| DSM 5 Identifiers: | Generalized anxiety disorder, F41.1 (ICD-10) R/O Autistic disorder, F84.0 (ICD-10) Dysthymic disorder, F34.1 (ICD-10) |
| Formulation of Plan (i.e. Treatment/ Interventions, Differential diagnosis, Medications, Non-pharmacological treatment, Follow-up): | Current weight 140lbs, Height 5'10. Screenings: GAD-7- exact score of 5 ADHD symptom screening. Plan: 1. Wellbutrin 150mg XR. Take 1 tab PO daily in the morning. Possible Side effects discussed with patient. 2. Follow up on 1/27/23 at 10am. 3. Continue weekly therapy Patient in agreement with the plan. No further questions or concerns were voiced. |
| Time with patients (in minutes): | 60 |
| Consult with preceptor (in minutes): | 60 |
| Patient Interaction: | In Person |
| Clinical Notes: | Summary: This session the patient's focus was on feelings of anxiety. Family problems were also discussed. Relationship problems were also discussed. This session the therapeutic focus was on helping the patient improve communication skills. The focus of today's session was on stabilizing the patient. The focus of today's session was on educating the patient about symptoms. This session the therapeutic focus was on emotional support. Therapeutic efforts also included encouragement to ventilate feelings. Help identifying the sources of certain feelings was also provided. Mr. Couto was counseled and educated regarding the importance and scheduling of all follow up instructions. Mr. C. was given medication instructions and education. . |
PMHNP Case Log
| Date: | 12/20/2022 |
| Rotation Type: | NL 812 Family Psychiatric Nursing III |
| Comments: | |
| Patient Age: | 12 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| SOAP Note: | Ms. SM, this 12 year old female, is accompanied by her mom and dad for in person visit for medication management. Medication is helping her through her homework. Mom allows structure and allows her to take breaks while she is completing her homework. Pt is able to complete homework easier when her parents are home. Brother's behaviors makes her annoyed, anxious stressed out. Pt has spoken to her brother and dad. Dad likes to have her call his house her home. She does not agree and calls it her dads house. Trying to communicate to dad through Anna. Pt was told by parents to leave the room if she is uncomfortable and is asked to come back when she leaves the room so she is often confused. Lucas has read her diary, gone through her texts messages so she doesn't want her brother to use her phone to talk to dad. She has asked parents not to drink Etoh when they are in the house because she and her brother has not had a good experience when other people drank alcohol in their presence. She has been upset with both her mom and dad because she feels that they drink alcohol when she and her brother of with them. |
| Age: | 12-17 yrs: |
| Gender: | Female |
| Race: | White Non-Hispanic |
| Insurance: | Other |
| Referral: | None |
| Client Presentation: | Ms. S presents as irritable, appears calm, attentive, communicative, well groomed, She exhibits speech that is normal in rate, volume, and articulation and is coherent and spontaneous. Language skills are intact. Mood presents as normal with no signs of either depression or mood elevation. Affect is appropriate, full range, and congruent with mood. There are no apparent signs of hallucinations, delusions, bizarre behaviors, or other indicators of psychotic process. Associations are intact, thinking is logical, and thought content appears appropriate. Homicidal ideas or intentions are denied. Insight into problems appears normal. Judgment appears intact. There are no signs of anxiety. Ms S is restless. the patient 's behavior in the session was cooperative and attentive with no gross behavioral abnormalities. |
| DSM 5 Identifiers: | Generalized anxiety disorder, F41.1 (ICD-10) Attention-deficit hyperactivity disorder, predominantly inattentive type, F90.0 (ICD-10) |
| Formulation of Plan (i.e. Treatment/ Interventions, Differential diagnosis, Medications, Non-pharmacological treatment, Follow-up): | Instructions / Recommendations / Plan: #1) Adderall XR (dextroamphetamine-amphetamine) 5 mg, capsule, extended release 24hr, Take 1 capsule by mouth every morning #2 Follow up in 4 weeks, Feb 17 |
| Time with patients (in minutes): | 60 |
| Consult with preceptor (in minutes): | 60 |
| Patient Interaction: | In Person |
| Clinical Notes: | The patient expressed many angry feelings this session. Feelings of anxiety were also expressed. Feelings of frustration were also expressed. Family problems were also discussed. The patient also discussed interpersonal problems. The focus of today's session was on helping to increase insight and understanding. This session the therapeutic focus was on helping the patient improve communication skills. The patient was today given emotional support. Stress reduction techniques were also discussed. Help identifying the sources of certain feelings was also provided. Ms S was counseled and educated regarding recent diagnostic results. Stella was counseled and educated regarding the importance and scheduling of all follow up instructions. |
PMHNP Case Log
| Date: | 12/20/2022 |
| Rotation Type: | NL 812 Family Psychiatric Nursing III |
| Comments: | |
| Patient Age: | 6 Years |
| Patient Sex: | M |
| Patient Ethnicity: | White |
| SOAP Note: | Mr. LM presents to office and is accompanied by his mother and father for medication management. As per dad, the patient has not noticed any mood swings, no change in appetite or sleep. Pt is engaged in school basketball. As per mom, behavior was escalating over the last couple of years. Pt has a therapist that comes to the home for two hours a week since Aug 2022. Mom mentioned that the patient has a connection with a therapist, Anna. Mr LM has a hesitancy in speaking about his feelings despite having a connection with the therapist, Anna. No outbursts noted in the last 2 weeks. Pt continues to have difficulty sleeping. Mom notes a change in mood when he drinks Gatorade, or fast food, chicken nuggets and tries to change his diet. Still no change in sleep. He wakes up in the middle of the night. Parents are in the process of a divorce and live in 2 separate households. |
| Age: | 5-11 yrs: |
| Gender: | Male |
| Race: | White Non-Hispanic |
| Insurance: | Other |
| Referral: | None |
| Client Presentation: | Mr. LM appears irritable, distracted, communicative, normal weight, and tense. and appears anxious. He exhibits speech that is normal in rate, volume, and articulation and is coherent and spontaneous. Language skills are intact. Mood presents as normal with no signs of either depression or mood elevation. Affect is appropriate, full range, and congruent with mood. There are no apparent signs of hallucinations, delusions, bizarre behaviors, or other indicators of psychotic process. Associations are intact, thinking is logical, and thought content appears appropriate. Insight into problems appears to be poor. Judgment appears to be poor. There are signs of anxiety. He is easily distracted. Lucas displayed defiant behavior during the examination. Lucas displayed uncooperative behavior during the examination. |
| DSM 5 Identifiers: | Major depressive disorder, single episode, moderate, F32.1 (ICD-10) In younger children, symptoms of depression may include sadness, irritability, clinginess, worry, aches and pains, refusing to go to school, or being underweight. In teens, symptoms may include sadness, irritability, feeling negative and worthless, anger, poor performance or poor attendance at school, feeling misunderstood and extremely sensitive. Feelings of worthlessness or guilt, fixating on past failures or self-blame. Trouble thinking, concentrating, making decisions and remembering things. Frequent or recurrent thoughts of death, suicidal thoughts, suicide attempts or suicide. |
| Formulation of Plan (i.e. Treatment/ Interventions, Differential diagnosis, Medications, Non-pharmacological treatment, Follow-up): | Major depressive disorder, single episode, moderate, F32.1 (ICD-10) Instructions / Recommendations / Plan: #1) Prozac (fluoxetine) 20 mg, capsule, Take 1 capsule by mouth once a day at bedtime, Qty: 30, Refills: 1 #2) Follow up in 4 weeks 2/17/2023 |
| Time with patients (in minutes): | 60 |
| Consult with preceptor (in minutes): | 60 |
| Patient Interaction: | In Person |
| Clinical Notes: | This session the patient's focus was on feelings of anger. Feelings of anxiety were also expressed. Feelings of frustration were also expressed. How to cope with depression was also discussed. Problems in the family were also discussed by the patient. Problematic relationships were also discussed. School problems were also discussed. This session the therapeutic focus was on helping the patient improve communication skills. The focus of today's session was on helping the patient improve coping skills. The patient was today given emotional support. Stress reduction techniques were also discussed. Therapeutic efforts also included an investigation, with the patient, of the patterns of certain behaviors. Help in exploring the sources of certain behaviors was also given to the patient today. Mr LM was counseled and educated regarding the importance and scheduling of all follow up instructions. Lucas was counseled regarding the need for compliance with all medical instructions, particularly having to do with medication. The patient was given medication instructions and education. |
PMHNP Case Log
| Date: | 01/14/2023 |
| Rotation Type: | NL 812 Family Psychiatric Nursing III |
| Comments: | |
| Patient Age: | 41 Years |
| Patient Sex: | M |
| Patient Ethnicity: | Black or African American |
| SOAP Note: | Mr. T. was seen today in person for medication management. The patient was escorted to his residence staff Ms. A. The patient alert and oriented to self. The patient walks into the examination room in steady gait and broad smile. He was able to identify his name and date of birth. He was able to identify items in the room and color. The patient denies any discomfort. as per staff, the patient is doing well on medication, no behavioral issue observed or reported. No angry outburst reported. Staff reported that the patient has good appetite and sleeps well. Last visit with primary care doctor was 10/24/2023. Pt attends day program Monday to Friday 0830 to 1430. No fall reported. |
| Age: | 18-49 yrs: |
| Gender: | Male |
| Race: | Black |
| Insurance: | Other |
| Referral: | Other |
| Client Presentation: | Exam: Mr. T presents as calm, Mr. T appears friendly, attentive, communicative, Mood presents as normal with no signs of either depression or mood elevation. Affect is appropriate, full range, and congruent with mood. There are no apparent signs of hallucinations, delusions, bizarre behaviors, or other indicators of psychotic process. Vocabulary and fund of knowledge suggest cognitive functioning in the intellectually disabled range. He is easily distracted. |
| DSM 5 Identifiers: | Intermittent explosive disorder, F63.81 (ICD-10) Moderate intellectual disabilities. IQ level 35-40 to 50-55., F71 (ICD-10) According to the DSM_5, intermittent explosive disorder is characterized by impulsive and aggressive outbursts. These outbursts can be in the form of verbal tirades or physical aggression. These outbursts are impulsive, not premeditated and extremely difficult to predict. Additionally, the outbursts happen without trigger or are not proportionate to the preceding trigger or stressor. To qualify for diagnosis, outbursts must occur about twice a week for at least three months (American Psychiatric Association, 2013) |
| Formulation of Plan (i.e. Treatment/ Interventions, Differential diagnosis, Medications, Non-pharmacological treatment, Follow-up): | Instructions / Recommendations / Plan: #1) Risperdal (risperidone) 0.5 mg, tablet, Take 1 tablet by mouth at bedtime Take along with 2mg @ 8pm, Qty: 30, Refills: 2, Duration: 30, #2) Risperdal (risperidone) 2 mg, tablet, Take 1 tablet by mouth at bedtime Take 1 tablet @ 8pm, Qty: 30, Follow up : MARCH 11TH, 2023 @ 2:40PM |
| Time with patients (in minutes): | 30 |
| Consult with preceptor (in minutes): | 30 |
| Patient Interaction: | In Person |
| Clinical Notes: | Therapy Content/Clinical Summary: Mr. S.T and his staff was counseled and educated regarding the risks and benefits of treatment. |
PMHNP Case Log
| Date: | 01/14/2023 |
| Rotation Type: | NL 812 Family Psychiatric Nursing III |
| Comments: | |
| Patient Age: | 30 Years |
| Patient Sex: | M |
| Patient Ethnicity: | White |
| SOAP Note: | Mr C.O was seen today for his follow up care. The patient describes self as " feeling well" but some environment factors are affecting his focus and there still no improvement as he still feeling tired. when ask to elaborate on those environmental factors the patient states that he is going through some transition at work. There will be a reassignment of position and location. Denies having a promotion stating, " maybe a reshuffling". The patient report feeling tired, not related to medication or work stating that this is common issue for him. Sleep six hours a day. Appetite is consistent, the patient report fast metabolism. And he is trying to become a vegetarian. He wants to try something new. Currently living in a shared room, denies any issue with roommate. The patient denies suicidal and homicidal ideation. Admits compliance with medication stating Adderall 30 mg work better for him. The patient states he will travel to Ohio in two day and will need medication refill so that he has enough supply during his stay in Ohio. Support therapy rendered. DENNIS EMMANUEL, APN, INTERN HUSSON UNIVERSITY |
| Age: | 18-49 yrs: |
| Gender: | Male |
| Race: | White Non-Hispanic |
| Insurance: | Other |
| Referral: | None |
| Client Presentation: | Mr. C.O presents as calm, attentive, communicative, He exhibits speech that is normal in rate, volume, and articulation and is coherent and spontaneous. Language skills are intact. Affect is appropriate, full range, and congruent with mood. There are no apparent signs of hallucinations, delusions, bizarre behaviors, or other indicators of psychotic process. Associations are intact, thinking is logical, and thought content appears appropriate. Suicidal ideas or intent are denied. Homicidal ideas or intentions are denied. Insight into problems appears fair. Judgment appears fair. There are no signs of anxiety. There are no signs of hyperactive or attentional difficulties. Mr. C.O 's behavior in the session was cooperative and attentive with no gross behavioral abnormalities. |
| DSM 5 Identifiers: | Attention-deficit hyperactivity disorder, other type, F90.8 (ICD-10) Inattention - Does not pay close attention to details, difficulty sustaining attention, does not listen when spoken to directly, does not follow instructions/finish schoolwork, difficulty organizing tasks/activities, avoids sustained mental effort, loses important things, easily distracted, forgetful. Hyperactivity-Impulsivity - Fidgets/squirms, leaves seat, runs about/climbs, difficulty playing quietly, often 'on the go,' talks excessively, blurts out answers before questions completed, difficulty waiting one's turn, interrupts or intrudes on others. Major depressive disorder, single episode, unspecified, F32.9 (ICD-10) Symptoms of Major Depressive Disorder Feelings of sadness and hopelessness. Loss of interest or pleasure in activities. Loss or weight or weight gain. Difficulties sleeping or excessive sleepiness. Noticeable restlessness or slowness. Lack of energy. Troubles concentrating and indecisiveness. |
| Formulation of Plan (i.e. Treatment/ Interventions, Differential diagnosis, Medications, Non-pharmacological treatment, Follow-up): | Instructions / Recommendations / Plan: #1) The patient to continue taking medication as prescribes. dextroamphetamine-amphetamine (dextroamphetamine-amphetamine) 30 mg. #2) Follow up February 11th 2023 @ 1145 #1) Adderall XR (dextroamphetamine-amphetamine) 20 mg, capsule, extended release 24hr, Take 1 capsule by mouth twice a day 7am and 2pm, Qty: 60, Refills: |
| Time with patients (in minutes): | 30 |
| Consult with preceptor (in minutes): | 30 |
| Patient Interaction: | In Person |
| Clinical Notes: | Therapy Content/Clinical Summary: This session the patient's focus was on feelings of anxiety. Interpersonal problems were also discussed by the patient. The focus of today's session was on helping the patient improve coping skills. The focus of today's session was improvement of problem-solving skills. This session the therapeutic focus was on the exploration of patterns of behavior. Mr. CANNON was counseled regarding the need for compliance with all medical instructions, particularly having to do with medication. Mr. CO was given medication instructions and education. Mr. CANNON was counseled and educated regarding the risks and benefits of the recommended procedure. |
PMHNP Case Log
| Date: | 01/14/2023 |
| Rotation Type: | NL 812 Family Psychiatric Nursing III |
| Comments: | |
| Patient Age: | 70 Years |
| Patient Sex: | M |
| Patient Ethnicity: | White |
| SOAP Note: | Mr. Harris is a 70-year-old Caucasian male who was seen today in person for medication management. The patient was escorted to his residence staff Ms. Aeisha. The patient in not verbal and not able to provide pertinent health information. The patient walks into the examination room in steady gait. Flat affect. He was able to follow simple command. He removed his jacket when prompted. As per staff, the patient is doing well on medication, no behavioral issue observed or reported. No angry outburst reported, no suicidal gesture. Staff reported that the patient has good appetite and sleeps well. Last visit with PCP up to date. Pt attends day program Monday to Friday 0830 to 1430. No fall reported. current Weight :165 Lbs |
| Age: | >=65 yrs: |
| Gender: | Male |
| Race: | White Non-Hispanic |
| Insurance: | Other |
| Referral: | Other |
| Client Presentation: | Exam: Mr. Chernin presents as calm, casually groomed attentive, uncommunicative, and relaxed. His speech cannot be tested. It is not possible to determine if underlying psychotic symptoms are present. No suicide gestures reported nor observed. Vocabulary and fund of knowledge suggest cognitive functioning in the intellectually disabled range. No signs of withdrawal or intoxication are in evidence. |
| DSM 5 Identifiers: | Anxiety disorder, unspecified, F41.9 (ICD-10) Autistic disorder, F84.0 (ICD-10) Severe intellectual disabilities. IQ level 20-25 to 35-40, F72 (ICD-10) |
| Formulation of Plan (i.e. Treatment/ Interventions, Differential diagnosis, Medications, Non-pharmacological treatment, Follow-up): | Instructions / Recommendations / Plan: 1) Melatonin 3 mg PO Q PM. Take 1 tablet by mouth at 8 pm for insomnia. #2) Continue Desyrel 50mg PO Q PM. Take one Tablet by mouth at 8 pm. #3) Seroquel 25 mg PO. Take 1 tablet by mouth twice a day@ 8 am and 8 pm for agitation/insomnia #4) Risperdal 1 mg PO Take 1 tablet by mouth twice a day @ 8am and 8 pm for agitation and anxiety. #5) Risperdal (risperidone) 0.5 mg, tablet, Take 1 tablet by mouth twice a day @ 8 am and 8 pm. for agitation and anxiety. #6) Klonopin (Clonazepam) 0.5mg, tablet, take 1 tablet by mouth twice a day as directed. Give at 8am and 8pm. Follow up: March 11, 2023 @ 11am |
| Time with patients (in minutes): | 30 |
| Consult with preceptor (in minutes): | 60 |
| Patient Interaction: | In Person |
| Clinical Notes: | Therapy Content/Clinical Summary: The focus of today's session was discussing ways to improve coping skills. The staff was counseled and educated regarding the importance of scheduling of all follow up appointments. Mr. Chernin`s caregiver was counseled regarding the need for compliance with all medical instructions, particularly having to do with medication. The staff was also counseled on the importance to report worsening of dysphagia symptoms. |
PMHNP Case Log
| Date: | 01/13/2023 |
| Rotation Type: | NL 812 Family Psychiatric Nursing III |
| Comments: | |
| Patient Age: | 30 Years |
| Patient Sex: | M |
| Patient Ethnicity: | Black or African American |
| SOAP Note: | Mr. hHlmes was seen today for symptoms and medication management. Alert and oriented , in no sign of acute mental disturbances. He describes self as doing good but needs refill for his Zoloft 50 mg daily. Alert and orient in no sign of acute mental disturbances. Appetite:normal. Sleep : normal. Denies any thoughts of hurting self or others. The patient endorses a diagnosis of PTSD; states that he is experiences nightmares at times. Last episode WAS two days ago. The patient states that Zoloft 50 mg work better for him and would like a refill of same. Denies feeling worthless and helpless. Admits to smoking marijuana for PTSD management. Last use was yesterday. Patient in no sign of acute withdrawal symptoms. Denies the use of all other drugs. Support therapy rendered. Received instructions to pick up his medication and his local pharmacy. |
| Age: | 18-49 yrs: |
| Gender: | Male |
| Race: | Black |
| Insurance: | Other |
| Referral: | None |
| Client Presentation: | Mr. H presents as calm, attentive, well groomed, and relaxed. He exhibits speech that is normal in rate, volume, and articulation and is coherent and spontaneous. Language skills are intact. Affect is appropriate, full range, and congruent with mood. There are no apparent signs of hallucinations, delusions, bizarre behaviors, or other indicators of psychotic process. Associations are intact, thinking is logical, and thought content appears appropriate. Suicidal ideas or intent are denied. Homicidal ideas or intentions are denied. Insight into problems appears fair. Judgment appears fair. There are no signs of anxiety. There are no signs of hyperactive or attention difficulties. Mr. H's behavior in the session was cooperative and attentive with no gross behavioral abnormalities. No signs of withdrawal or intoxication are in evidence. |
| DSM 5 Identifiers: | Generalized anxiety disorder, F41.1 (ICD-10) |
| Formulation of Plan (i.e. Treatment/ Interventions, Differential diagnosis, Medications, Non-pharmacological treatment, Follow-up): | #1) 12/20/2022 Started Zoloft 25 mg PO Daily x30 days # 30 (thirty) None refills Order given by Titi Oyawusi, PMHNP on 12/20/2022 4:44:39 PM #2) 12/20/2022 Started Hydroxyzine 50 mg PO QHS PRN # 30 (thirty) (Anxiety) Order given by Titi Oyawusi, PMHNP on 12/20/2022 4:44:39 PM #3) Minipress (prazosin) 1 mg, capsule, Take 1 capsule by mouth at bedtime, Qty: 30, Refills: None, Duration: 30, Issued: 1/13/2023, USE Rx DISCOUNT CARD: $81.59, BIN:019876, PCN:CHIPPO, Group:EMR, ID:DFBE0E6031 #4) sertraline (sertraline) 50 mg, tablet, Take 1 tablet by mouth once a day, Qty: 30, Refills: None, Duration: 30, Issued: 1/13/2023, USE Rx DISCOUNT CARD: $32.11, BIN:019876, PCN:CHIPPO, Group:EMR, ID:DF6043CF79 Return 4 weeks, or earlier if needed. |
| Time with patients (in minutes): | 60 |
| Consult with preceptor (in minutes): | 60 |
| Patient Interaction: | In Person |
| Clinical Notes: | Feelings of helplessness predominated this session. Feelings of hopelessness were also expressed. The problem of non compliance was also discussed in today's session. This session the therapeutic focus was on helping to increase insight and understanding. This session the therapeutic focus was on helping the patient improve ability to cope. This session the therapeutic focus was on reducing symptoms. Mr. H was counseled and educated regarding the importance and scheduling of all follow up instructions. Mr. H was given medication instructions and education. Mr. H was counseled and educated regarding the risks and benefits of treatment. Mr. H was counseled and educated regarding the risks and benefits of the recommended procedure. |
PMHNP Case Log
| Date: | 01/13/2023 |
| Rotation Type: | NL 812 Family Psychiatric Nursing III |
| Comments: | |
| Patient Age: | 6 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| SOAP Note: | The patient was seen today via telehealth for psychotherapy and medication management. The patient was accompanied by her mother ( Ms. Fantasia). As per mother, the patient behaviors is not improving. The patient issues in school, exhibiting frequent increase in impulsivity. Patient's mother states that the medication Ritalin is not working and these behaviors are new to her. Patient mother denies any change in sleep pattern. Appetite is good and patient gains six pounds since last visit. As per mother, patient current pattern of behaviors is new to her and she is requesting a different medication approach to manage impulsivity and agitation. |
| Age: | 5-11 yrs: |
| Gender: | Female |
| Race: | White Non-Hispanic |
| Insurance: | Other |
| Referral: | None |
| Client Presentation: | The patient was heard on the background , did not make it to the camera. Mental status not completed. |
| DSM 5 Identifiers: | Deficits in social-emotional reciprocity, ranging, for example, from abnormal social approach and failure of normal back-and-forth conversation; to reduced sharing of interests, emotions, or affect; to failure to initiate or respond to social interactions. Deficits in nonverbal communicative behaviors used for social interaction, ranging, for example, from poorly integrated verbal and nonverbal communication; to abnormalitiesineye contact and body language or deficits in understanding and use of gestures; to a total lack of facial expressions and nonverbal communication. Deficits in developing, maintaining, and understanding relationships, ranging, for example, from difficulties adjusting behavior to suit various social contexts; to difficulties in sharing imaginative play or in making friends; to absence of interest in peers. |
| Formulation of Plan (i.e. Treatment/ Interventions, Differential diagnosis, Medications, Non-pharmacological treatment, Follow-up): | #1) DISCONTINUED: methylphenidate HCl (methylphenidate hcl) 5 mg/5 mL, solution, Take 2 1/2 ml by mouth twice a day as directed 7AM and 12 noon, #2) Risperdal (risperidone) 1 mg/mL, solution, Take 1/2 ml by mouth every evening, Qty: 15, Refills: None. #3) Dyanavel XR (amphetamine) 2.5 mg/mL, suspen, IR - ER, biphasic 24hr, Take 1 ml once a day as directed, Qty: 30, Refills: None, Duration: 30, Issued: 1/13/2023 Return 4 weeks, or earlier if needed |
| Time with patients (in minutes): | 60 |
| Consult with preceptor (in minutes): | 60 |
| Patient Interaction: | In Person |
| Clinical Notes: | Therapy Content/Clinical Summary: Angry feelings predominated this session. Feelings of frustration were also expressed. Coping with impulsivity was also discussed. Problems in school were also discussed. The main therapeutic techniques used today were supportive. Help in exploring the patterns of certain behaviors was also given to the care giver today. Care giver was counseled and educated regarding the risks and benefits of the recommended new medication. Care giver was counseled regarding the need for compliance with all medical instructions, particularly having to do with medication. |
PMHNP Case Log
| Date: | 12/30/2022 |
| Rotation Type: | NL 812 Family Psychiatric Nursing III |
| Comments: | |
| Patient Age: | 23 Years |
| Patient Sex: | M |
| Patient Ethnicity: | White |
| SOAP Note: | M.C. is a 23 year old male who arrived to the office today for a follow up appointment. He was last seen on 12/9/22 and reports doing better since. Patient reports he is in school to become a history teacher. Verbalized he still experiences anxiety symptoms when thinking about school and his family. Reports feeling like a failure when his father compares him to his other siblings. Verbalized his coping skills include talking to friends. States he attends therapy weekly and has been helpful. Appetite normal, sleep varies between 5-10 hours at night. Sates he feels well rested in the morning. Patient encouraged to have a night time routine. Patient reports he has a strong support system consisting of his close friends. Patient reports he has been experiencing difficulty concentrating in school, easily distracted, verbalized leaving tasks incomplete. Denies thoughts of hurting himself, suicide, or hallucinations. Current weight 140lbs, Height 5'1" |
| Age: | 18-49 yrs: |
| Gender: | Male |
| Race: | White Non-Hispanic |
| Insurance: | Other |
| Referral: | None |
| Client Presentation: | Mr. C.M presents as calm, Mr. C.M presents as friendly, Mr. C. appears happy, attentive, communicative, and relaxed. He exhibits speech that is normal in rate, volume, and articulation and is coherent and spontaneous. Language skills are intact. Mood presents as normal with no signs of either depression or mood elevation. Affect is appropriate, full range, and congruent with mood. Associations are intact and logical. Suicidal ideas or intent are denied. Homicidal ideas or intentions are denied. Insight into problems appears normal. Judgment appears intact. There are no signs of anxiety. There are no signs of hyperactive or attentional difficulties. Mr. CM's behavior in the session was cooperative and attentive with no gross behavioral abnormalities. |
| DSM 5 Identifiers: | Generalized anxiety disorder, F41.1 (ICD-10) R/O Autistic disorder, F84.0 (ICD-10) Dysthymic disorder, F34.1 (ICD-10) |
| Formulation of Plan (i.e. Treatment/ Interventions, Differential diagnosis, Medications, Non-pharmacological treatment, Follow-up): | Instructions / Recommendations / Plan: 1) Start 30 day supply of Wellbutrin 150mg XR tablet. Take 1 tablet by mouth every morning 2)Continue BI-weekly therapy 3) Follow up 1/27/23 at 10am Patient in agreement with the plan. No further questions or concerns were voiced. |
| Time with patients (in minutes): | 60 |
| Consult with preceptor (in minutes): | 60 |
| Patient Interaction: | In Person |
| Clinical Notes: | Therapy Content/Clinical Summary: This session the patient's focus was on feelings of anxiety. Family problems were also discussed. Relationship problems were also discussed. This session the therapeutic focus was on helping the patient improve communication skills. The focus of today's session was on stabilizing the patient. The focus of today's session was on educating the patient about symptoms. This session the therapeutic focus was on emotional support. Therapeutic efforts also included encouragement to ventilate feelings. Help identifying the sources of certain feelings was also provided. Mr. CM. was counseled and educated regarding the importance and scheduling of all follow up instructions. Mr. C.M was given medication instructions and education. |
PMHNP Case Log
| Date: | 11/18/2022 |
| Rotation Type: | NL 812 Family Psychiatric Nursing III |
| Comments: | |
| Patient Age: | 23 Years |
| Patient Sex: | M |
| Patient Ethnicity: | White |
| SOAP Note: | History: Mr. C is a 23-year-old Caucasian male, Portugal descent who presents to this practice today to establish care . His chief complaint is, "I want to be tested for autism, anxiety, and bipolar disorder". I was told I might be autistic Information Received From: self. Mr. C. Autistic Process: The patient reports signs of autistic process, characterized by impaired social interaction. Impaired Social Interaction: Mr. C exhibits a marked and sustained impairment of social interaction. There is no interested in developing relationships with peers, lack of social cues. The patient has relational problems with peers and unable to keep long term friendships. He has difficulty understanding and using gestures to regulate social interactions. He is easily overwhelmed in a stressful situation. Impaired Communication: Mr. C does not exhibits a marked and sustained impairment of communication that affects both verbal and nonverbal skills, but states he has time expressing his feelings. Impaired Behavior: Mr. C does not exhibits a marked and sustained impairment of behavior. Targeted Behaviors: No specific behaviors requiring therapeutic intervention were targeted during the session. Anxiety Symptoms: Mr. C exhibits symptoms of anxiety. His anxiety symptoms have been present for 9 years. He was emotionally abused by father and mother was diagnosed with schizophrenia and bipolar disorder. Anxiety get worse in socially situation. Mr. C describes the following anxiety symptoms: *Avoidance *Blushes when feeling anxious in a social setting. *Feels embarrassment *Fears of losing control *Irritability *Feelings of restlessness *Sleep disturbance, Mr. C 's symptoms are occurring about once a week. Mr. C's first episode of anxiety occurred at age 14. Severity is estimated to be low based on Mr. C's risk of morbidity without treatment and his description of interference with functioning. Depression History: Mr. C describes symptoms of a depressive disorder. Precipitant: Mother's mental condition. Speed of Onset and Course: Mr. C 's depressive symptoms began insidiously over a period of years. When Depression Occurs:Depression is chronic or occurs daily. Prior Depressive/Manic Episodes: He has had multiple prior depressive episodes. He reports one episode of abnormal mood elevation, such as doing multiple things at the same time and couldn't finish. Current Symptoms: Mr. C 's reported depressive symptoms are as follows: *Previously Enjoyed Activities are No Longer Enjoyed *Appetite has Decreased *Concentration Difficulties *Feelings of Worthlessness are Present *Increased Worrying *Isolation *Difficulty Sleeping Suicidality: The Patient expresses wishes to be dead but suicidal ideas or intentions are denied. Severity/Complexity: Mr. C's severity is estimated to be low based on the risk of morbidity without treatment and description of interference with functioning. Past Psychiatric History: Information Received From: *Mr. C Psychiatric Hospitalization: Mr. C has never been psychiatrically hospitalized. Outpatient Treatment: Thought he saw a psychiatrist when he was younger. The patient admits to currently seeing a therapist once a week Suicidal/Self Injurious: Mr. C has a history of suicidal thoughts but has never made an attempt. Addiction/Use History: Mr. C denies any history of substance use however admits to occasional marijuana use. Social/Developmental History: Mr. C is a 23 year old man. Abuse/Neglect: Mr. C was emotionally abused. This occurred during childhood. The abuse and/or neglect continued through childhood. Abuse consisted of severe neglect. Abuse consisted of constant belittling. Mr. C was raised by his Biological father and step mother. His parents got divorced when he was 2 years old. admits to emotional abuse growing up, therefore denies flashbacks and nightmares. He is withdrawn and timid presumably as a consequence of the abuse and/or neglect. Coping Strengths: Motivated for Treatment Criminal Justice History: Mr. C has never been arrested or incarcerated, has no history of violence, and is not currently under any kind of court supervision. Educational History: Mr. C attended college, but did not graduate. He attends Kean University Gender/Sexual Identity: Current Gender identity: *Male Sexual Orientation: *Bi-curious. Housing Status: He lives with his father. Gestational and Developmental Histories: Mr. C 's gestational and developmental histories are unavailable to me at this time. Family History: Mother carries diagnosis of bipolar disorder and schizophrenia. Aunt: Down syndrome Medical History: Review of syetem Adverse Drug Reactions and Allergies: There is no known history of adverse drug reactions or allergies. Current Medical Diagnoses: Dermatologic: *Eczema Current Medications: none. Hearing/Vision: Hearing and vision are unimpaired. Surgical History: *None Primary Care Provider: Mr. C was last seen: few months Name of the Facility or Clinician: Dr. Dawn @ 908-686-XXXX Tobacco: Tobacco has never been used. He smokes weed once a while. |
| Age: | 18-49 yrs: |
| Gender: | Male |
| Race: | White Non-Hispanic |
| Insurance: | Other |
| Referral: | Other |
| Client Presentation: | Exam: Mr. C appears calm, sad looking, guarded, attentive, well groomed, but appears anxious. He exhibits speech that is normal in rate, volume, and articulation and is coherent and spontaneous. Language skills are intact. Affect is appropriate, full range, and congruent with mood. It is not possible to determine if underlying psychotic symptoms are present. Insight into problems appears fair. Judgment appears intact. There are signs of anxiety. There are no signs of hyperactive or attentional difficulties. Mr. C's behavior in the session was cooperative and attentive with no gross behavioral abnormalities. No signs of withdrawal or intoxication are in evidence. |
| DSM 5 Identifiers: | The specific DSM-5 criteria for persistent depressive disorder (dysthymia) are as follows: Depressed mood for most of the day, for more days than not, as indicated by either subjective account or observation by others, for at least 2 years. Presence while depressed of two or more of the following: Poor appetite or overeating Insomnia or hypersomnia Low energy or fatigue Low self-esteem Poor concentration or difficulty making decisions Feelings of hopelessness The anxiety and worry are associated with three or more of the following six symptoms (with at least some symptoms present for more days than not for the past 6 months). Restlessness or feeling keyed up or on edge Being easily fatigued Difficulty concentrating or mind going blank Irritability Muscle tension Sleep disturbance (difficulty falling or staying asleep, or restless unsatisfying sleep) |
| Formulation of Plan (i.e. Treatment/ Interventions, Differential diagnosis, Medications, Non-pharmacological treatment, Follow-up): | Diagnoses: The following Diagnoses are based on currently available information and may change as additional information becomes available. Generalized anxiety disorder, F41.1 (ICD-10) R/O Autistic disorder, F84.0 (ICD-10) Dysthymic disorder, F34.1 (ICD-10) Instructions / Recommendations / Plan: 1#) NO medication prescribed at this visit. #2) will continue with Therapy once a week. #3) Follow in two week December 9th, 2022 @ 1530. #4) The patient to white a paragraph about self to present at next visit. |
| Time with patients (in minutes): | 60 |
| Consult with preceptor (in minutes): | 60 |
| Patient Interaction: | In Person |
| Clinical Notes: | Therapy Content/Clinical Summary: Feelings of anxiety predominated this session. Feelings of sadness were also expressed. This session the therapeutic focus was on helping the patient improve communication skills. The focus of today's session was on symptom reduction. This session the therapeutic focus was on stabilizing the patient. This session the therapeutic focus was on emotional support. Help identifying the sources of certain feelings was also provided. Therapeutic efforts also included aiding the patient in identifying the precipitants of unproductive feelings and behaviors. Mr. Couto was given medication instructions and education. Mr. C was given medication instructions and education. Mr. C was counseled and educated regarding the risks and benefits of treatment. Mr. C was counseled and educated regarding the importance and scheduling of all follow up instructions. |
PMHNP Case Log
| Date: | 11/16/2022 |
| Rotation Type: | NL 810 Family Psychiatric Nursing II |
| Comments: | |
| Patient Age: | 6 Years |
| Patient Sex: | F |
| SOAP Note: | Subjective INITIAL INTAKE: Duration: 1 hour. DOB: 11/15/2016 IDENTIFYING DATA: REFERRAL SOURCE: RELIABILITY : Good. CHIEF COMPLAINT: As per mother " I am curious about her" HISTORY OF PRESENT ILLNESS: This is a case of a 6 year old AA female who comes to the clinic today to establish care with this program today. Pt. was brought in by her foster parent. it was reported pt. exhibits ADHD symptoms, having difficulty sitting still, goes to bed 1am and wakes up 6am, problem waiting for her turn, and she is hyperactive and interrupts frequently. Pt. was adopted at age 2 months. Biological parents have substance use disorder, mother is bipolar with one attempted suicide. mother was on Crystal meth and alcohol. Pt. started jumping out of cribs at age 9 months, also she started walking at age 9 months. Pt. achieved normal milestone at the right time. there was no medical issues reported. pt. vaccination is up to date. Pt. reported to be eating well, though picky. During evaluation, pt. appears restless, jumping and moving up and down and was getting in and out of the chair.. Pt. not in any distress or discomfort. Pt. has no physical limitation. as per the teacher, pt. does well at school academically but restless and interrupts. no mood symptoms observed. ALLERGIES: NKDA CURRENT PSYCH MEDICATIONS: Pt not on any medication CURRENT NON-PSYCH MEDICATIONS: Pt not taking any medication or supplement PAST PSYCHIATRIC HISTORY: None O/P Psychiatrist/therapists: None Previous diagnosis: None Previous admissions: None Previous suicide attempts: None Past Medication History: SUBSTANCE ABUSE HISTORY: Tobacco: None ETOH: None Illicit Drugs: None Rehab Programs: None SOCIAL HISTORY: pt. was born and raised in Hopewell, NJ. pt. was adopted at age 2 months. pt. has one step sibling who is 2 years younger. pt.'s biological had another child after the patient who passed away after birth. As per mother , the patient was born full tern, no complication and patient accomplished developmental milestones. Living Situation: lives with her foster parent in a single family home. Marital History: single Children: 0 Occupation: student Education: Kindergartens. *Menses: Pt is 6 year old Parents: yes Siblings: one step sibling Sexual Orientation: heterosexual. History of Abuse: denies. Legal: none FAMILY PSYCHIATRIC HISTORY: Biological parents have substance use disorder, mother is bipolar with one attempted suicide. mother was on Crystal meth and alcohol. |
| Age: | 5-11 yrs: |
| Gender: | Female |
| Race: | White Non-Hispanic |
| Insurance: | Other |
| Referral: | Other |
| Client Presentation: | Objective Objective note Import past encounter MSE: General: Good eye contact, well groomed, good hygiene, cooperative and friendly. Psychomotor Activity: [ x] Mood. Affect: [ x] euthymic, Speech: [x ] normal, [ ] tangential. Thought Process: [ x] goal directed, Thought Content: [ x] absent of suicidal or homicidal intent, Perception: [ x] does not appear to be reacting to internal or external stimuli today. Judgment: [ x] fair Insight: [ x] fair |
| DSM 5 Identifiers: | Assessment R/O: ?ADHD: ICD-Code F90.9 |
| Formulation of Plan (i.e. Treatment/ Interventions, Differential diagnosis, Medications, Non-pharmacological treatment, Follow-up): | #1) No medication prescribed during this visit. #2)Continue to monitor patient #3) Follow up in 12 weeks. Mother agreed with plan of care |
| Time with patients (in minutes): | 60 |
| Consult with preceptor (in minutes): | 60 |
| Patient Interaction: | In Person |
PMHNP Case Log
| Date: | 10/28/2022 |
| Rotation Type: | NL 810 Family Psychiatric Nursing II |
| Comments: | |
| Patient Age: | 15 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| SOAP Note: | This is tele-health visit for evaluation of symptoms. Writer met with patient and mom; The patient is working with her therapist during this evaluation; Writer was able to talk to The Patient at the end of her therapy session. She reports improvement in her sleep and appetite; She reports less anxious symptoms. She denies S/H. Last menstrual period was 2 weeks. Following Information received from mom: She states that the Patient is gradually doing okay since she went back on Mirtazapine 15 mg tablet, but now taking Mirtazapine 30 mg tablet daily. She saw eating disorder specialist; Dr. M., who recommended for Patient to go back to inpatient eating disorder program. Patient's last weight was 103 Ibs a week ago. She is eating better and now asking for more food. She tested positive to COVID, but have mild symptoms. She had an evaluation on 2/26/22 @ Center for discovery in Bridgewater location. |
| Age: | 12-17 yrs: |
| Gender: | Female |
| Race: | White Non-Hispanic |
| Insurance: | Other |
| Referral: | Other |
| Client Presentation: | Patient 's mental status has no gross abnormalities. Her dress and grooming are appropriate, she is friendly and communicative, and she appears to be her stated age. Mood is euthymic with no signs of depression or manic process. Her speech is normal in rate, volume, and articulation and language skills are intact. Suicidal or self injurious ideas or impulses are denied, as are assaultive or homicidal ideas or intentions. She denies hallucinations and delusions and there is no apparent thought disorder. Associations are intact, thinking is generally logical, and thought content is appropriate. Her cognitive functioning, based on vocabulary and fund of knowledge, is intact and age appropriate, and she is fully oriented. There are no signs of anxiety. There are no signs of attentional or hyperactive difficulties. Insight and judgment appear intact. |
| DSM 5 Identifiers: | Social phobia, unspecified, F40.10 (ICD-10) (Active) Anorexia nervosa, restricting type, F50.01 (ICD-10) (Active) R/O Attention-deficit hyperactivity disorder, predominantly inattentive type, F90.0 (ICD-10) (Active) Post-traumatic stress disorder, unspecified, F43.10 (ICD-10) (Active) |
| Formulation of Plan (i.e. Treatment/ Interventions, Differential diagnosis, Medications, Non-pharmacological treatment, Follow-up): | Instructions / Recommendations / Plan: D/C Sertraline 25 mg tab Continue Mirtazapine 30 mg 1 tab at HS for sleep Continue psychotherapy once weekly #1) DISCONTINUED: sertraline (sertraline) 25 mg, tablet, Take 1 tablet by mouth once a day, Qty: 30, Refills: 1, Duration: 30, Issued: 9/30/2022, Discontinued: 10/28/2022 (Completion of Therapy) #2) mirtazapine (mirtazapine) 30 mg, tablet, Take 1 tablet by mouth at bedtime, Qty: 30, Refills: None, Duration: 30, Issued: 10/28/2022, USE Rx DISCOUNT CARD: $32.57, BIN:019876, PCN:CHIPPO, Group:EMR, ID:DF6D9D8D11 Return 4 weeks, or earlier if needed. |
| Time with patients (in minutes): | 30 |
| Consult with preceptor (in minutes): | 30 |
| Patient Interaction: | Telemedicine |
PMHNP Case Log
| Date: | 10/28/2022 |
| Rotation Type: | NL 810 Family Psychiatric Nursing II |
| Comments: | |
| Patient Age: | 13 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| SOAP Note: | HPI: History: Mom requested evaluation because her daughter, Sayesha, was admitted from June 28-July 6th to Summit Oaks Hospital after a suicide attempt. � As per mom, one night, pt tried to strangle herself with a shirt sleeve and called for her parents. Pt was taken to Summit Oaks for evaluation. After the patient was discharged from the hospital, pt participated in partial hospitalization. The patient was in partial hospitalization from July to August. After admission, pt was then transfer IOP until Aug 23rd. Pt was started on lexapro 7.5 mg daily with improvement in symptoms. Mom gives pt pills in a pill pack and pt takes it on her own. No side effect. Pt reports that her depression started Dec 2021 regarding her parents and her 15 year old sister fighting. Pt feels angry and upset. Pt spoke to her family about the fights. Pt also reports being bullied in school by her peers and makes her feel sad. Pt does not feel sad everyday. Pt had thoughts of hurting herself 2 weeks ago after a kid in school was spreading rumors about her being a bad person. Pt does not believe that she is a bad person. Pt has difficulty falling asleep and poor appetite. Today, pt had a croissant for breakfast, pizza for lunch and is unsure about dinner plans. � Pt reports that she has attempted suicide before and tried to strangle herself Dec 2021. Pt told the High Focus staff about that incident. June 2022 suicide attempt was the second time and she was planning it for a while because she was annoyed with life. Pt stopped because she thought it was not working and called for help. Pt reports that she may attempt suicide again if the situation was bad enough. Thinking about her dog and a friend would cause her to stop with the suicidal thoughts. Pt that she may attempt suicide if the situation was bad enough. Thinking about her dog and a friend would cause her to stop with the suicidal thoughts. Pt engages in self cutting sometimes. Pt reports waking up feeling happy. Pt loves being with her friends, loves playing. Pt isolate herself from her family. Pt does not feel close with her family and never have been close with her family. Difficulty focusing in school, more fidgety at school, lexapro helps. Pt feels anxious about completing tasks Past Psychiatric History: Information Received From: *The family (mom) Psychiatric Hospitalization Sayesha was hospitalized on one occasion. Psychiatric hospitalization was at Sumit Oaks Hospital. She was first hospitalized at 12 years old. Suicidal or self injurious behaviors were present. Other Agencies Involved: She was in partial hospitalization and IOP from 7/6/22-8/22/22. Outpatient Treatment: Currently receiving psychotherapy at outpatient mental health treatment Suicidal/Self Injurious: Sayesha has a history of suicidal thoughts and has made an attempt on 2 separate occasions. The first episode was Dec 2021 and the last episode was June 2022. Sayesha has made suicidal attempts. She made a suicide attempt by strangling herself. Sayesha has been self injurious. Self cutting behavior, without suicidal intent, is reported. Pt engages in self cutting sometimes. She cuts her arm and feels fine during and painful afterward. Last episode was a month ago. started cutting at 12 due to family issues Social/Developmental History: School History: Sayesha is currently in eighth grade. Intellectual Functioning: *Intellectual performance is above average School Satisfaction: *Good Gestational & Developmental Histories: Sayesha's gestational and developmental histories were normal. Coping Strengths: Pt has a friend and her pet dog Leisure Activities: Pt likes to play and hang out with her friends. Reason for Referral: Suicide attempt Family of Origin: Pt lives at home with her parents and 15 year old sister and has a pet dog School History: Pt is in the 8th grade at Monroe Township Middle school. Does well in school- good grades so far, A's & B's No history of being expelled or suspended from school. Takes regular classes. Family History: Sayesha's family psychiatric history is negative. There is no history of psychiatric disorders, psychiatric treatment or hospitalization, suicidal behaviors or substance abuse in closely related family members. Medical History: Medical history is negative and Sayesha has no history of serious illness, injury, operation, or hospitalization. Does not have a history of asthma, seizure disorder, head injury, concussion or heart problems. No medications are currently taken. Primary Care Provider: Sayesha was last seen: Name of the Facility or Clinician: Dr V. R Tel : 732-545-6005 Reason Seen: Unknown Reproductive History: Age at Menarche: 11 years Menstrual Cycle: Regular Last Menstrual Period was: two weeks ago Past Medical History: Denies Hospitalized: *Dates of Hospitalization: June 28-July 6th at Summit Oak Hospital |
| Age: | 12-17 yrs: |
| Gender: | Female |
| Race: | White Non-Hispanic |
| Insurance: | Other |
| Referral: | Other |
| Client Presentation: | Sayesha appears calm, sad looking, flat, attentive, communicative, well groomed, and relaxed. but looks unhappy. She exhibits speech that is normal in rate, volume, and articulation and is coherent and spontaneous. Language skills are intact. Signs of moderate depression are present. Demeanor is sad. Body posture and attitude convey an underlying depressed mood. Facial expression and general demeanor reveal depressed mood. She denies having suicidal ideas. Insight into problems appears fair. Judgment appears fair. There are no signs of anxiety. There are no signs of hyperactivity. Sayesha's behavior in the session was cooperative and attentive with no gross behavioral abnormalities. |
| DSM 5 Identifiers: | Post-traumatic stress disorder, unspecified, F43.10 (ICD-10) (Active) |
| Formulation of Plan (i.e. Treatment/ Interventions, Differential diagnosis, Medications, Non-pharmacological treatment, Follow-up): | Instructions / Recommendations / Plan: #1) escitalopram oxalate (escitalopram oxalate) 5 mg, tablet, Take 1 1/2 tablet by mouth once a day, Qty: 45, Refills: None, Duration: 30, Issued: 9/30/2022 #2) Continue psychotherapy #3) In 2 weeks, phone call to see how she is doing Oct 14 5:30pm. #4) Pt will write down something about herself and share at next appointment #5)Oct 28th 2022 #1) escitalopram oxalate (escitalopram oxalate) 5 mg, tablet, Take 1 1/2 tablet by mouth once a day, Qty: 45, Refills: None, Duration: 30, Issued: 9/30/2022 Return 4 weeks, or earlier if needed. |
| Time with patients (in minutes): | 60 |
| Consult with preceptor (in minutes): | 60 |
| Patient Interaction: | In Person |
PMHNP Case Log
| Date: | 11/03/2022 |
| Rotation Type: | NL 810 Family Psychiatric Nursing II |
| Comments: | |
| Patient Age: | 12 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| SOAP Note: | HPI: This is a 12yr old female, who is the primary, reliable, informant, accompanied by: mother, who presents for e/m appt related to her anxiety and depression. Patient reports that she is feeling "little better this week". Patient spoke with provider without mom present and expressed her frustration with her mother. Patient became tearful when talking about how overwhelmed she feels regarding mother. Patient reports that she never feels good enough or like "everything I do is wrong". Patient denies any SI/HI/SIB at this time. Discussed medications, options, s/e, risks vs benefits, goals, and psychotherapy and mother verbalized understanding. |
| Age: | 12-17 yrs: |
| Gender: | Female |
| Race: | White Non-Hispanic |
| Insurance: | Other |
| Referral: | Other |
| Client Presentation: | Constitutional/Gen: Denies any significant weight changes. Denies any fever/chills. Denies pain. Sees PCP regularly. Reports good sleep. HEENT: denies visual changes, neck supple, no JVD. Denies changes in hearing. Pulmonary: normal inspiratory effort noted. Denies cough/sob Cardiovascular: Denies cp/palpitations/sob/dizziness. GI: Denies n/v/d. Denies heartburn/pain. No complaints/concerns in bowel habits. GU: denies incontinence, hesitancy, pain. OB/GYN: LMP - /2022- not currently on birth control Musculoskeletal: No peripheral edema noted. No asymmetry noted. No flaccidity, cog wheel, or spasticity noted. Neuro: Denies seizure activity/loss of function/consciousness. AAOx3, mood and affect appropriate. Skin/Hair: intact, good turgor, no rash/open areas noted. Denies hair loss |
| DSM 5 Identifiers: | Anxiety associated w depression; Anxiety with depression; Mixed anxiety and depressive disorder : ICD-10 Code F43.23 |
| Formulation of Plan (i.e. Treatment/ Interventions, Differential diagnosis, Medications, Non-pharmacological treatment, Follow-up): | -Continue to provide supportive talk therapy and encourage patient to continue with individual therapy sessions. -Patient again referred to psychotherapy (mother given resource for family therapy) and patient willing to go. Continue current dose of Lexapro and hydroxyzine PRN for anxiety. Follow up in 1 month. |
| Time with patients (in minutes): | 60 |
| Consult with preceptor (in minutes): | 60 |
| Patient Interaction: | Telemedicine |
PMHNP Case Log
| Date: | 11/08/2022 |
| Rotation Type: | NL 810 Family Psychiatric Nursing II |
| Comments: | |
| Patient Age: | 9 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| SOAP Note: | HPI: This is a 9yr old female, who is the primary, reliable, informant, accompanied by her mother, who presents for evaluation and management anxiety, behaviors, and medication management stating " a mixture of things". Mother reports that patient's biological father was diagnosed with schizophrenia when in his 20's and she has been noticing some "odd behaviors" in patient that have her worried and she feels as though "I cannot ignore them". Mother denies any previous psychiatric treatment prior to today other than a short period of psychotherapy approximately one year ago. Patient is not currently in therapy. No previous medication trials and no inpatient, IOP, or PHP treatment. As per mother, patient's odd behaviors began and worsened approximately 10-11 months ago. Mother reports that patient has digressed in social activities, lacks interest in doing "kid stuff", unable to stay on track during homework time, not wanting to go to school, "reclusive" tendencies, making "odd" sounds such as humming or high-pitched sounds, having conversations with herself, difficulty self-regulating, scratching legs for several minutes, and talking to someone named "Patricia". As per patient, reports "feeling good". Patient appeared apprehensive and spoke in low tone. She often looked at mother for reassurance before answering questions. Patient denies any hallucinations, paranoia, or delusions. Both mother and patient report that patient is often hyper-focused on things she enjoys, disorganized, unable to stay on task with things she does not enjoy, loses items daily (shoes), easily distracted, and forgetful. Patient was able to sit and talk with provider throughout visit and did not appear to fidget or squirm. Mother also denies any concerns with hyperactivity. Mother reports she herself has been diagnosed with ADHD. Patient denies any SI/HI/SIB. Discussed medications, options, s/e, risks vs benefits, goals, and psychopharmacology with mother who verbalized understanding. |
| Age: | 5-11 yrs: |
| Gender: | Female |
| Race: | White Non-Hispanic |
| Insurance: | Other |
| Referral: | None |
| Client Presentation: | Constitutional: Fever/Chills: none Chronic pain: none Appetite/Weight changes: No significant changes in weight. Fluctuating appetite Sleep: reports difficulty falling asleep at times HEENT: EOMI, denies visual changes, neck supple, no JVD. Denies changes in hearing. Pulmonary: normal inspiratory effort noted. Denies cough/sob. Cardiovascular: Denies cp/palpitations/sob/dizziness GI: Denies n/v/d. Denies heartburn/pain. No complaints/concerns in bowel habits. GU: denies incontinence, hesitancy, pain. OB/GYN: LMP - has not had menses yet Musculoskeletal: No flaccidity, cog wheel, or spasticity noted. Neuro: Denies seizure activity/loss of function/consciousness. AAOx3, mood and affect appropriate. Skin/Hair: intact, good turgor, no rash/open areas noted. Denies hair loss |
| DSM 5 Identifiers: | Both the patient's mother and the patient's report that the patient is frequently too concentrated on the things she loves, disorganized, unable to focus on the tasks she finds unpleasant, constantly losing things (shoes), easily distracted, and forgetful. Mother reports that patient has digressed in social activities, lacks interest in doing "kid stuff", unable to stay on track during homework time, not wanting to go to school, "reclusive" tendencies, making "odd" sounds such as humming or high-pitched sounds, having conversations with herself, difficulty self-regulating, scratching legs for several minutes, and talking to someone named "Patricia" Significant family Hx of mental illness: Mother reports she herself has been diagnosed with ADHD Biological father was diagnosed with schizophrenia when in his 20's ICD-10 code F20. 9 for Schizophrenia, unspecified ICD-10Code F90. 9 is the diagnosis code used for Attention-Deficit Hyperactivity Disorder, |
| Formulation of Plan (i.e. Treatment/ Interventions, Differential diagnosis, Medications, Non-pharmacological treatment, Follow-up): | 1-Provide supportive talk therapy and build rapport with patient. 2-Patient appears to have limited insight to her needs and stressors, however, this is most likely due to her age and some initial apprehension for today's visit. Patient was active in her treatment today. 3-Given family history of both ADHD and schizophrenia, will proceed with provisional differential diagnoses of schizoaffective disorder, MDD with psychotic features, ADHD, GAD, mild depression. 4-Pt will need to question patient further as she is currently denying any audio/visual/tactile hallucinations. Will hold off on medications at this time. 5-Refer to neuro-psych for further evaluation (ADHD, possible learning disability, etc.). Mother agreeable. 6-Will follow up in 1 month. |
| Time with patients (in minutes): | 60 |
| Consult with preceptor (in minutes): | 60 |
| Patient Interaction: | Telemedicine |
PMHNP Case Log
| Date: | 11/01/2022 |
| Rotation Type: | NL 810 Family Psychiatric Nursing II |
| Comments: | |
| Patient Age: | 8 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| SOAP Note: | HPI: An 8-year-old girl who is the secondary, trustworthy informant and who is present for an evaluation for anxiety is accompanied by her mother and her mother's boyfriend. "It has been dreadful - she is off the charts recently," said the mother, supported by the mother's significant other. They note that the patient consistently gets into problems at home, at school, and on the bus. The patient is swearing, making lewd gestures, and lying-she allegedly urinated on her bedroom floor before asking her mother what caused the stain and denying any involvement-all while being supported by evidence. The patient apparently saw a video showing her engaging in improper conduct at school, but she would not acknowledge that it is a picture of her. According to reports, the patient put scratches on her own arm before blaming another student and telling a school official that her mother allows her to drink beer at home. The patient continues to receive in-home care and now sees the therapist twice weekly. According to the mother, the patient's therapist yesterday recommended inpatient therapy for them. Mothers said they will be meeting with the school and therapist on November 22 to talk about their child's present condition. At this moment, neither mother has admitted to knowing of any potential sexual abuse. The patient said "Everything's OK," She responded "good" when asked how classes were going. She said "no" when asked whether she had ever been into problems at school. The patient currently rejects any SI, HI, or SIB. With the mother, who expressed comprehension verbally, I spoke about drugs, alternatives, s/e, risks vs. benefits, objectives, and psychopharmacology. |
| Age: | 5-11 yrs: |
| Gender: | Female |
| Race: | White Non-Hispanic |
| Insurance: | Other |
| Referral: | None |
| Client Presentation: | Constitutional: Fever/Chills: none Chronic pain: none Appetite/Weight changes: Patient reports good appetite and no significant weight changes Sleep: reports poor sleep - difficulty staying asleep HEENT: EOMI, denies visual changes, neck supple, no JVD. Denies changes in hearing. Pulmonary: normal inspiratory effort noted. Denies cough/sob Cardiovascular: Denies cp/palpitations/sob/dizziness GI: Denies n/v/d. Denies heartburn/pain. No complaints/concerns in bowel habits. GU: denies incontinence, hesitancy, pain. OB/GYN: LMP - patient has not started menses yet Musculoskeletal: No flaccidity, cog wheel, or spasticity noted. Neuro: Denies seizure activity/loss of function/consciousness. AAOx3, mood and affect appropriate. Psych: see mental status exam Skin/Hair: intact, good turgor, no rash/open areas noted. Denies hair loss |
| DSM 5 Identifiers: | ADHD |
| Formulation of Plan (i.e. Treatment/ Interventions, Differential diagnosis, Medications, Non-pharmacological treatment, Follow-up): | Plan: continue to provide supportive talk therapy. Patient has limited insight to her needs, stressors, and strengths given her age. Patient is active in her treatment plan and willing to learn new coping skills. Recommended patient be seen and evaluated by neuro-psych for full ADHD evaluation - mother agreeable but has not been completed yet. Continue current dose of Zoloft at 50mg daily to address anxiety. Trial addition of Abilify 1mg daily to address aggression and inappropriate behaviors. Will follow up in 1 week. |
| Time with patients (in minutes): | 60 |
| Consult with preceptor (in minutes): | 60 |
| Patient Interaction: | Telemedicine |
PMHNP Case Log
| Date: | 10/20/2022 |
| Rotation Type: | NL 810 Family Psychiatric Nursing II |
| Comments: | |
| Patient Age: | 14 Years |
| Patient Sex: | M |
| Patient Ethnicity: | White |
| SOAP Note: | Subjective Subjective note INITIAL INTAKE: Duration: 1 hour. DOB: IDENTIFYING DATA: REFERRAL SOURCE: RELIABILITY : Good. CHIEF COMPLAINT: " HISTORY OF PRESENT ILLNESS: This is a case of a 14 years old Caucasian who comes to the clinic today to establish care with this program today. Pt's mom consented for this interview. Patient's mom reports she came to Iconic health to officially get a diagnosis for her son and also to be cleared for home schooling. Pt reports that he have been seeing a therapist since last year for anxiety and depression. Pt's mom reports that pt. is afraid to leave mom at home alone because mom have a pre-existing condition that places her at risk of having a heart attack and especially after she had her first attack last year. Pt is currently seeing a therapist since oct 2021 for same problem but it's not getting better. Patient started to be home schooled since after he's dad dead in 2020. Pt mother reports that the school will not approved of patient being home schooled except he is evaluated and cleared to be home schooled by a psychiatrist. Pt reports that after patient's father dead oct 2020 from a massive heart attack, pt. developed anxiety problem and will not want to leave mom at home because he doesn't want anything to happen to his mother. Pt's mother wants patient to be home schooled because patient is still having trouble with anxiety and despite having worked with a therapist since last year. This is the first time patient is seeing a psychiatrist for an official diagnoses and to perform psych evaluation. Patient rated depression at 5/10, anxiety 4/10. Patient reported that he didn't want to go to school because he was the one who saved mom when she had stoke when het was 10 years old, he called dad who came and was able to take his mom to the hospital. Pt is very afraid that if he goes to school and mom happen to have another stroke no one will save her and she's his only living parent. Pt reports the following symptoms of Depression; sadness, lack of interest in activities, lack of motivation, sleep poorly, racing thoughts. lack of energy, sleep changes, poor concentration, lack of motivation, social isolation, and difficulty getting out of bed. Anhedonia/lack of interest, persistent sadness, worthlessness Hopelessness, Helplessness, guilty, generalized anxiety, nightmares sometimes. Denies social anxiety, denies panic attack, Denies auditory hallucination, denies visual hallucination, denies paranoid, denies being suspicious of others. ALLERGIES: NKDA CURRENT PSYCH MEDICATIONS: None CURRENT NON-PSYCH MEDICATIONS: None PAST PSYCHIATRIC HISTORY: None O/P Psychiatrist/therapists: Have been seeing a therapist since last Oct 2021 Previous diagnosis: Therapist diagnosed him with Anxiety and depression Previous admissions: None Previous suicide attempts: None Past Medication History: None SUBSTANCE ABUSE HISTORY: None Tobacco: None ETOH: None Illicit Drugs: None Rehab Programs: None SOCIAL HISTORY: pt. lives with mother and a sister. Pt was born and raised in NJ Living Situation: lives with mother Marital History: Mother is currently widowed Children: N/A Occupation: N/A Education: 8th Parents: lives with mother and dad dead Siblings: one sister Sexual Orientation: heterosexual. History of Abuse: denies. Legal: n/a FAMILY PSYCHIATRIC HISTORY: Denies PAST MEDICAL HISTORY: Denies |
| Age: | 12-17 yrs: |
| Gender: | Male |
| Race: | White Non-Hispanic |
| Insurance: | Other |
| Referral: | None |
| Client Presentation: | Alert and oriented . |
| DSM 5 Identifiers: | Depression [ICD-10: F32.A], Separation anxiety [ICD-10: F93.0], |
| Formulation of Plan (i.e. Treatment/ Interventions, Differential diagnosis, Medications, Non-pharmacological treatment, Follow-up): | Plan Plan note -Pt is cleared to be home schooled until his symptoms of depression and anxiety improves. Start Lexapro 5mg for Depression and Anxiety. -Follow up in 4 weeks. |
| Time with patients (in minutes): | 60 |
| Consult with preceptor (in minutes): | 60 |
| Patient Interaction: | In Person |
PMHNP Case Log
| Date: | 10/26/2022 |
| Rotation Type: | NL 810 Family Psychiatric Nursing II |
| Comments: | |
| Patient Age: | 5 Years |
| Patient Sex: | F |
| Patient Ethnicity: | Black or African American |
| SOAP Note: | Subjective Subjective note INITIAL INTAKE: Duration: 1 hour. DOB: IDENTIFYING DATA: REFERRAL SOURCE: RELIABILITY : Good. CHIEF COMPLAINT: " This mom reports that Arrianah have been doing some wired things and talking to her self all the time" HISTORY OF PRESENT ILLNESS: This is a case of a 5 year AA toddler who comes to the clinic today to establish care with this program. Pt's mother brought her to Iconic heath to be evaluated because pt keep doing some wired things" Pt's mother states that in early may 2022, Pt killed her Kitten and she have been doing a lot of mean things to her siblings and will states that the "devil made her to do it". Pt mother also report another incident that pt told her younger sibling to stab pt with a knife. Arrianah states that she see devil in her room they look "red". Pt's mother reports that pt always get in trouble in school, throws temper tantrum, tries to beat other children or teacher and smears feces on the wall all the time. Pt's mom reports that patient have been talking to a therapist once biweekly, mom doesn't"t think it's helping. Pt's mother reports that patient talks to her self all the times and she doesn't think it's the talking to imaginary friends that children's her age does. Mom states that patient's father have history of mental illness in his family. Pt is also defiant to authorities. other symptoms are ; Pt mother states that she wipe feces all over the wall, like to watch you when you sleep, likes to stay in the dark, she likes to harm other kids, like to get others in trouble, she's violent with her toys, she mimic her mother all the time. She talks and laughs and make fun of her friends, patient will always say that the devil make her hurt her siblings, patient always draws elien, or monsters, pt. also doesn't listen, nightmares and she dosen't sleep well. Patient also urinates on self at night and sometimes during the day while she's taking a nap. Pt denies hearing voices or seeing things. CURRENT PSYCH MEDICATIONS: None CURRENT NON-PSYCH MEDICATIONS: None PAST PSYCHIATRIC HISTORY: O/P Psychiatrist/therapists: Previous diagnosis: None Previous admissions: None Previous suicide attempts: None Past Medication History: Seizure when she was 13 months and was admitted for 2 or 3 days and she was given antibiotic. SUBSTANCE ABUSE HISTORY:N/A Tobacco: N/A ETOH: N/A Illicit Drugs: N/A Rehab Programs: N/A SOCIAL HISTORY: born in NJ. vaginal delivery, and a full term baby Living Situation: lives with mother and step father Marital History: N/A Children: 2N/A Occupation: N/A Education: n/a Parents: Both parent alive Siblings: 2 sisters Sexual Orientation: heterosexual. History of Abuse: denies. Legal: n/a FAMILY PSYCHIATRIC HISTORY: n/a PAST MEDICAL HISTORY: n/a |
| Age: | 5-11 yrs: |
| Gender: | Female |
| Race: | Black |
| Insurance: | Other |
| Referral: | Other |
| Client Presentation: | Constitutional: Fever/Chills: none Chronic pain: none Appetite/Weight changes: Patient reports good appetite and no significant weight changes Sleep: reports poor sleep - difficulty staying asleep HEENT: EOMI, denies visual changes, neck supple, no JVD. Denies changes in hearing. Pulmonary: normal inspiratory effort noted. Denies cough/sob Cardiovascular: Denies cp/palpitations/sob/dizziness GI: Denies n/v/d. Denies heartburn/pain. No complaints/concerns in bowel habits. GU: denies incontinence, hesitancy, pain. OB/GYN: LMP - patient has not started menses yet Musculoskeletal: No flaccidity, cog wheel, or spasticity noted. Neuro: Denies seizure activity/loss of function/consciousness. AAOx3, mood and affect appropriate. Psych: see mental status exam Skin/Hair: intact, good turgor, no rash/open areas noted. Denies hair loss |
| DSM 5 Identifiers: | Mood disorder [ICD-10: F39] Oppositional defiant [ICD-10: F91.3] |
| Formulation of Plan (i.e. Treatment/ Interventions, Differential diagnosis, Medications, Non-pharmacological treatment, Follow-up): | Abilify 2 MG Oral Tablet half tab x one week then increase to 1 tabs (start date: 10/26/2022) (stop date: 11/26/2022) |
| Time with patients (in minutes): | 60 |
| Consult with preceptor (in minutes): | 60 |
| Patient Interaction: | In Person |
PMHNP Case Log
| Date: | 10/15/2022 |
| Rotation Type: | NL 810 Family Psychiatric Nursing II |
| Comments: | |
| Patient Age: | 29 Years |
| Patient Sex: | F |
| SOAP Note: | History: Ms. J. is a single Asian-American 28-year-old woman. Her chief complaint is, " I want to talk to someone to make sure I am ok" Past Psychiatric History: Patient is a 28 year old Asian American patient of Filipino descent. Patient was born in Toronto Canada, moved to the United at age 11. Patient had her first child at age 16, was in a relationship from age 15 with a boyfriend who was 19 year old then. Patient reports emotional, physical abuse by her baby's father from time she gave birth to her first child. Then patient had another child at age 18 for the the same boy. Patient reports she found out that the boyfriend was cheating on her and the boy said he was leaving her and will take the children away. Patient reports she told her babies father she was going to kill herself if he leaves him. Patient reports she cut her wrists, crying, sad. Social/Developmental History: Patient is a single 28 year old woman. She is Asian-American. She is a Catholic. Denies any cultural barriers to treatment Abuse/Neglect: There is no known history of physical, sexual or emotional abuse. Activities of Daily Living: Activities of Daily Living: *Dresses self *Bathes self *Able to perform household chores *Does errands *Shops *Able to drive *Does laundry *Pays bills *Able to handle money Assistive Devices: Patient uses no mechanical devices to assist walking. Criminal Justice History: Patient has never been arrested or incarcerated, has no history of violence, and is not currently under any kind of court supervision. Cultural and Religious Considerations: Religious Identification: Catholic Educational History: Patient attended college, has an associate degree as a medical assistance. Employment History: Full time job for 5 years. Denies work related stress Financial Status: *Financially stable Housing Status: Lives with her fiance and 2 young children in a 2 family house type. Military History: Patient never served in the military. Personal Goal(s): Pt's goal(s) are as follows: "for someone to evaluate me and give me a diagnose". Relationship/Marriage: Never married but has 4 children with 3 different fathers. Family History: Pt 's family psychiatric history is negative. There is no history of psychiatric disorders, psychiatric treatment or hospitalization, suicidal behaviors or substance abuse in closely related family members. Medical History: Medical history is negative and the Patient has no history of serious illness, injury, operation, or hospitalization. Does not have a history of asthma, seizure disorder, head injury, concussion or heart problems. No medications are currently taken. Adverse Drug Reactions and Allergies: There is no known history of adverse drug reactions or allergies. Height: 4"9" Weight: 128 lbs PCP: Carol . Last visit some six month ago Current Medical Diagnoses: None Current Medications: *None Health & Behavior: Likes to go the gym and work out at home. Hearing/Vision: Hearing and vision are unimpaired. Infection or Disease: None: There are no indications of current infectious disease or recent exposure to an infectious disease. Pain: Patient denies recent pain. Past Medical History: Past Medical History is essentially negative. Surgical History: No surgical history and all 4 children were carried to term. Tobacco: Tobacco has never been used. Diagnoses: The following Diagnoses are based on currently available information and may change as additional information becomes available. |
| Age: | 18-49 yrs: |
| Gender: | Female |
| Race: | Asian |
| Insurance: | Other |
| Referral: | Other |
| Client Presentation: | Alert and oriented in no distressed. Pt appears goal oriented to take care of self. |
| DSM 5 Identifiers: | Other specified anxiety disorders, F41.8 (ICD-10) Major depressive disorder, single episode, in partial remission, F32.4 (ICD-10) |
| Formulation of Plan (i.e. Treatment/ Interventions, Differential diagnosis, Medications, Non-pharmacological treatment, Follow-up): | Pt denies medication. Admits to feeling well without medication and do not plan to Start med now. -No medication prescribes at this time. -Pt educated on the importance to call the office if considering taking medication at a latter time. Call 911 if feeling suicidal / homicidal/ |
| Time with patients (in minutes): | 60 |
| Consult with preceptor (in minutes): | 60 |
| Patient Interaction: | In Person |
PMHNP Case Log
| Date: | 10/20/2022 |
| Rotation Type: | NL 810 Family Psychiatric Nursing II |
| Comments: | |
| Patient Age: | 14 Years |
| Patient Sex: | M |
| SOAP Note: | Subjective Subjective note INITIAL INTAKE: Duration: 1 hour. DOB: IDENTIFYING DATA: self/Mother REFERRAL SOURCE: Therapist RELIABILITY : Good. CHIEF COMPLAINT: " HISTORY OF PRESENT ILLNESS: This is a case of a 14 years old Caucasian who comes to the clinic today to establish care with this program today. Pt's mom consented for this interview. Patient's mom reports she came to Iconic health to officially get a diagnosis for her son and also to be cleared for home schooling. Pt reports that he have been seeing a therapist since last year for anxiety and depression. Pt's mom reports that pt. is afraid to leave mom at home alone because mom have a pre-existing condition that places her at risk of having a heart attack and especially after she had her first attack last year. Pt is currently seeing a therapist since oct 2021 for same problem but it's not getting better. Patient started to be home schooled since after he's dad dead in 2020. Pt mother reports that the school will not approved of patient being home schooled except he is evaluated and cleared to be home schooled by a psychiatrist. Pt reports that after patient's father dead oct 2020 from a massive heart attack, pt. developed anxiety problem and will not want to leave mom at home because he doesn't want anything to happen to his mother. Pt's mother wants patient to be home schooled because patient is still having trouble with anxiety and despite having worked with a therapist since last year. This is the first time patient is seeing a psychiatrist for an official diagnoses and to perform psych evaluation. Patient rated depression at 5/10, anxiety 4/10. Patient reported that he didn't want to go to school because he was the one who saved mom when she had stoke when het was 10 years old, he called dad who came and was able to take his mom to the hospital. Pt is very afraid that if he goes to school and mom happen to have another stroke no one will save her and she's his only living parent. Pt reports the following symptoms of Depression; sadness, lack of interest in activities, lack of motivation, sleep poorly, racing thoughts. lack of energy, sleep changes, poor concentration, lack of motivation, social isolation, and difficulty getting out of bed. Anhedonia/lack of interest, persistent sadness, worthlessness Hopelessness, Helplessness, guilty, generalized anxiety, nightmares sometimes. Denies social anxiety, denies panic attack, Denies auditory hallucination, denies visual hallucination, denies paranoid, denies being suspicious of others. ALLERGIES: NKDA CURRENT PSYCH MEDICATIONS: None CURRENT NON-PSYCH MEDICATIONS: None PAST PSYCHIATRIC HISTORY: None O/P Psychiatrist/therapists: Have been seeing a therapist since last Oct 2021 Previous diagnosis: Therapist diagnosed him with Anxiety and depression Previous admissions: None Previous suicide attempts: None Past Medication History: None SUBSTANCE ABUSE HISTORY: None Tobacco: None ETOH: None Illicit Drugs: None Rehab Programs: None SOCIAL HISTORY: pt. lives with mother and a sister. Pt was born and raised in NJ Living Situation: lives with mother Marital History: Mother is currently widowed Children: N/A Occupation: N/A Education: 8th Parents: lives with mother and dad dead Siblings: one sister Sexual Orientation: heterosexual. History of Abuse: denies. Legal: n/a FAMILY PSYCHIATRIC HISTORY: Denies PAST MEDICAL HISTORY: Denies |
| Age: | 12-17 yrs: |
| Gender: | Male |
| Race: | White Non-Hispanic |
| Insurance: | Other |
| Referral: | Physician |
| Client Presentation: | Objective Objective note MSE: General: Good eye contact, well groomed, good hygiene, cooperative and friendly. Psychomotor Activity: [ x] Affect: congruent with mood, [x ] constricted/guarded, [x ] Speech: [x ] normal, Thought Process: [ x] goal directed, Thought Content: [ ] absent of suicidal or homicidal intent Perception: [x ] does not appear to be reacting to internal or external stimuli today. Judgment: [x ] fair to good. Insight: [ x] fair to good.. |
| DSM 5 Identifiers: | Depression [ICD-10: F32.A], Separation anxiety [ICD-10: F93.0], |
| Formulation of Plan (i.e. Treatment/ Interventions, Differential diagnosis, Medications, Non-pharmacological treatment, Follow-up): | Plan Plan note -Pt is cleared to be home schooled until his symptoms of depression and anxiety improves. Start Lexapro 5mg for Depression and Anxiety. -Follow up in 4 weeks. |
| Time with patients (in minutes): | 60 |
| Consult with preceptor (in minutes): | 60 |
| Patient Interaction: | In Person |
PMHNP Case Log
| Date: | 10/18/2022 |
| Rotation Type: | NL 810 Family Psychiatric Nursing II |
| Comments: | |
| Patient Age: | 18 Years |
| Patient Sex: | F |
| Patient Ethnicity: | Black or African American |
| SOAP Note: | Subjective Subjective note Individual(s) present: with a good mood. pt. was seen 4 weeks after her first initial. pt. reports she eats and sleeps well. pt. denies SI/HI, denies A/V/H. pt. voiced no complaints or discomfort. Patient denies suicidal ideation. Patient denies homicidal ideation. PAST PSYCHIATRIC HISTORY: pt. reports she has been having mental health issues since age 16/17. pt. states she has been having issues but not that bad until age 16. pt. states she was hospitalized, not sleeping, her mind was everywhere. pt. states this is her second time in the hospital. pt. states she was doing good while on meds. pt. states she stopped medications, that she could not get refill and she decided to stop taking them. SOCIAL HISTORY: pt. was born and raised in Trenton, NJ. pt.'s both parents still alive, separated. pt. has 7 siblings. pt. is single, not in any relationship at this time, states she is males. pt. has no children. Living Situation: lives with her mother in a single family home. Marital History: single Children: 0 Occupation: student Education: freshman in college, for nursing. Parents: still alive, separated. Siblings: 7 Sexual Orientation: heterosexual. History of Abuse: denies. Legal: pt. denies |
| Age: | 18-49 yrs: |
| Gender: | Female |
| Race: | Black |
| Insurance: | Other |
| Referral: | Other |
| Client Presentation: | Objective Objective note No change in mental status.. Improvement of mood/affect.. Improvement of thought process/content.. Appearance, attitude, and motor activity: good. Mood and affect: fair. Orientation: alert and oriented x 3 Insight and judgment: fair. . |
| DSM 5 Identifiers: | (F31.9) Bipolar disorder, unspecified |
| Formulation of Plan (i.e. Treatment/ Interventions, Differential diagnosis, Medications, Non-pharmacological treatment, Follow-up): | Divalproex Sodium 250 MG Oral Tablet Delayed Release iii tabs daily at bedtime hydrOXYzine Pamoate 25 MG Oral Capsule 1 capsule (25 mg) orally 2 times per day as needed risperiDONE 4 MG Oral Tablet Take 1 tablet (4 mg) by mouth daily at bedtime traZODone HCl 50 MG Oral Tablet 1 tablet (50 mg) orally daily at bedtime |
| Time with patients (in minutes): | 30 |
| Consult with preceptor (in minutes): | 30 |
| Patient Interaction: | In Person |
PMHNP Case Log
| Date: | 10/17/2022 |
| Rotation Type: | NL 801 Family Psychiatric Nursing I- Advance Mental Health Assessment Across Lifespan |
| Comments: | |
| Patient Age: | 21 Years |
| Patient Sex: | F |
| Patient Ethnicity: | Asian |
| SOAP Note: | Subjective Subjective note Duration: 1 hour. DOB: 10/27/2000 IDENTIFYING DATA: Self REFERRAL SOURCE: self RELIABILITY : Good. CHIEF COMPLAINT: HISTORY OF PRESENT ILLNESS: This is a case of a 21 year old single white female who comes to the clinic today to establish care with this program today. pt. reports she came to Iconichealth because her medications do not seem to be working, reports mood swings and impulsiveness. pt. states when she is depressed she is for several weeks and when she is not she feels on the top of the world. pt. reports she has been taking meds for some months but seems not to be working. pt. states she did not see any effectiveness from meds from the world go. pt. describes her mood today as irritable, appetite is low, sleep is interrupted. pt. denies SI/HI, denies A/V/H. pt. states her future goal is "I do not really have any". strength is good with his job. weaknesses is "I do not know". pt. is alert and oriented x3, presents with good judgement. ALLERGIES: NKDA CURRENT PSYCH MEDICATIONS: pt. is presently Zoloft 50 mg po daily, buspirone 7.5 mg po bid, states she has been taking it since March, 2022. CURRENT NON-PSYCH MEDICATIONS: None PAST PSYCHIATRIC HISTORY: pt. reports she was diagnosed of depression/anxiety at age 14/15, hospitalized because of self harm and suicide ideations. pt. reports only one psych hospitalization. pt. states when she was discharged, she was given some meds but her mother did not want her to take it and flushed it down the toilet. pt. reports she did out patient programs. pt. reports she spent a couple of months at the hospital. pt. reports she kept threatening to kill self, states she attempted once by taking several tylenol. states she did not tell anyone. pt. reports sexual, physical and emotional abuse in the past. pt. denies being in any car accident, no head injury or loss of consciousness. O/P Psychiatrist/therapists: Yes Previous diagnosis: depression and anxiety Previous admissions: once Previous suicide attempts: once Past Medication History: high liver enzymes, no surgery. G0P0. LMP-09/2022. SUBSTANCE ABUSE HISTORY: Tobacco: pt. denies ETOH: pt. reports she does not drink anymore, last had a drink in April, 2022. pt. started drinking at age 14. Illicit Drugs: pt. reports she was using cocaine everyday. pt. last used last week. pt. started using cocaine at age 19. pt. reports she spent $375 every three days on cocaine. pt. states cocaine was her primary use. states she used to use Xanax at age 18/19. pt. last used at age 19. pt. reports she used to get it from people she knew. Rehab Programs: 0 SOCIAL HISTORY: pt. was born and raised in Trenton, NJ. pt.'s both parents still alive, never married. pt. has 3 half sisters. pt. has not children. pt. is single, states she is attracted to both males and females. pt. reports she is in a relationship at this time. Living Situation: lives with her grand parent, but states she stay at her boyfriend's place a lot. Marital History: single Children: 0 Occupation: EMT staff Education: high school. Parents: both alive, never married Siblings: 3 half sisters Sexual Orientation: Bisexual. History of Abuse: pt. reports sexual, physical and emotional abuse. Legal: pt. denies FAMILY PSYCHIATRIC HISTORY: pt. reports mother has Bipolar disorder and other family members. depression and anxiety run in the family. PAST MEDICAL HISTORY: |
| Age: | 18-49 yrs: |
| Gender: | Female |
| Race: | Asian |
| Insurance: | Other |
| Referral: | None |
| Client Presentation: | Objective Objective note MSE: General: Good eye contact, well groomed, good hygiene, cooperative and friendly. Psychomotor Activity: [x ] normal, [ ] retardation, [ ] agitation, [ ] irritability, [ ] tremors, [ ] tics, [ ] fidgety. Mood. Affect: [ ] euthymic, [ ] congruent with mood, [x ] depressed, [ ] constricted/guarded, [ ] flat, [ ] blunted, [ ] expansive, [ ] euphoric, [ ] anxious, [ ] irritated, [ ] angry, [ ] sedated, [ ] paranoid, [ ] tearful. Speech: [x ] normal, [ ] normal volume, [ ] normal tone, [ ] normal prosody, [ ] spontaneous, [ ] rapid, [ ] tangential. Thought Process: [x ] goal directed, [ ] logical, [ ] flight of ideas, [ ] looseness of associations. Thought Content: [ x] absent of suicidal or homicidal intent, [ ] paranoia, [ ] delusions, [ ] obsessions. Perception: [ x] does not appear to be reacting to internal or external stimuli today. Judgment: [ x] fair to good. Insight: [ x] fair to good.. |
| DSM 5 Identifiers: | (F31.9) Bipolar disorder, unspecified (F32.9) Major depressive disorder, single episode, unspecified |
| Formulation of Plan (i.e. Treatment/ Interventions, Differential diagnosis, Medications, Non-pharmacological treatment, Follow-up): | Plan Medications as detailed below: 1. Increase Zoloft 100 mg po daily 2. Buspar 7.5 mg po bid 3. Vraylar 1.5 mg po daily in am 4. Follow-up Appointment: in 4 weeks. |
| Time with patients (in minutes): | 60 |
| Consult with preceptor (in minutes): | 60 |
| Patient Interaction: | In Person |
PMHNP Case Log
| Date: | 10/10/2022 |
| Rotation Type: | NL 810 Family Psychiatric Nursing II |
| Comments: | |
| Patient Age: | 11 Years |
| Patient Sex: | M |
| SOAP Note: | S = Subjective Client identified problem (Chief complaint) Pt is 10 year old male, Caucasian, who presents today via telehealth, accompanied by mother for follow up care . Pt was initially referred to this practice for management of symptoms of ADHD and Impulse Disruptive behaviors. When ask how feeling: the patient answered " Good ". Both, patient and mother report good appetite and good sleep habit. Denied any recent ER visit. Denied any recent behavioral issue or explosive behaviors. However , pt admits to some trouble in school where he chew a chair because he was called name " D@*ck head". Pt and mother admit to medication compliance : Focalin ER 25 mg daily, Clonidine 0.1 mg HS and Risperidone 0.5 mg BID. The patient states that he is able to follow in school and he is getting all A's. Pt denied suicidal and homicidal ideation, plan or intent to hurt self or others. Fever/Chills: denied Chronic pain: none Appetite/Weight changes: adequate appetite and no significant weight changes Sleep: reports adequate sleep HEENT: Denies visual changes; denies changes in hearing. Pulmonary: normal inspiratory effort noted. Denies cough/sob Cardiovascular: Denies cp/palpitations/sob/dizziness GI: Denies n/v/d. Denies heartburn/pain. No complaints/concerns in bowel habits. GU: denies incontinence, hesitancy, pain. OB/GYN: denies pain , burning sensation on urination |
| Age: | 5-11 yrs: |
| Gender: | Male |
| Race: | White Non-Hispanic |
| Insurance: | Other |
| Referral: | None |
| Client Presentation: | MENTAL STATUS EXAM (MSE): Appearance: Appear clean and appropriately dressed. Maintains good eye contact. Behavior: well-postured Speech: clear and fluent Mood: Anxious Affect: Appropriate to context Thought Process: reasonable and focused Thought Content: Denies suicidal thoughts. Denies homicidal ideation Insight: Good. Appears goal oriented. |
| DSM 5 Identifiers: | F90. 1, Attention-deficit hyperactivity disorder ICD-10 code F34. 81 for Disruptive mood dysregulation disorder |
| Formulation of Plan (i.e. Treatment/ Interventions, Differential diagnosis, Medications, Non-pharmacological treatment, Follow-up): | will continue with current medication regiment. Clonidine 0.1mg HS Focalin 25 mg Po daily Risperidone 0.5mg Po BIT Follow up in four weeks |
| Time with patients (in minutes): | 30 |
| Consult with preceptor (in minutes): | 30 |
| Patient Interaction: | Telemedicine |
PMHNP Case Log
| Date: | 10/10/2022 |
| Rotation Type: | NL 810 Family Psychiatric Nursing II |
| Comments: | |
| Patient Age: | 9 Years |
| Patient Ethnicity: | White |
| SOAP Note: | S = Subjective Client identified problem (Chief complaint) Pt is 9 year old male, Caucasian, who presents today via telehealth, accompanied by mother for follow up care . Pt was initially referred to this practice for management of symptoms of MDD, GAD and Intermittent explosive disorder. Mother describes patient as " he is doing all right" . When ask how feeling: the patient answered " Good , Yeah". Both, patient and mother report good appetite and good sleep habit. Denied any recent ER visit. denied any recent behavioral issue or explosive behaviors. Pt and mother admit to medication compliance : Zoloft 25 mg daily. Pt denied suicidal and homicidal ideation, plan or intent to hurt self or others. Fever/Chills: denied Chronic pain: none Appetite/Weight changes: adequate appetite and no significant weight changes Sleep: reports adequate sleep History of present/current illness This is the case of a 9 year old male who was escorted by mother for medication management. The patient was alert and oriented, and in no sign of acute distress. As per mother, the patient is doing all right with no recent behaviors issue observed or reported. As per mother , the patient is in 3rd grade and doing good in school and practices soccer and Hockey. HEENT: Denies visual changes; denies changes in hearing. Pulmonary: normal inspiratory effort noted. Denies cough/sob Cardiovascular: Denies cp/palpitations/sob/dizziness GI: Denies n/v/d. Denies heartburn/pain. No complaints/concerns in bowel habits. GU: denies incontinence, hesitancy, pain. OB/GYN: N/A Pt is 9 year old male. |
| Age: | 5-11 yrs: |
| Gender: | Male |
| Race: | White Non-Hispanic |
| Insurance: | Other |
| Referral: | Other |
| Client Presentation: | MENTAL STATUS EXAM (MSE): Appearance: Appear clean and appropriately dressed. Maintains good eye contact. Behavior: well-postured Speech: clear and fluent Mood: Anxious Affect: Appropriate to context Thought Process: reasonable and focused Thought Content: Denies suicidal thoughts. Denies homicidal ideation Insight: Good. Appears goal oriented. |
| DSM 5 Identifiers: | F33.0 Major depressive disorder Code F41. 1 is the diagnosis code used for Generalized Anxiety Disorder ICD-10 code F63. 81 for Intermittent explosive disorder |
| Formulation of Plan (i.e. Treatment/ Interventions, Differential diagnosis, Medications, Non-pharmacological treatment, Follow-up): | Will continue with current plan of care. Sertraline 25 mg Po daily Hydroxyzine 10 mg PO PRN Follow up Monday December 5th, 2022. |
| Time with patients (in minutes): | 30 |
| Consult with preceptor (in minutes): | 30 |
| Patient Interaction: | Telemedicine |
PMHNP Case Log
| Date: | 09/13/2022 |
| Rotation Type: | NL 810 Family Psychiatric Nursing II |
| Comments: | |
| Patient Age: | 8 Years |
| Patient Sex: | M |
| Patient Ethnicity: | White |
| SOAP Note: | Fever/Chills: none Chronic pain: none Appetite/Weight changes: adequate appetite and no significant weight changes Sleep: reports adequate sleep HEENT: EOMI, denies visual changes, neck supple, no JVD. Denies changes in hearing. Pulmonary: normal inspiratory effort noted. Denies cough/sob/ chills Cardiovascular: Denies chest pain/palpitations/sob/dizziness GI: Denies nausea/ Vomiting. Denies heartburn/pain. No complaints/concerns in bowel habits (Last BM...). GU: denies incontinence, hesitancy, pain/ burning. OB/GYN: N/A Musculoskeletal: No flaccidity, cog wheel, or spasticity noted. Neuro: Denies seizure activity/loss of function/consciousness. AAOx3, mood and affect appropriate. Denies headaches GU: denies incontinence, hesitancy, pain. Neuro: Denies seizure activity/loss of function/consciousness. AAOx3, mood and affect appropriate. Denies headaches Psych: No previous psych admission Skin/Hair: intact, good turgor, no rash/open areas noted. Denies hair loss HPI: This is the case of 8yr old male, who presents for follow up care as scheduled. Pt was accompanied by care give, he is alert and oriented and in no sign of acute distress. Patient and care giver describe mood as "I am good" other than some agitations a few times a week. Initially, patient was referred to this program for medication management. Pt was adopted by current care giver. He has Hx of Fetal alcohol syndrome. The patient and care giver admits compliance with medication Abilify 5 mg PO daily, Fluoxetine 10 mg and Focalin 15 mg PO daily. Currently denies suicidal and homicidal ideation; plan or intent to hurt self or others. |
| Age: | 5-11 yrs: |
| Gender: | Male |
| Race: | White Non-Hispanic |
| Insurance: | Unmarked |
| Client Presentation: | Pt alert and oriented in no distress. |
| DSM 5 Identifiers: | Oppositional defiant disorder. ICD-10 code F91. 3 F43.1 Post-traumatic stress disorder DMDD: ICD-10-CM Code for Disruptive mood dysregulation disorder F34. 81. ADHD: F90. 1, Attention-deficit hyperactivity disorder Conduct disorder: ICD-10 code F91. 9 for Conduct disorder, unspecified |
| Formulation of Plan (i.e. Treatment/ Interventions, Differential diagnosis, Medications, Non-pharmacological treatment, Follow-up): | Will continue with current medication regiment Follow up in 4 Weeks |
| Time with patients (in minutes): | 60 |
PMHNP Case Log
| Date: | 09/12/2022 |
| Rotation Type: | NL 810 Family Psychiatric Nursing II |
| Comments: | |
| Patient Age: | 11 Years |
| Patient Sex: | M |
| Patient Ethnicity: | White |
| SOAP Note: | HPI: This is the case of an 11 year old Caucasian male who was accompanied by his mother for follow up care. Mother reported that , patient had an episode in school. Patient ran out of the school like having a panic attack during his birthday celebration with other pupils. Today, patient presents alert and oriented in no distress. Pt describes his mood as "Fine". Patient and mother admit compliance with medication Zoloft 12.5 mg daily. Appetite and sleep good. Patient denies suicidal and homicidal ideation, plan or intent to hurt self or others. |
| Age: | 5-11 yrs: |
| Gender: | Male |
| Race: | White Non-Hispanic |
| Insurance: | Other |
| Client Presentation: | ecurrent excessive distress when anticipating or experiencing separation from home or from major attachment figures Persistent and excessive worry about losing major attachment figures or about possible harm to them, such as illness, injury, disasters, or death Persistent and excessive worry about experiencing an untoward event (eg, getting lost, being kidnapped, having an accident, becoming ill) that causes separation from a major attachment figure Persistent reluctance or refusal to go out, away from home, to school, to work, or elsewhere because of fear of separation |
| DSM 5 Identifiers: | Separation anxiety disorder ICD-10-Diagnosis Code F93.0 Post-Traumatic Stress Disorder, ICD 10 Code F43. 12 Generalized anxiety disorder ICD 10 Code : F41.1 |
| Formulation of Plan (i.e. Treatment/ Interventions, Differential diagnosis, Medications, Non-pharmacological treatment, Follow-up): | Will increase Zoloft 25 mg Daily Will consider Exposure Therapy. Follow up in 4 Weeks |
| Time with patients (in minutes): | 60 |
PMHNP Case Log
| Date: | 08/29/2022 |
| Rotation Type: | NL 810 Family Psychiatric Nursing II |
| Comments: | |
| Patient Age: | 14 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| SOAP Note: | Subjective Data Subjective note Duration: 1 hour. DOB: 10/10/2008 IDENTIFYING DATA: Mother REFERRAL SOURCE: Self/Mother RELIABILITY : Good. Fever/Chills: none Chronic pain: none Appetite/Weight changes: adequate appetite and no significant weight changes Sleep: reports poor sleep HEENT: Denies visual changes; denies changes in hearing. Pulmonary: normal inspiratory effort noted. Denies cough/sob Cardiovascular: Denies cp/palpitations/sob/dizziness GI: Denies n/v/d. Denies heartburn/pain. No complaints/concerns in bowel habits. GU: denies incontinence, hesitancy, pain. OB/GYN: Current on her menses Musculoskeletal: No flaccidity. denies problem with coordination, ambulatory Neuro: Denies seizure activity/loss of function/consciousness. AAOx3, mood and affect appropriate. Denies headaches Psych: As per mother pt had behavior chances that need to be evaluated. Hx of Anxiety, depression and Flash backs. Skin/Hair: intact, good turgor, no rash/open areas noted. Denies hair loss MENTAL STATUS EXAM (MSE): Appearance: Appear clean and appropriately dressed. Maintains fair eye contact. Behavior: well-postured Speech: clear and fluent Mood: Anxious Affect: Appropriate to context Thought Process: reasonable and focused Thought Content: Denies suicidal thoughts. Denies homicidal ideation. Positive for flashbacks. Insight: Fair HPI: This is the case of a 14 year old Caucasian female who presents today to establish care with this program stated " My mom and other people think I should be on medication". Pt alert and oriented, was accompanied by mother ( Ms. X) for initial intake assessment. Pt identified self as Bisexual. Poor motivation and self isolation in her room are reported by both patient and mother. Pt was complaining of poor motivation, and self Isolation and flashbacks since what happened last summer. Pt failed to elaborate on what happened last summer. Pt identified her strength as Journaling and talking to her mother help with her mood and her weakness " not alone worsens her symptoms. She denied currently using any illicit drugs or alcohol. Denies suicidal and Homicidal ideation, plan or intent to hurt self or others. Denies issue with the law. Plan note Continue to provide encouraging talk therapy Prazosin 1 mg Po Pristiq 20 mg PO In four weeks, follow up. Contract for safety Keep journaling Seek mother for assistance Call 911 if feeling acutely suicidal Text 988 for assistance |
| Age: | 12-17 yrs: |
| Gender: | Female |
| Race: | White Non-Hispanic |
| Insurance: | Other |
| Client Presentation: | Depressed mood Self isolation behaviors poor concentration Poor energy poor sleep flashbacks |
| DSM 5 Identifiers: | Loss of interest or pleasure in most or all normal activities, such as sex, hobbies or sports Sleep disturbances, including insomnia or sleeping too much Tiredness and lack of energy, so even small tasks take extra effort Reduced appetite and weight loss or increased cravings for food and weight gain Anxiety, agitation or restlessness |
| Formulation of Plan (i.e. Treatment/ Interventions, Differential diagnosis, Medications, Non-pharmacological treatment, Follow-up): | Continue to provide encouraging talk therapy Prazosin 1 mg Po Desvenlafaxine 20 mg PO Contract for safety Keep journaling Seek mother for assistance Call 911 if feeling acutely suicidal Text 988 for assistance In four weeks, follow up. |
| Time with patients (in minutes): | 60 |
PMHNP Case Log
| Date: | 08/29/2022 |
| Rotation Type: | NL 810 Family Psychiatric Nursing II |
| Comments: | |
| Patient Age: | 9 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| SOAP Note: | Subjective Data Subjective note Duration: 1 hour. DOB: 12/12/2013 IDENTIFYING DATA: Mother REFERRAL SOURCE: Self/Mother RELIABILITY : Good. Fever/Chills: none Chronic pain: none Appetite/Weight changes: adequate appetite and no significant weight changes Sleep: reports adequate sleep HEENT: Denies visual changes; denies changes in hearing. Pulmonary: normal inspiratory effort noted. Denies cough/sob Cardiovascular: Denies cp/palpitations/sob/dizziness GI: Denies n/v/d. Denies heartburn/pain. No complaints/concerns in bowel habits. GU: denies incontinence, hesitancy, pain. OB/GYN: N/A Pt is 9 year old. Musculoskeletal: No flaccidity. denies problem with coordination, ambulatory Neuro: Denies seizure activity/loss of function/consciousness. AAOx3, mood and affect appropriate. Denies headaches Psych: As per mother pt was diagnosed with Anxiety and Intermittent explosive disorder and angry outburst. Pt endorsed " feeling upset a little bit" . He has never been committed or admitted to a mental institution. He denied earlier loss of consciousness, head injuries, or MVA. Skin/Hair: intact, good turgor, no rash/open areas noted. Denies hair loss MENTAL STATUS EXAM (MSE): Appearance: Appear clean and appropriately dressed. Maintains good eye contact. Behavior: well-postured Speech: clear and fluent Mood: Anxious Affect: Appropriate to context Thought Process: reasonable and focused Thought Content: Denies suicidal thoughts. Denies homicidal ideation Insight: Good. Appears goal oriented. Pt excited to go to school next week to attend ART class as her favorite. HPI: This is the case of a 9 year old Caucasian female who presents today to establish care with this program stated " I got up set for a little bit". Pt alert and oriented, was accompanied by mother ( Ms. X) for initial intake assessment. Pt identified self as female, sixth grader. Positive mood, healthy eating, and sleep are all reported by the patient's mother. When asked how she felt, the patient offered a thumbs up. The client was calm and interacting appropriately during encounter. Pt has a new puppy named Sprite, which mother describes as very helpful. She denied currently using any illicit drugs or alcohol. Denies suicidal and Homicidal ideation, plan or intent to hurt self or others. Denies issue with the law. Denies fire setting and abuse to animals. Plan note Continue to provide encouraging talk therapy Keep taking Abilify at the current dosage for mood stabilization. Discontinuation of the sertraline In four weeks, follow up. |
| Age: | 5-11 yrs: |
| Gender: | Female |
| Race: | White Non-Hispanic |
| Insurance: | Other |
| Client Presentation: | Pt alert and oriented X 3 Appearance: Appear clean and appropriately dressed. Maintains good eye contact. Behavior: well-postured Speech: clear and fluent Mood: Anxious Affect: Appropriate to context Thought Process: reasonable and focused Thought Content: Denies suicidal thoughts. Denies homicidal ideation Insight: Good |
| DSM 5 Identifiers: | Explosive eruptions occur suddenly, with little or no warning, and usually last less than 30 minutes. These episodes may occur frequently or be separated by weeks or months of nonaggression. Less severe verbal outbursts may occur in between episodes of physical aggression. irritability, impulsive, aggressive or chronically angry most of the time. |
| Formulation of Plan (i.e. Treatment/ Interventions, Differential diagnosis, Medications, Non-pharmacological treatment, Follow-up): | Abilify 2 mg PO daily Stop Zoloft 12.5 mg Po daily. Pt will benefit from talk therapy Follow up in Four weeks time. |
| Time with patients (in minutes): | 60 |
PMHNP Case Log
| Date: | 08/31/2022 |
| Rotation Type: | NL 801 Family Psychiatric Nursing I- Advance Mental Health Assessment Across Lifespan |
| Comments: | |
| Patient Age: | 44 Years |
| Patient Sex: | M |
| Patient Ethnicity: | White |
| SOAP Note: | Subjective This 40 year old Caucasian male, single , presents today for his monthly Abilify Maintena 400 MG Intramuscular. The Patient presents with a good mood, somehow anxious and restless. Admits compliance with medication and treatment plan. Pt. voiced no complaints or discomfort. Pt states that he has completed his blood work for Lithium level. Currently, denies SI/HI, denies A/V/H. Patient denies suicidal ideation. Patient denies homicidal ideation. Objective note MENTAL STATUS EXAM (MSE): Orientation: alert and oriented x3. Insight and judgment: fair. Appearance: Appear clean and appropriately dressed. Maintains good eye contact. Behavior: well-postured Speech: clear and fluent Mood: Anxious Affect: Flat Thought Process: reasonable and focused Thought Content: Denies suicidal thoughts. Insight: Good Judgment: Fair Assessment note: Alert and oriented to all spheres. Plan note Continue treatment plan as prescribed. Continue taking medication as prescribed. Pending Blood lithium level Follow up appointment: in 4 weeks. |
| Age: | 18-49 yrs: |
| Gender: | Male |
| Race: | White Non-Hispanic |
| Insurance: | Other |
| Client Presentation: | The patient claims that schizoaffective disorder was his first mental disease diagnosis when he was 17 years old. Pt described his symptom as when he first diagnosed as : Suspiciousness and a general fear of others' intentions. Persistent, unusual thoughts or beliefs. The patient says he has been taking medicine ever since and well tolerated. The patient claims to have spent ten hospital stays at a mental health facility. The previous time was a few months ago. Pt. denies earlier efforts at suicide. Pt. disputes any physical, mental, or sexual abuse in the past. Denies any recent trauma. |
| DSM 5 Identifiers: | Insomnia, anxiety, anger and irritability. Paranoia Seeing, hearing, or tasting things that others do not. Difficulty thinking clearly. Withdrawing from family or friends. A significant decline in self-care. |
| Formulation of Plan (i.e. Treatment/ Interventions, Differential diagnosis, Medications, Non-pharmacological treatment, Follow-up): | Abilify Maintena 400 MG Intramuscular Prefilled Syringe 400 mg intramuscularly every 28 days Lithium Carbonate 300 MG Oral Capsule 1 capsule (300 mg) orally 2 times per day Paranoid schizophrenia : ICD-10: F20.0 |
| Time with patients (in minutes): | 60 |
PMHNP Case Log
| Date: | 08/31/2022 |
| Rotation Type: | NL 801 Family Psychiatric Nursing I- Advance Mental Health Assessment Across Lifespan |
| Comments: | |
| Patient Age: | 22 Years |
| Patient Sex: | F |
| Patient Ethnicity: | Black or African American |
| SOAP Note: | Subjective note Pt is a with a good mood presents today for a follow care. Pt denied any change from previous visit stating " All is fine". Patient reports she is starting a new job new week , voiced no complaints or discomfort. Patient denies SI/HI, denies A/V/H. Patient denies suicidal ideation. Patient denies homicidal ideation. Fever/Chills: none Chronic pain: none Appetite/Weight changes: adequate appetite and no significant weight changes Sleep: reports adequate sleep HEENT: EOMI, denies visual changes, neck supple, no JVD. Denies changes in hearing. Pulmonary: normal inspiratory effort noted. Denies cough/sob Cardiovascular: Denies cp/palpitations/sob/dizziness GI: Denies n/v/d. Denies heartburn/pain. No complaints/concerns in bowel habits. GU: denies incontinence, hesitancy, pain. OB/GYN: NA - has not gotten menses yet Musculoskeletal: No flaccidity, cog wheel, or spasticity noted. Neuro: Denies seizure activity/loss of function/consciousness. AAOx3, mood and affect appropriate. Denies headaches Psych: Denies recent ER visit and hospitalization Skin/Hair: intact, good turgor, no rash/open areas noted. Denies hair loss Objective note MENTAL STATUS EXAM (MSE): Appearance: Appear clean and appropriately dressed. Maintains good eye contact. Behavior: well-postured Speech: clear and fluent Mood: anxiety and fears not to recover Affect: easily irritable Thought Process: reasonable and focused Thought Content: Denies suicidal thoughts. Flashbacks, anxiety, nightmares Insight: Good Judgment: Fair No change in mental status. Improvement of mood/affect. Improvement of thought process/content. Appearance, attitude, and motor activity: good. Mood and affect: good. Orientation: alert and oriented x3. Insight and judgment: good . Plan note Continue treatment plan as prescribed. Continue taking medication as prescribed. No change to medication. Follow up appointment: in 8 weeks. |
| Age: | 18-49 yrs: |
| Gender: | Female |
| Race: | Black |
| Insurance: | Other |
| Client Presentation: | Appearance: Appear clean and appropriately dressed. Maintains good eye contact. Behavior: well-postured Speech: clear and fluent Mood: anxiety and fears not to recover Affect: easily irritable Thought Process: reasonable and focused Thought Content: Denies suicidal thoughts. Flashbacks, anxiety, nightmares Insight: Good Judgment: Fair No change in mental status. Improvement of mood/affect. Improvement of thought process/content. Appearance, attitude, and motor activity: good. Mood and affect: good. Orientation: alert and oriented x3. Insight and judgment: good . |
| DSM 5 Identifiers: | Depressed mood > six Months |
| Formulation of Plan (i.e. Treatment/ Interventions, Differential diagnosis, Medications, Non-pharmacological treatment, Follow-up): | Trintellix 20 MG Oral Tablet 1 tablet (20 mg) orally daily (start date: 3/17/2022) Quetiapine Fumarate 50 MG Oral Tablet 2 tablets (100 mg) orally daily at bedtime (start date: 3/17/2022) Topiramate 50 MG Oral Tablet 1 tablet (50 mg) orally daily (start date: 3/17/2022) ICD 10 code: (F33.9) Major depressive disorder, recurrent, unspecified Plan note Continue treatment plan as prescribed. Continue taking medication as prescribed. No change to medication. Follow up appointment: in 8 weeks. |
| Time with patients (in minutes): | 60 |
PMHNP Case Log
| Date: | 08/31/2022 |
| Rotation Type: | NL 801 Family Psychiatric Nursing I- Advance Mental Health Assessment Across Lifespan |
| Comments: | |
| Patient Age: | 56 Years |
| Patient Sex: | M |
| Patient Ethnicity: | Black or African American |
| SOAP Note: | Subjective Data Subjective note Duration: 1 hour. DOB: 12/08/1965 IDENTIFYING DATA: Self REFERRAL SOURCE: Self RELIABILITY : Good. Fever/Chills: none Chronic pain: none Appetite/Weight changes: adequate appetite and no significant weight changes Sleep: reports adequate sleep HEENT: EOMI, denies visual changes, neck supple, no JVD. Denies changes in hearing. Pulmonary: normal inspiratory effort noted. Denies cough/sob Cardiovascular: Denies cp/palpitations/sob/dizziness GI: Denies n/v/d. Denies heartburn/pain. No complaints/concerns in bowel habits. GU: denies incontinence, hesitancy, pain. OB/GYN: NA - has not gotten menses yet Musculoskeletal: No flaccidity, cog wheel, or spasticity noted. Neuro: Denies seizure activity/loss of function/consciousness. AAOx3, mood and affect appropriate. Denies headaches Psych: Pt endorsed Hx Schizophrenia. He claims that in 2000, after visiting a crisis facility, he received his first diagnosis of schizophrenia. He was in crisis for 7 to 10 days. He claims that since experiencing a crisis in the 2000s, he has never been committed or admitted to a mental institution. He denied earlier loss of consciousness, head injuries, or MVA. Skin/Hair: intact, good turgor, no rash/open areas noted. Denies hair loss HPI: A 56-year-old African American male, single, who presents today to continue receiving treatment via this program. According to the patient, he visited the clinic to keep receiving his injectable treatment for schizophrenia stating " I want to get my injection shot, I am Schizophrenic". The patient states that for the previous four to five years, he has been taking his injection. His last injection was some 6-7 months ago as stated by patient. Pt denied being on any any oral drugs. He claims to take 156 mg of Invega monthly. He denied currently using any illicit drugs other than occasional Alcohol intake. Last ETOH use two weeks ago. Denies any symptoms of withdrawal. Denies suicidal and Homicidal ideation, plan or intent to hurt self or others. Denies issue with the law. Plan note 1. Start IM Invega Sustenna 156 mg every 4 weeks 2. Follow-up Appointment: in 4 weeks. |
| Age: | 50-64 yrs: |
| Gender: | Female |
| Race: | Black |
| Insurance: | Other |
| Client Presentation: | MENTAL STATUS EXAM (MSE): Appearance: Appear clean and appropriately dressed. Maintains good eye contact. Behavior: well-postured Speech: clear and fluent Mood: anxiety and fears not to recover Affect: irritable Thought Process: reasonable and focused Thought Content: Denies suicidal thoughts. Flashbacks, anxiety, nightmares Insight: Good Judgment: Fair |
| DSM 5 Identifiers: | Auditory hallucination Visual hallucination |
| Formulation of Plan (i.e. Treatment/ Interventions, Differential diagnosis, Medications, Non-pharmacological treatment, Follow-up): | Invega Sustenna 156 mg every 4 weeks Follow-up Appointment: in 4 weeks. Will consider Routine blood work |
| Time with patients (in minutes): | 60 |
PMHNP Case Log
| Date: | 06/07/2022 |
| Rotation Type: | NL 801 Family Psychiatric Nursing I- Advance Mental Health Assessment Across Lifespan |
| Comments: | |
| Patient Age: | 10 Years |
| Patient Sex: | M |
| Patient Ethnicity: | Black or African American |
| SOAP Note: | Subjective Subjective note INITIAL INTAKE: Duration: 1 hour. DOB: 09/19/2011 IDENTIFYING DATA: REFERRAL SOURCE: RELIABILITY : Good. CHIEF COMPLAINT: Mother states " The school wants him to be evaluated". This is a case of a 10 year old AA male who comes to the clinic today to establish care with this program today. Pt. reports his school requests him to do psychiatric evaluation. Pt. states he found a knife in the classroom about a week ago. Pt. states he found the knife on the floor and placed it in his back. this was around 1:30pm. Mother states it was an art tool. Pt. states he took the blade off and threw it away. Pt. kept the bottom of the knife. Pt. was later accused by his teacher of putting his peer in a choke hold and point the knife at his classmate. Pt. allegedly found the knife and kept the it inside his bag. As per the mother, this is not the first time this incident would happen to patient in school. This is his fourth encounter. Pt. has been suspended twice this year. Mother reports that she gets calls everyday reporting that Pt. not following the rules and was disruptive. Pt. could be disrespectful at times as per mother. Pt. can sometimes stay up all night and goes to bed at 11/11:30pm then wakes up 7:30/8am. Pt denies SI/HI, denies A/V/H. ALLERGIES: NKDA CURRENT PSYCH MEDICATIONS: denied CURRENT NON-PSYCH MEDICATIONS: denied PAST PSYCHIATRIC HISTORY: pt. was delivered at 37 weeks, no complications on the baby. Pt. achieved normal milestone. Pt. states Pt. has been having issues from age 3, Pre-K, like behavior issues, getting in to trouble. pt. mostly not listening and talking back. Pt. denies past hospitalization both medical and psych. Pt. denies any head injury or loss of consciousness. Pt. denies sexual, emotional and physical abuse. Pt. denies any suicide attempts or SIB. O/P Psychiatrist/therapists: denied Previous diagnosis: denied Previous admissions: denied Previous suicide attempts: denied Past Medication History: denied SUBSTANCE ABUSE HISTORY: Tobacco: pt. denies ETOH: pt. denies Illicit Drugs: pt. denies Rehab Programs: pt. denies SOCIAL HISTORY: Pt. was born and raised in Trenton, NJ. pt.'s both parents still alive, not married. pt. is the middle child of three. pt. reports other two children have no issues. Living Situation: lives with his mother in a single family home. Marital History: child Children: 0 Occupation: student Education: 5th grade Parents: both alive, never married Siblings: 2 Sexual Orientation: Heterosexual. History of Abuse: denies. Legal: pt. denies IMMUNIZATION: Up to date as per mother FAMILY PSYCHIATRIC HISTORY: Pt. denies family history of psychiatric disorders. Pt. denies history of substance use. PAST MEDICAL HISTORY: Denies Objective Objective note: General: Good eye contact, well groomed, good hygiene, cooperative and friendly. Psychomotor Activity: [x ] normal Affect: [ x] euthymic Speech: [ x] normal, Thought Process: [ x] goal directed Thought Content: [x ] absent of suicidal or homicidal intent Perception: [ x] does not appear to be reacting to internal or external stimuli today. Judgment: [x ] fair to good. Insight: [x ] fair to good. Assessment: Pt. is alert and oriented x3. Pt. presents with a good judgement. Pt. is not on any medication. Orient to all spheres . Poor eye contact noted. Plan Plan note 1. Consider CBT referral. 2. Follow-up Appointment: in 4 weeks |
| Age: | 5-11 yrs: |
| Gender: | Male |
| Race: | Black |
| Insurance: | Other |
| Client Presentation: | Alert and oriented in no distress |
| DSM 5 Identifiers: | not following the rules and was disruptive Full of energy frequent disruption in school and at home. |
| Formulation of Plan (i.e. Treatment/ Interventions, Differential diagnosis, Medications, Non-pharmacological treatment, Follow-up): | Consider CBT referral. Follow-up Appointment: in 4 weeks No medication at this visit |
| Time with patients (in minutes): | 60 |
PMHNP Case Log
| Date: | 06/21/2022 |
| Rotation Type: | NL 801 Family Psychiatric Nursing I- Advance Mental Health Assessment Across Lifespan |
| Comments: | |
| Patient Age: | 20 Years |
| Patient Sex: | F |
| Patient Ethnicity: | Black or African American |
| SOAP Note: | Duration: 1 hour. DOB: 11/14/2001 IDENTIFYING DATA: G. W 20 year old Black Female REFERRAL SOURCE: self RELIABILITY : Good. CHIEF COMPLAINT: "I was recommended by M...G from Mind-Well Behavioral Health to make an appointment for right after my therapist appointment. I Submitted a form request already but my meeting with Melanie has changed so have to change my appointment to Tuesday". Subjective Subjective note INITIAL INTAKE: This is a case of a 20 year old AA single female who comes to the clinic today to establish care with this program today. pt. reports she had a therapist before and attended TCNJ where she also saw a therapist. pt. was referred to Iconichealth by her therapist. Pt. reports she went to see a therapist for depression and anxiety. Pt states that hi mental issue happened early this year when she had a mental breakdown, where she can not eat or sleep. pt. states feeling anxious 24/7. This happened first week in March, 2022. The patient describes feeling extremely joyful and sad at the same time when she is stressed, her heart beating quickly, lacking drive, and crying a lot. The patient claims that she sometimes neglects herself, finds it difficult to complete her tasks, and avoids situations that make her feel uneasy. The patient claims that her depression and anxiety are nothing new.Her symptoms became more severe as school opens back post pandemic. She describes herself as the kind of person who utilizes diversion as a coping mechanism. The patient reports that she is okay but exhausted today. Pt. denies SI/HI now and claims she used to have suicidal thoughts when her symptoms were severe, depressing, or worrisome. The patient claims to only sleep for around five hours at night. Eating patterns change at times.According to the patient, she has manic episodes occasionally-about three times a year. Objective Objective note Appearance: Appear clean and appropriately dressed. Maintains good eye contact. Behavior: well-postured Speech: clear and fluent Mood: anxiety and fears not to recover. Affect: easily irritable Thought Process: reasonable and focused Thought Content: Denies suicidal thoughts Insight: Good Judgment: Fair Assessment Assessment note The patient is a 20-year old Black male , appears a stated age. In accordance with ICD 10, the patient is diagnosed with (F32.9) Major depressive disorder, single episode, unspecified and (F41.1) Generalized anxiety disorder. Plan Plan note 1. Medication changes as detailed below:. Lexapro 5 mg po daily. 2. Follow-up Appointment: in 4 weeks. |
| Age: | 18-49 yrs: |
| Gender: | Male |
| Race: | Black |
| Insurance: | Other |
| Client Presentation: | Pt. is alert and oriented x3, presents with a good judgment. Pt. states she is open to taking medications. Pt. states she thinks her symptoms getting a bit worse. |
| DSM 5 Identifiers: | she can not eat or sleep. pt. states feeling anxious 24/7. This happened first week in March, 2022. The patient describes feeling extremely joyful and sad , lacking drive, and crying a lot. |
| Formulation of Plan (i.e. Treatment/ Interventions, Differential diagnosis, Medications, Non-pharmacological treatment, Follow-up): | Escitalopram Oxalate 5 MG Oral Tablet Hydroxyzine Pamoate (Vistaril) 25 MG Oral Capsule |
| Time with patients (in minutes): | 60 |
PMHNP Case Log
| Date: | 06/15/2022 |
| Rotation Type: | NL 801 Family Psychiatric Nursing I- Advance Mental Health Assessment Across Lifespan |
| Comments: | |
| Patient Age: | 15 Years |
| Patient Sex: | M |
| Patient Ethnicity: | Black or African American |
| SOAP Note: | Note that is subjective C/C: "He has ADHD, has been off his medication for a year " Male AA, 16 years old male, single. The patient claims that his diagnosis of ADHD is why he came to the clinic today. According to the mother of the patient, the child was given an ADHD diagnosis when he was eight years old. According to the mother of the patient, the patient struggled to focus and follow basis instructions in class. The mother of the patient claims that bullying occurred at that time. Pt. was prescribed generic Ritalin, which he took intermittently, mostly when he wasn't in school. Pt.'s mother states he found out pt. became aggressive, therefore no assaultive behavior. Pt. was placed on Vyvance in 2015/2016. and Pt. response was the same, no improvement. Pt. was reported to be normal kid, creative at a younger age. The pt. was described as a typical youngster who was imaginative. Pt. says they only have ADHD and nothing else. However, the patient claims having had suicidal ideas in the past. Pt. denies having experienced prior sexual, physical, or emotional abuse. A vehicle accident, a brain injury, or losing consciousness are all denied by the patient. Objective Objective note Pt. is calm, cooperative, alert and oriented x3, presents with a good judgement. Pt.'s mother will like genetic testing for the patient. mood/affect Flat Appearance, attitude, and motor activity: good. Mood and affect: good and appropriate. Orientation: alert and oriented x 3. Insight and judgment: good. Assessment Assessment note Appearance: Appear clean and appropriately dressed. Maintains poor eye contact. Behavior: well-postured Speech: clear and fluent Mood: anxiety and fears not to recover Affect: easily irritable Thought Process: reasonable and focused Thought Content: Denies suicidal thoughts. Flashbacks, anxiety, nightmares Insight: Good Judgment: Fair Plan Plan note EKG Genetic testing |
| Age: | 12-17 yrs: |
| Gender: | Male |
| Race: | Black |
| Insurance: | Other |
| Client Presentation: | Pt. is calm, cooperative, alert and oriented x3. Poor eye contact with evasive thought process. |
| DSM 5 Identifiers: | Five or more symptoms of inattention and/or ≥5 symptoms of hyperactivity/impulsivity must have persisted for ≥6 months to a degree that is inconsistent with the developmental level and negatively impacts social and academic/occupational activities. |
| Formulation of Plan (i.e. Treatment/ Interventions, Differential diagnosis, Medications, Non-pharmacological treatment, Follow-up): | Genetic testing Lexapro 20 mg po daily Adderall 15 mg po daily EKG UDS Follow up appointment: in 3 weeks. (F90.0) Attention-deficit hyperactivity disorder, predominantly inattentive type Continue taking medication as prescribed. |
| Time with patients (in minutes): | 60 |
PMHNP Case Log
| Date: | 06/08/2022 |
| Rotation Type: | NL 801 Family Psychiatric Nursing I- Advance Mental Health Assessment Across Lifespan |
| Comments: | |
| Patient Age: | 15 Years |
| Patient Sex: | M |
| Patient Ethnicity: | White |
| SOAP Note: | INITIAL INTAKE: Duration: 1 hour. DOB: 05/09/2007 IDENTIFYING DATA: REFERRAL SOURCE: Patient / Father RELIABILITY : Good. CHIEF COMPLAINT: Subjective Subjective note: This is a case of a 15-year-old AA man who comes to the clinic today to start receiving care through this program. Father claims that the patient was depressed and that the patient had been exhibiting indications of depression for some time. Pt. has attended treatment sessions. Feeling down, having poor self-esteem, not being good enough, having suicidal thoughts, and losing interest in what he used to do are symptoms. insomnia. Pt is requesting to leave during intake. Pt. admits to occasionally lacks appetite. Sleep is horrible. Currently denies any lethality. The patient is willing to take medication but is not currently taking any. Objective Objective note Pt. displays sound judgment, is focused and aware x 3. Appearance: Appear clean and appropriately dressed. Maintains fair eye contact. Behavior: well-postured Speech: clear and fluent Mood: anxiety, anxious, Labile Affect: easily irritable Thought Process: reasonable and focused Thought Content: Denies suicidal thoughts. Flashbacks, anxiety, nightmares Insight: Poor Judgment: Poor Assessment Assessment note MDD, mild; Anxiety D/O NOS Poor impulse control and Insight Pt. claims that as a child, he struggled with his rage. At age 4, the subject's current parents adopted him. Before being adopted, the patient experienced trauma and resided in seven different foster homes. would become so enraged that she would assault others. When a patient is extremely agitated, they may be restrained for up to 45 minutes. According to behavior, the patient is substantially better presently. Pt. is now wiser and more mature as per father. Pt. began experiencing at the age of 4 on and off. Patient was given Strattera, but is no longer taking it. strong academic performance, including As and Bs. Pt. denies past suicidal attempt. Pt. denies any physical, sexual, or emotional abuse. The biological parents of the pt. struggle with drugs and mental illness. The patient stays in touch with their biological parents. Pt.'s biological parents have addictions and mental health issues. Pt. still has contact with biological parents. |
| Age: | 12-17 yrs: |
| Gender: | Male |
| Race: | Black |
| Insurance: | Other |
| Client Presentation: | Impatience, and rage. Moreover, anxiousness. |
| DSM 5 Identifiers: | Feeling down, having poor self-esteem, not being good enough, having suicidal thoughts, and losing interest in what he used to do are symptoms. insomnia |
| Formulation of Plan (i.e. Treatment/ Interventions, Differential diagnosis, Medications, Non-pharmacological treatment, Follow-up): | Plan Plan note Consider CBT referral. Medication changes as detailed below:. 1. prozac 20 mg po daily 2. Abilify 5 mg po daily 3. Follow-up Appointment: in 4 weeks. |
| Time with patients (in minutes): | 60 |
PMHNP Case Log
| Date: | 06/07/2022 |
| Rotation Type: | NL 801 Family Psychiatric Nursing I- Advance Mental Health Assessment Across Lifespan |
| Comments: | |
| Patient Age: | 64 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| SOAP Note: | INITIAL INTAKE: Duration: 1 hour. DOB: 08/14/1958 IDENTIFYING DATA: REFERRAL SOURCE: RELIABILITY : Good. CHIEF COMPLAINT: " I was referred here for my medication and intake " Subjective Subjective note: This is a case of a 63-year-old AA single female who comes to the clinic today to initiate care under this program. The patient claims she visited this clinic for her prescriptions and recalls experiencing rage and mood problems in 2009 while having her period. According to the patient, she sought out anger management therapy to prevent losing her work. Pt. was given Prozac. The patient rates her mood as 7 out of 10 today, yet anxiousness is there. The patient claims that covid-19 is to blame for her poor sleep and poor appetite. Pt. rejects SI/HI and A/V/H. Pt. denies having access to any firearms. Objective Objective note Pt. has good judgment, is vigilant, and is multi-oriented. The patient claims to have constipation and claims that gallbladder stones were the cause of her condition. At this point, the patient is not in any discomfort. Since 2018, the patient has stopped using Prozac. Currently taking 50 mg of Vistaril orally three times a day, the patient claims it does not lessen her anxiety. The patient says she's open to changing her medicine, admits to hitting others, and claims that at night her brain won't go to sleep. The patient claims that her main problem is not sleeping. Assessment Assessment note MDD, mild; Anxiety D/O NOS, smoker. Appearance: Appear clean and appropriately dressed. Maintains good eye contact. Behavior: well-postured Speech: clear and fluent Mood: anxiety and fears not to recover Affect: easily irritable Thought Process: reasonable and focused Thought Content: Denies suicidal thoughts. F Insight: Good Judgment: Fair Plan Plan note Medications as detailed below:. 1. Mirtazapine 15 mg po at bedtime 2. effexor 75 mg po daily in am 3. Follow-up Appointment: in 4 weeks. |
| Age: | 50-64 yrs: |
| Gender: | Female |
| Race: | White Non-Hispanic |
| Insurance: | Other |
| Client Presentation: | Appearance: Appear clean and appropriately dressed. Maintains good eye contact. Behavior: well-postured Speech: clear and fluent Mood: anxiety and fears not to recover Affect: easily irritable Thought Process: reasonable and focused Thought Content: Denies suicidal thoughts. F Insight: Good Judgment: Fair Plan |
| DSM 5 Identifiers: | Poor sleep pattern, poor appetite intense and continued worries |
| Formulation of Plan (i.e. Treatment/ Interventions, Differential diagnosis, Medications, Non-pharmacological treatment, Follow-up): | (F32.9) Major depressive disorder, single episode, unspecified (F41.1) Generalized anxiety disorder Aripiprazole (ARIPiprazole) 5 MG Oral Tablet Haloperidol 5 MG Oral Tablet Mirtazapine 15 MG Oral Tablet Sertraline HCl 25 MG Oral Tablet Zolpidem Tartrate 10 MG Oral Tablet Zolpidem Tartrate 5 MG Oral Tablet |
| Time with patients (in minutes): | 60 |
PMHNP Case Log
| Date: | 06/06/2022 |
| Rotation Type: | NL 801 Family Psychiatric Nursing I- Advance Mental Health Assessment Across Lifespan |
| Comments: | |
| Patient Age: | 10 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| SOAP Note: | Subjective Subjective note: Patient with a sad mood, reports she still feels sad. as per pt.'s mother, pt. has nausea and vomiting when first started on Zoloft. pt. 's mother also report issues taking her meds, that when the patient goes to her father's house, she does not comply with meds. pt. and mother were encouraged to take meds everyday. pt. denies SI/HI, denies A/V/H. Patient denies suicidal ideation. Patient denies homicidal ideation. Objective Objective note No change in mental status.. Discussed parenting skills with patient.. Identified patient's relapse triggers.. Patient participated in play therapy.. Appearance, attitude, and motor activity: good. Mood and affect: neutral. Orientation: alert and oriented x3. Insight and judgment: fair. Assessment Assessment note Pt alert and oriented, denied pain, denied Nausea and vomiting. Also denied hx of rash. V/s WNL. As per chart review: Per mother, patient has serious attention issues. She does her homework then forget. Her father and sister were diagnosed with ADHD. There is also anxiety. She reports patient is impulsive. She has a lot of emotion but don't think to act out. She cursed a kid and said would put in a murder list. The behavior has been there since pre-school at about ages 3-4. Attention wise. her teacher has complained about her presence in class. She has issues focusing in class. She is not restless in class. She is angry, irritable. Her emotions are "very big". Mother has depression and she is on Wellbutrin and Strattera. Plan Plan note Continue treatment plan as prescribed.. 1. Zoloft 25 mg po daily in am 2. Follow up appointment: in 4 weeks. |
| Age: | 5-11 yrs: |
| Gender: | Female |
| Race: | White Non-Hispanic |
| Insurance: | Other |
| Client Presentation: | Appearance: Appear clean and appropriately dressed. Maintains good eye contact. Behavior: well-postured Speech: clear Mood: anxiety and fears not to recover Affect: easily irritable Thought Process: distracted Thought Content: Denies suicidal thoughts. Insight: Fair Judgment: Fair |
| DSM 5 Identifiers: | Attention issue Impulsivity |
| Formulation of Plan (i.e. Treatment/ Interventions, Differential diagnosis, Medications, Non-pharmacological treatment, Follow-up): | Sertraline HCl 25 MG Oral Tablet 1 tablet (25 mg) orally daily (start date: 4/29/2022) Amphetamine-Dextroamphetamine 5 MG Oral Tablet Take 1 tablet (5 mg) by mouth a (F90.0) Attention-deficit hyperactivity disorder, predominantly inattentive type |
| Time with patients (in minutes): | 60 |
PMHNP Case Log
| Date: | 07/01/2022 |
| Rotation Type: | NL 801 Family Psychiatric Nursing I- Advance Mental Health Assessment Across Lifespan |
| Comments: | |
| Patient Age: | 19 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| SOAP Note: | Subjective Patient presents today for his follow care. Pt. claims she lacks motivation and finds it challenging to get out of bed or take a shower. Pt. claims that as a result of her low attendance, she is on the verge of failing her classes. The patient reports finding it difficult to begin tasks, having trouble talking, avoiding social settings, being anxious while making phone calls, and feeling overwhelmed. The pt. claims she worries that her friends won't think well of her. The patient claims she dislikes the notion of having sex. The patient claims to be feeling down, worried, and depressed. The patient claims she has a little appetite and eats little and 5 hours is not enough sleep at night. Pt. claims having suicidal thoughts but denies making preparations. Frequent off and on suicidal thought. Currently patient denies SI/HI, denies A/V/H. Objective Objective note: No change in mental status.. A& O X 4 Improvement of mood/affect.. Improvement of thought process/content.. Appearance, attitude, and motor activity: good. Mood and affect: good. Orientation: alert and oriented x3. Insight and judgment: good. Assessment Assessment note: The patient is a 19-year old Caucasian female. MDD, mild; Anxiety D/O NOS. The patient shows positive progress with hardly any suicidal attempts. Goal oriented to take care of self. Plan Plan note: Continue treatment plan as prescribed.. 1. increase Lexapro 10 mg PO daily in AM 2. Follow up appointment: in 4 weeks. |
| Age: | 18-49 yrs: |
| Gender: | Female |
| Race: | White Non-Hispanic |
| Insurance: | Other |
| Client Presentation: | MENTAL STATUS EXAM (MSE): Appearance: Appear clean and appropriately dressed. Maintains good eye contact. Behavior: well-postured Speech: clear and fluent Mood: anxiety and fears not to recover Affect: easily irritable Thought Process: reasonable and focused Thought Content: Denies suicidal thoughts. Insight: Good Judgment: Fair |
| DSM 5 Identifiers: | The patient reports finding it difficult to begin tasks. having trouble talking, avoiding social settings, being anxious while making phone calls, and feeling overwhelmed. The pt. claims she worries that her friends won't think well of her intense fear low self esteem Poor sleep pattern Poor concentration The inability to feel pleasure |
| Formulation of Plan (i.e. Treatment/ Interventions, Differential diagnosis, Medications, Non-pharmacological treatment, Follow-up): | Escitalopram Oxalate 10 MG Oral Tablet 1 tablet (10 mg) orally daily buPROPion HCl ER (XL) 150 MG Oral Tablet Extended Release 24 Hour 1 tablet (150 mg) orally daily in the morning. Vistaril 25 MG Oral Capsule Take 1 capsule (25 mg) by mouth every 12 hours as needed F32.9) Major depressive disorder, single episode, unspecified (F41.1) Generalized anxiety disorder (F90.9) Attention-deficit hyperactivity disorder, unspecified type |
| Time with patients (in minutes): | 60 |
PMHNP Case Log
| Date: | 06/06/2022 |
| Rotation Type: | NL 801 Family Psychiatric Nursing I- Advance Mental Health Assessment Across Lifespan |
| Comments: | |
| Patient Age: | 30 Years |
| Patient Sex: | F |
| Patient Ethnicity: | Black or African American |
| SOAP Note: | Subjective Subjective note INITIAL INTAKE: DOB: 12/21/1991 IDENTIFYING DATA: T.L REFERRAL SOURCE: Self RELIABILITY : Good. CHIEF COMPLAINT: "I come to the clinic today to establish care with this program today". I was referred by HJ. HISTORY OF PRESENT ILLNESS: This is a case of a 30 year old AAF single who comes to the clinic today to establish care with this program . Pt. states she has been having anxiety, feels depressed. Pt. states this has been going on for the past two years when she had her daughter. Pt. states she could not focus, very forgetful and could not remember any conversation. Pt. states her fiance is pregnant. Pt. reports her mood today as up and down, states she woke up ok this morning but as day progresses she feels irritated and frustrated for the past two week. Pt. reports she sleeps ok, but sometimes she stay awake untill 5 AM thinking about random stuff. Appetite is "OK" but not to good. Pt. reports suicide thoughts, mostly when she is alone in her car. Pt. reports she has suicide thoughts everyday, denies having any active plans or intent . Pt. contracted for safety. Pt. denies A/V/H. pt. Denies fire setting or animal cruelty. ALLERGIES: NKDA CURRENT PSYCH MEDICATIONS: Pt. not taking any medications at this time. Pt. states she is open to taking medication and see a therapist. CURRENT NON-PSYCH MEDICATIONS: Pt denied contraceptive , OTC or supplements PAST PSYCHIATRIC HISTORY: Pt. denies past psychiatric disorders/diagnosis. Pt. reports she has anger issues, usually provoked. Pt. denies past psychiatric hospitalization. Pt. denies past suicide attempts, but reports self harm by cutting at age 16. She states she was frustrated a lot, family issues and changing school. Pt. reports being in car accident in senior high school, just once, denies head injury or loss of consciousness. Pt. reports emotional and physical abuse from father, denies sexual abuse. O/P Psychiatrist/therapists: 0 Previous diagnosis: 0 Previous admissions: 0 Previous suicide attempts: 0 Past Medication History: LMP- 05/2022. SURJURIE: Gall bladder removal in October 2020. Hyperthyroid SUBSTANCE ABUSE HISTORY: Tobacco: Pt. denies smoking, states she smoked in the past. ETOH: Pt. states she barely drinks. last had a drink a couple of days ago. Illicit Drugs: Pt. reports she smokes 5 to 8 times daily. pt. last smoked this morning. Pt. started smoking at age 19. Rehab Programs: 0 SOCIAL HISTORY: Pt. was born in Lower Bucks, PA and raised in Ewing, NJ. pt.'s both parents still alive, never married. Pt. has 5 siblings, patient is the first child. Pt. is in a relationship currently, attracted to both males and females. Pt. has one daughter. Living Situation: lives with her fiance and children in a single family home. Marital History: single Children: one Occupation: works at Helzburg Diamond. Education: bachelors. Parents: both alive, never married Siblings: 5 Sexual Orientation: Bisexual. History of Abuse: physical and emotional. Legal: Pt. denies FAMILY PSYCHIATRIC HISTORY: Pt. denies family history of psychiatric disorders. Father has anger issues. Pt. denies family history of substance use. PAST MEDICAL HISTORY: Gallbladder Stones Objective Objective note: Pt. is calm, alert and oriented x 3, presents with a good judgment. General: Good eye contact, well groomed, good hygiene, cooperative and friendly Psychomotor Activity: normal Affect: congruent with mood, Speech: normal Thought Process: goal directed Thought Content: absent of suicidal or homicidal intent Perception: does not appear to be reacting to internal or external stimuli today. Judgment: [ x] fair to good. Insight: fair to good. Plan Plan note: 1.Laboratory or Medical Tests: pt. reports she used to have hyperthyroid. 2. Consider CBT referral. 3. Medications as detailed below: 4. Wellbutrin XL 150 mg po daily 5. Sertraline 25 mg po daily in am 6. Follow-up Appointment: in 4 weeks. 7. CBC+ Diff, T3, T4, TSH, HgA1c, LFT. |
| Age: | 18-49 yrs: |
| Gender: | Female |
| Race: | Black |
| Insurance: | Other |
| Client Presentation: | Pt appears as stated age, alert and oriented to all spheres. |
| DSM 5 Identifiers: | Depressed mood poor sleep patterns could not remember any conversation reports suicide thoughts when alone Poor appetite |
| Formulation of Plan (i.e. Treatment/ Interventions, Differential diagnosis, Medications, Non-pharmacological treatment, Follow-up): | Plan Plan note 1. Routine blood work including pregnancy test 2. Consider CBT referral. 3. Medications as detailed below: 4. Wellbutrin XL 150 mg po daily 5. Sertraline 25 mg po daily in am 6. Follow-up Appointment: in 4 weeks. |
| Time with patients (in minutes): | 60 |
PMHNP Case Log
| Date: | 06/28/2015 |
| Rotation Type: | NL 801 Family Psychiatric Nursing I- Advance Mental Health Assessment Across Lifespan |
| Comments: | |
| Patient Age: | 6 Years |
| Patient Sex: | M |
| Patient Ethnicity: | White |
| SOAP Note: | Subjective Subjective note INITIAL INTAKE: DOB: 06/28/2015. IDENTIFYING DATA: REFERRAL SOURCE: Pt's Mother ( Ms. AF) RELIABILITY : Good. CHIEF COMPLAINT: This is a case of a 6 year old White male who comes to the clinic today, accompanied by mother "to establish care with this program". HISTORY OF PRESENT ILLNESS: Pt is a 6 year old Caucasian male who walk-In, accompanied by his mother for initial intake assessment. Pt.'s mother reports that pt has anxiety and OCD tendencies. Mother reports these symptoms came about age 3 and got more intense by age 5. Pt. argues with teachers in school. Pt. reports having lumps in his throat, or feeling shaking. Pt. was reportedly having obsessive thoughts most time. He keeps talking about things over and over again and he will not stop. this was also reports by patient's school counselor as per mother. Pt. sleeps well, appetite is low, very picky at times. Pt. had no complications during birth, achieve normal milestone while growing up.. ALLERGIES: Cephalosporin- delayed reactions- swelling and joint swellings. Immunization: Up to date as per mother. No food allergies CURRENT PSYCH MEDICATIONS: No meds CURRENT NON-PSYCH MEDICATIONS: No meds PAST PSYCHIATRIC HISTORY: no formal diagnosis. O/P Psychiatrist/therapists: none Previous diagnosis: no Previous admissions: no Previous suicide attempts: no Past Medication History: no SUBSTANCE ABUSE HISTORY: Tobacco: no ETOH: no Illicit Drugs: no Rehab Programs: no SOCIAL HISTORY: Living Situation: lives with his parents and one younger brother. Marital History: child Children: 0 Occupation: first grade Education: student Parents: married. Siblings: one younger brother. Sexual Orientation: heterosexual. History of Abuse: denies. Legal: 0 FAMILY PSYCHIATRIC HISTORY: Mother had OCD, started taking medications at age 22. Mother currently on Zoloft. Father has depression and anxiety and ADHD. PAST MEDICAL HISTORY: none Objective Objective note: Pt. is alert, oriented x3. Pt. not in any discomfort or distress. Pt. is active, playing. No abnormalities noted. V/S WNL. Plan Plan note: Laboratory or Medical Tests: EKG. Follow-up Appointment: in 4 weeks. Medications as detailed below:. Sertraline HCl 25 MG Oral Tablet 1 tablet (25 mg) orally daily |
| Age: | 5-11 yrs: |
| Gender: | Male |
| Race: | White Non-Hispanic |
| Insurance: | Other |
| Client Presentation: | Pt. is alert, oriented x3. Pt. not in any discomfort or distress. Pt. is active, playing. No abnormalities noted |
| DSM 5 Identifiers: | (F42.9) Obsessive-compulsive disorder, unspecified |
| Formulation of Plan (i.e. Treatment/ Interventions, Differential diagnosis, Medications, Non-pharmacological treatment, Follow-up): | (F42.9) Obsessive-compulsive disorder, unspecified Follow-up Appointment: in 4 weeks. |
| Time with patients (in minutes): | 60 |
PMHNP Case Log
| Date: | 05/24/2022 |
| Rotation Type: | NL 801 Family Psychiatric Nursing I- Advance Mental Health Assessment Across Lifespan |
| Comments: | |
| Patient Age: | 4 Years |
| Patient Sex: | M |
| Patient Ethnicity: | Hispanic or Latino |
| SOAP Note: | Subjective Pt presents with a good mood. As per mother, pt. is doing well averagely. pt. Currently taking Abilify and Intuniv 2 mg po prescribed by another provider. Mother reports pt. seems to eat a lot. no other behavior issues this time. Patient reports he eats and sleeps well. pt. uses to throw tantrums, disruptive in class, and has been sent to the Principal's office a couple of times. pt. sleeps well, appetite is increased. pt. finds it difficult to do age related task, easily distracted, plays rough play with his younger brother. Patient denies suicidal ideation. Patient denies homicidal ideation. Objective Appearance, attitude, and motor activity: Good. Mood and affect: good. Alertness: alert and oriented x3. Concentration: fair for age Insight and judgment: fair for age Assessment: This is a case of a 7 year old Hispanic male who comes to the clinic today to establish care with this program today. pt. came to iconichealth because patient's previous provider could not medicate him anymore. Pt escorted by mother no apparent distress. Patient is calm, dressed appropriately. Pt is neat and superficially cooperative. Patient presents with fair eye contact and was observed looking on the other side of the room and easily distracted. Speech/Language: Patient speaks slowly, soft with low volume of words but audible. Pt. was attending children specialist hospital in Hamilton, NJ. pt. was told his care was beyond the hospital resources and they do not take his age anymore. pt. has been going to Children specialist hospital since age 3. pt. was having difficulty at school at the time. pt. started with Ritalin around 5/6 year old, was having bad reaction to the med by gagging. Plan Consider CBT referral. Intuniv 2 mg po daily at bedtime Abilify 5 mg po daily in am Follow-up Appointment: in 4 week. Continue treatment plan as prescribed. Continue taking medication as prescribed. No change to medication. |
| Age: | 2-4 yrs: |
| Gender: | Male |
| Race: | Hispanic |
| Insurance: | Other |
| Client Presentation: | alert and oriented in no distress |
| DSM 5 Identifiers: | (F90.9) Attention-deficit hyperactivity disorder, unspecified type (F39) Unspecified mood [affective] disorder |
| Formulation of Plan (i.e. Treatment/ Interventions, Differential diagnosis, Medications, Non-pharmacological treatment, Follow-up): | Consider CBT referral. Intuniv 2 mg po daily at bedtime Abilify 5 mg po daily in am Poor Impulse control behaviors. |
| Time with patients (in minutes): | 60 |
PMHNP Case Log
| Date: | 07/13/2022 |
| Rotation Type: | NL 810 Family Psychiatric Nursing II |
| Comments: | |
| Patient Age: | 90 Years |
| Patient Sex: | M |
| Patient Ethnicity: | White |
| SOAP Note: | PSYCHIATRIC SOAP NOTE Date: 7/13/2022 Time: 1130 AM Name and Credentials of the person writing this note: Emmanuel Denis, RN Preceptor: LeeAnne, McCauley Significant Events: Pt was referred to this clinic to establish care for VA admission. Presents with of Memory loss with no aggression. Subjective (S) Presents today via telehealth accompanied by daughter Ms (X) requesting initial comprehensive mental health assessment for nursing home placement. Pt identified self as 90 Caucasian male. Living alone in his home. Retired from the Army and support self by SSI. Good family support with two adult daughters. Admits to complying with medication regiment Seroquel 50 mg Hs, Aspirin 81 mg and Lipitor 40 mg Po. Denies Hx of illicit substance use. Denies Hx of abuse of any sort. Denies self-injured behaviors. PMH of high blood pressure and high cholesterol. Pain level 0/10. The patient denies any allergy to food or medication. Patient states that he is upset because his family took away his car and now he is not driving anymore. Objective (O) Alert and oriented in no sign of acute mental disturbances. Mental illness of Memory loss and agitation with no evidence of aggression. Vital sign with acceptable limit. Wt 160 LBs Ht : 5" 1'. MENTAL STATUS EXAM (MSE): Appearance: Appear clean and appropriately dressed. Maintains good eye contact. Behavior: well-postured Speech: clear , fluent but slow Mood: anxious Affect: appropriate Thought Process: reasonable and focused Thought Content: Denies suicidal thoughts. Flashbacks, anxiety, nightmares Insight: Good Judgment: Good Assessment (A) The patient is a 90-year old Caucasian male. Living alone with his adult daughter for the past six months. V/s Within acceptable limit. Diagnosis : Other amnesia ICD -10 Code : R41. 3: The differential diagnosis: Adjustment disorder. ICD-10 code : F23.29, wandering: ICD-10 : Z91.83 Plan: Will continue with current plan of care Recommendation made to arrange for Home attend. Will be referred to therapist Follow up in one month |
| Age: | >=65 yrs: |
| Gender: | Male |
| Race: | White Non-Hispanic |
| Insurance: | Other |
| Client Presentation: | Appropriate as stated age. Congruent. |
| DSM 5 Identifiers: | substantial impairment to be present in one or (usually) more cognitive domains. |
| Formulation of Plan (i.e. Treatment/ Interventions, Differential diagnosis, Medications, Non-pharmacological treatment, Follow-up): | Plan: Will continue with current plan of care Recommendation made to arrange for Home attend. Will be referred to therapist Follow up |
| Time with patients (in minutes): | 60 |
PMHNP Case Log
| Date: | 10/07/2022 |
| Rotation Type: | NL 810 Family Psychiatric Nursing II |
| Comments: | |
| Patient Age: | 14 Years |
| Patient Sex: | M |
| SOAP Note: | Donovan was seen in person with his mother on 10/7/2022. Patient was evaluated after being recently suspended from school for throwing a juice box at another student. The juice box missed the intended target, subsequently hit a teacher. Patients mother (Mrs. Barksdale) was present during the interview, stating that she is overwhelming and cannot "handle taking care of Donovan as a single mother much longer". There are no apparent signs of hallucinations, delusions, bizarre behaviors, or other indicators of psychotic process. Associations are intact, thinking is logical, and thought content appears appropriate. Suicidal ideas or intent are denied. He smiles inappropriately and was playing constantly with his tlitle sister who was present during visit. Associations are intact and logical. Homicidal ideas or intentions are denied. Insight into problems appears to be poor. Judgment appears to be poor. There are no signs of anxiety. A short attention span is evident. There is physical hyperactivity as patient was restless, moving aimlessly in the chair, and was playing with is shoe laces. He is easily distracted. Donovan displayed defiant behavior during the examination stating that he does not like school and does not want to do home work because he is smart than most people . The patient appears grandiose. Donovan displayed uncooperative behavior during the examination. Donovan was intrusive during the examination. Donovan made poor eye contact during the examination |
| Age: | 12-17 yrs: |
| Gender: | Male |
| Race: | Black |
| Insurance: | Other |
| Referral: | Other |
| Client Presentation: | Pt distracted and playful, alert and oriented to all spheres. Distracted, inattentive, defensive, and tense. and appears anxious. His speech is rapid, mumbled, and loud. Mood appears moderately elevated and patient presents as manic. Easy distractibility and a short attention span are in evidence. He is grandiose. He is excited. He is intrusive. Speech is rapid. |
| DSM 5 Identifiers: | Attention-deficit hyperactivity disorder, predominantly hyperactive type, F90.1 (ICD-10) Oppositional defiant disorder, F91.3 (ICD-10) |
| Formulation of Plan (i.e. Treatment/ Interventions, Differential diagnosis, Medications, Non-pharmacological treatment, Follow-up): | #1) dexmethylphenidate (dexmethylphenidate) 10 mg, tablet, Take 1 tablet by mouth as directed TK 2 TABS PO IN THE MORNING AND 1 TAB AFTER LUNCH Daily, Qty: 90, Refills: #2) clonidine HCl (clonidine hcl) 0.1 mg, tablet, Take 1 tablet by mouth twice a day as needed, Qty: 60, Refills: 1 #3) Risperdal (risperidone) 0.5 mg, tablet, Take 1 tablet by mouth every night, Qty: 30, Refills: 1 Goal at this time is to stabilize patient with an IOP and have him return to Amity Services. Follow up set for November 4th just in case Donovan is unable to be placed at an IOP by that time. Refills provided. Plan is for patient to start at Gen Psych IOP. |
| Time with patients (in minutes): | 30 |
| Consult with preceptor (in minutes): | 45 |
| Patient Interaction: | In Person |
PMHNP Case Log
| Date: | 10/12/2022 |
| Rotation Type: | NL 810 Family Psychiatric Nursing II |
| Comments: | |
| Patient Age: | 12 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| SOAP Note: | S = Subjective Client identified problem (Chief complaint) Pt is 12 year old female, Caucasian, who presents today via telehealth, accompanied by mother to establish care and medication. Mother states "I am not able to get an early appointment with her Neurologist and she will need her meds soon". Pt was first diagnosed with ADHA May 2022 History of present/current illness This is the case of a 12 year old female who was escorted by mother for medication management. The patient was alert and oriented, and in no sign of acute distress. As per mother, the patient was experiencing symptoms of ADHD and Anxiety which were getting worst since COVID. Pt was prescribed Adderall 10 mg daily. Both, patient and mother admit compliance with medication and improvement of symptoms. Pt report hx of panic attacks while in school, last episode some was September 14 which last 15 mns. Pt states that she listens to cope with her panic. Pt denies fear of having panic attch in public places. The patient and mother admits to self-destructive behaviors when being upset by pulling hair and eye lashes. Last attempt was sometime this year. Psychiatric history Pt and mother denied Hx of previous psychiatric admission. Medical history Pt and mother denied Hx of medical problem. Allergic to PCN; mild Rash. Denies any Hx of surgery Pt states her menses May 29, 2022 Denies birth control use History of substance use and abuse Pt denied Hx of illicit substance use. Denied cigarette smoking or vape or Tabaco. Developmental history Patient was delivered healthy, normal via C-section, and reached developmental milestones at the expected age. Born and raised in New Jersey. She one older sibling. They were raise by biological parents. Family history Mother reported family history of mental illness. Mother: depression and Anxiety, Asthma, DM Father : Asthma Aunt: Thyroid issue and Ovarian issues? Aunt (Maternal sister): Bipolar, ADHD. Social history Patient is a 7 grader. Enjoys math in school. Un employed with good family support system. Patient and mother deny practicing any sport in school. Pt admits to episode of panic attacks while in school. Last menses: October 1th-5th. Regular Trauma history Pt and mother deny Hx of abuse of any sort. Psychiatric review of systems (ROS) Neuro: Denies seizure activity/loss of function /consciousness. AAOx3, mood and affect appropriate. Denies headaches |
| Age: | 12-17 yrs: |
| Gender: | Female |
| Race: | White Non-Hispanic |
| Insurance: | Other |
| Referral: | Other |
| Client Presentation: | MENTAL STATUS EXAM (MSE): Appearance: Appear clean and appropriately dressed. Maintains good eye contact. Behavior: well-postured Speech: clear and fluent Mood: Anxious Affect: Appropriate to context Thought Process: reasonable and focused Thought Content: Denies suicidal thoughts. Denies homicidal ideation Insight: Good. Appears goal oriented |
| DSM 5 Identifiers: | Anxiety Disorder, ICD-Code F41. 9 Major Depressive Disorder. ICD-Code F33. 0 Panic attack I CD-10 code: F41. 0 Attention deficit hyperactivity disorder: ICD-10 code F90. 2 Social phobias, unspecified CD-10 code F40. 10 |
| Formulation of Plan (i.e. Treatment/ Interventions, Differential diagnosis, Medications, Non-pharmacological treatment, Follow-up): | P = Plan Psychotherapy Will refer for therapy (List of providers sent to mother via email. Adderall immediate release 5 mg TID Folow up in four weeks |
| Time with patients (in minutes): | 60 |
| Consult with preceptor (in minutes): | 60 |
| Patient Interaction: | Telemedicine |
| Clinical Notes: | S = Subjective Client identified problem (Chief complaint) Pt is 12 year old female, Caucasian, who presents today via telehealth, accompanied by mother to establish care and medication. Mother states "I am not able to get an early appointment with her Neurologist and she will need her meds soon". Pt was first diagnosed with ADHA May 2022 History of present/current illness This is the case of a 12 year old female who was escorted by mother for medication management. The patient was alert and oriented, and in no sign of acute distress. As per mother, the patient was experiencing symptoms of ADHD and Anxiety which were getting worst since COVID. Pt was prescribed Adderall 10 mg daily. Both, patient and mother admit compliance with medication and improvement of symptoms. Pt report hx of panic attacks while in school, last episode some was September 14 which last 15 mns. Pt states that she listens to cope with her panic. Pt denies fear of having panic attch in public places. The patient and mother admits to self-destructive behaviors when being upset by pulling hair and eye lashes. Last attempt was sometime this year. Psychiatric history Pt and mother denied Hx of previous psychiatric admission. Medical history Pt and mother denied Hx of medical problem. Allergic to PCN; mild Rash. Denies any Hx of surgery Pt states her menses May 29, 2022 Denies birth control use History of substance use and abuse Pt denied Hx of illicit substance use. Denied cigarette smoking or vape or Tabaco. Developmental history Patient was delivered healthy, normal via C-section, and reached developmental milestones at the expected age. Born and raised in New Jersey. She one older sibling. They were raise by biological parents. Family history Mother reported family history of mental illness. Mother: depression and Anxiety, Asthma, DM Father : Asthma Aunt: Thyroid issue and Ovarian issues? Aunt (Maternal sister): Bipolar, ADHD. Social history Patient is a 7 grader. Enjoys math in school. Un employed with good family support system. Patient and mother deny practicing any sport in school. Pt admits to episode of panic attacks while in school. Last menses: October 1th/5th. Regular Trauma history Pt and mother deny Hx of abuse of any sort. Psychiatric review of systems (ROS) Neuro: Denies seizure activity/loss of function /consciousness. AAOx3, mood and affect appropriate. Denies headaches |
PMHNP Case Log
| Date: | 09/27/2022 |
| Rotation Type: | NL 810 Family Psychiatric Nursing II |
| Comments: | |
| Patient Age: | 12 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| SOAP Note: | This is the case of a 12 year old male was presented to day for her monthly follow up care. Pt was accompanied by mother o discuss medication management. Pt and mother admits to fair appetite and good sleep habit. Pt describes her mood as "Ok" and doing well in school ( 7 grade). Admits to compliance with medication. Denies any pain/discomfort. Denies suicidal and homicidal ideation. |
| Age: | 12-17 yrs: |
| Gender: | Female |
| Race: | White Non-Hispanic |
| Insurance: | Other |
| Referral: | Mental Health |
| Client Presentation: | Alert and oriented in no distress |
| DSM 5 Identifiers: | Major Depressive Disorder (MDD) Code F33. 1 |
| Formulation of Plan (i.e. Treatment/ Interventions, Differential diagnosis, Medications, Non-pharmacological treatment, Follow-up): | Abilify 10mg daily Cymbalta 20 mg daily |
| Time with patients (in minutes): | 30 |
| Consult with preceptor (in minutes): | 30 |
| Patient Interaction: | Telemedicine |
PMHNP Case Log
| Date: | 09/26/2022 |
| Rotation Type: | NL 810 Family Psychiatric Nursing II |
| Comments: | |
| Patient Age: | 12 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| SOAP Note: | Constitutional/Gen: Denies any significant weight changes. Denies any fever/chills. Denies pain. Sees PCP regularly. Reports good sleep. HEENT: denies visual changes, neck supple, no JVD. Denies changes in hearing. Pulmonary: normal inspiratory effort noted. Denies cough/sob Cardiovascular: Denies cp/palpitations/sob/dizziness. GI: Denies n/v/d. Denies heartburn/pain. No complaints/concerns in bowel habits. GU: denies incontinence, hesitancy, pain. OB/GYN: LMP - /2022- not currently on birth control Musculoskeletal: No peripheral edema noted. No asymmetry noted. No flaccidity, cog wheel, or spasticity noted. Neuro: Denies seizure activity/loss of function/consciousness. AAOx3, mood and affect appropriate. Psych: Denies previous psych admission Skin/Hair: intact, good turgor, no rash/open areas noted. Denies hair loss HPI: This is a 12yr old Caucasian female, who is the primary, reliable, informant, accompanied by: mother, who presents for follow up appointment related to patient anxiety and depression. Mother stated that patient had told her about 2 weeks ago, that she feels like her anxiety is worse and more "quick tempered". Patient requesting to be able to use her PRN hydroxyzine 25 mg while at school. Patient stated "it helps and school is where I get the most anxious". Mother and patient also report that patient is doing very well and has a positive attitude in the home. Patient reports that she continues with therapy and this is going "good". Patient denies any SI/HI/SIB. Discussed medications, options, s/e, risks vs benefits, goals, and psychopharmacology with mother who verbalized understanding. |
| Age: | 12-17 yrs: |
| Gender: | Female |
| Race: | White Non-Hispanic |
| Insurance: | Other |
| Referral: | Other |
| Client Presentation: | Alert and oriented in no acute distress. |
| DSM 5 Identifiers: | Code F33. 1 is the diagnosis code used for Major Depressive Disorder (MDD) Code F41. 1 is the diagnosis code used for Generalized Anxiety Disorder Symptoms of GAD include: Feeling restless, wound-up, or on-edge. Being easily fatigued. Having difficulty concentrating. Being irritable |
| Formulation of Plan (i.e. Treatment/ Interventions, Differential diagnosis, Medications, Non-pharmacological treatment, Follow-up): | Will continue to provide supportive talk therapy and encourage patient to continue with individual therapy sessions. Will encouragement and direction to use positive coping skills. Encourage continued participation in individual therapy. Continue current dose of Lexapro and hydroxyzine for anxiety. Will complete school medication administration form for daytime dosing of PRN hydroxyzine by school nurse. Follow up in 1 month. |
| Time with patients (in minutes): | 30 |
| Consult with preceptor (in minutes): | 30 |
| Patient Interaction: | Telemedicine |
PMHNP Case Log
| Date: | 09/12/2022 |
| Rotation Type: | NL 810 Family Psychiatric Nursing II |
| Comments: | |
| Patient Age: | 12 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| SOAP Note: | Fever/Chills: none Chronic pain: none Appetite/Weight changes: adequate appetite and no significant weight changes Sleep: reports adequate sleep HEENT: EOMI, denies visual changes, neck supple, no JVD. Denies changes in hearing. Pulmonary: normal inspiratory effort noted. Denies cough/sob/ chills Cardiovascular: Denies chest pain/palpitations/sob/dizziness GI: Denies nausea/ Vomiting. Denies heartburn/pain. No complaints/concerns in bowel habits (Last BM...). GU: denies incontinence, hesitancy, pain/ burning. OB/GYN: LMP... Musculoskeletal: No flaccidity, cog wheel, or spasticity noted. Neuro: Denies seizure activity/loss of function/consciousness. AAOx3, mood and affect appropriate. Denies headaches GU: denies incontinence, hesitancy, pain. Neuro: Denies seizure activity/loss of function/consciousness. AAOx3, mood and affect appropriate. Denies headaches Psych: Patient has hx of suicidal attempt by hanging self. Was institutionalized for five days. Skin/Hair: intact, good turgor, no rash/open areas noted. Denies hair loss HPI: This is a 12yr old female, who present for follow up care as scheduled. Pt was accompanied by care give, she is alert and oriented and in no sign of acute distress. Pt described herself as doing "Ok " and exiting about her new school. Initially, patient was discharged to this program post her hospitalization for medication management. Mother and patient both report positive mood, good appetite, and sleep. Patient was attentive with good eye contact during interaction with provider. Mother conformed that patient is doing well with current medication regiment and exiting about her new school and new friends. Patient denies any current thought of self harm. Patient denied feeling depressed or overwhelmed. Discussed medications, options, s/e, risks vs benefits, goals, and psychopharmacology with both patient and mother who verbalized good understanding. |
| Age: | 12-17 yrs: |
| Gender: | Female |
| Race: | White Non-Hispanic |
| Insurance: | Other |
| Client Presentation: | MENTAL STATUS EXAM (MSE): Appearance: Appear clean and appropriately dressed. Maintains good eye contact. Behavior: well-postured Speech: clear and fluent Mood: Patient describes mood as "ok" Affect: Flat Thought Process: reasonable and focused Thought Content: Denies suicidal thoughts. Flashbacks, anxiety, nightmares Insight: Good Judgment: Good |
| DSM 5 Identifiers: | ADHD MDD Suicidal attempt |
| Formulation of Plan (i.e. Treatment/ Interventions, Differential diagnosis, Medications, Non-pharmacological treatment, Follow-up): | Plan: Continue to provide supportive talk therapy. Will continue sessions with therapist Continue current dose of Adderall ER 10 mg Daily . Prozac 10 mg Daily and Atarax 25 mg As needed. Follow up in 4 weeks. |
| Time with patients (in minutes): | 60 |
PMHNP Case Log
| Date: | 05/09/2022 |
| Rotation Type: | NL 801 Family Psychiatric Nursing I- Advance Mental Health Assessment Across Lifespan |
| Comments: | |
| Patient Age: | 15 Years |
| Patient Sex: | M |
| Patient Ethnicity: | White |
| SOAP Note: | Identifying Information Client Name: T.T Address: Ewing New Jersey MR#: Home Phone: 609-000-2000 D.O.B.: 01/11/2007 Work Phone: N/A Referral Source: N/A Phone: 609-426-7000 Sources of Information: Self/ mother Phone: 609-868-9040 Parent/Legal Guardian: Mrs . C. G Phone: 609-868-9040 Dates of Evaluation: 05/31/2022 Primary Care Provider: Dr Hills Phone/Fax: N/A Other Providers: N/A Phone/Fax: N/A Evaluation Performed by: NP Oladeru Attending Psychiatrist: N/A Subjective: Pt' s mother reports that when patient's med was switched from Lexapro to Zoloft, pt.'s mood changed drastically and had to go back to Lexapro. Pt. reports she is doing well now, voiced no complaints or discomfort. Pt. denies SI/HI, denies A/V/H. Pt. reports she eats and sleeps well. Patient denies suicidal ideation. Patient denies homicidal ideation. Objective note: mood congruent. Appearance, attitude, and motor activity: good. Mood and affect: good and appropriate. Orientation: alert and oriented x 3. Insight and judgment: good. Assessment note: Pt presents with a good mood escorted by mother patient's. Patient is calm, dressed appropriately. Pt is neat and superficially cooperative. Patient presents with fair eye contact and was observed looking on the other side of the room and staring into space at times. Speech/Language: Patient speaks slowly, soft with low volume of words but audible. Plan note d/c Zoloft Restart Lexapro 10 mg po daily in AM Follow up appointment: in 4 weeks. |
| Age: | 12-17 yrs: |
| Gender: | Female |
| Race: | White Non-Hispanic |
| Insurance: | Other |
| Client Presentation: | Alert and oriented to self. Distracted at times |
| DSM 5 Identifiers: | (F32.9) Major depressive disorder, single episode, unspecified (F41.1) Generalized anxiety disorder |
| Formulation of Plan (i.e. Treatment/ Interventions, Differential diagnosis, Medications, Non-pharmacological treatment, Follow-up): | Escitalopram Oxalate 10 MG Oral Tablet 1 tablet (10 mg) orally daily Follow up appointment: in 5 weeks |
| Time with patients (in minutes): | 45 |
PMHNP Case Log
| Date: | 07/12/2022 |
| Rotation Type: | NL 810 Family Psychiatric Nursing II |
| Comments: | |
| Patient Age: | 70 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| SOAP Note: | PSYCHIATRIC SOAP NOTE Date: 7/12/2022 Time: 2:30 PM Name and Credentials of the person writing this note: Emmanuel Denis, RN Preceptor: LeeAnne, McCauley Significant Events: Pt was referred to this clinic to establish care. Presents with long Hx of Depression and one episode of TMS treatment. Subjective (S) The patient presents with elevated anxiety and complains of feeling depressed stating " I am suffering Depression all my life". Pt identified self as 70 year old Jewish descent female. Divorced with two adults children. Living alone with her dog. Unemployed since getting fired from her graphic designer job some years ago. Currently support self by her savings and social security. Pt denies family Hx of mental illness however admits to mother was dealing with some kind of unspecified depression and sister Colon CA. Admits to comply with medication regiment Cymbalta 90 mg daily and would like to go back to 60 mg daily instead. Born full tern with no special need. Denies Hx of illicit substance use. Denies Hx of abuse of any sort. Denies self-injured behaviors. PMH of Chronic lower back pain and celiac disease. Pain level 0/10. The patient denies any allergy to food or medication. Objective (O) The patient alert and oriented in no sign of acute mental disturbances. Talkative and evasive at times. Good insight of current psychiatric need. She experiences low concentration and has lost interest in daily activities. She does not have any substance use disorder. Ht: 5"5' Wt: 170 Lbs ( States by patient). and weight gain of 20 Lbs for the past few months. MENTAL STATUS EXAM (MSE): Appearance: Appear clean and appropriately dressed. Maintains good eye contact. Behavior: well-postured Speech: clear and fluent Mood: anxiety and fears not to recover Affect: appropriate Thought Process: reasonable and focused Thought Content: Denies suicidal thoughts. Flashbacks, anxiety, nightmares Insight: Good Judgment: Fair Assessment (A) The patient is a 70-year old Caucasian female, Jewish descent. Divorced with two adults children. Depression ICD-10 Codes F32. The differential diagnosis of the patient is F23.29, Adjustment disorder. The patient shows positive progress with hardly any suicidal attempts. Plan (P) Cymbalta 60mg for management of Depression symptoms The patient will undergo or continue with TMC treatment as previously started. Will be referred to therapist Follow up in two months |
| Age: | >=65 yrs: |
| Gender: | Female |
| Race: | White Non-Hispanic |
| Insurance: | Other |
| Client Presentation: | Patient appears as stated age; well groomed for the circumstances with good eye contact. |
| DSM 5 Identifiers: | 1-Depressed mood most of the day, nearly every day. 2-Markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day. 3-Significant weight loss when not dieting or weight gain, or decrease or increase in appetite nearly every day. 4-A slowing down of thought and a reduction of physical movement (observable by others, not merely subjective feelings of restlessness or being slowed down). 5-Fatigue or loss of energy nearly every day. |
| Formulation of Plan (i.e. Treatment/ Interventions, Differential diagnosis, Medications, Non-pharmacological treatment, Follow-up): | Cymbalta 60mg for management of Depression symptoms The patient will undergo or continue with TMC treatment as previously started. Will be referred to therapist Follow up in two months |
| Time with patients (in minutes): | 45 |
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