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Academic ServiceUpdated: 11-09-22
PMHNP Case Log
| Date: | 11/03/2022 |
| Rotation Type: | NL 812 Family Psychiatric Nursing III |
| Comments: | |
| Patient Age: | 25 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| SOAP Note: | S: "I feel pretty good" O: Pt here for med management appt, alert, oriented x3, dressed appropriately, hair clean and neat, smiling, calm, able to answer questions intelligently, denies any c/o at this time A: Med management appt P: Assess patient, renew medications, discuss plan of care |
| Age: | 18-49 yrs: |
| Gender: | Female |
| Race: | White Non-Hispanic |
| Insurance: | PPO |
| Referral: | None |
| Client Presentation: | Alert, oriented x3, cheerful, able to answer questions appropriately, calm, seated in chair, prompt, organized, speech rate normal. Denies any complaints, no anxiety attacks, no hallucinations. Has not had any issues with appetite or changes in weight. Able to focus and complete tasks. Sleeping at least 8 hour a night when taking the trazodone. |
| DSM 5 Identifiers: | PTSD F43.10 Generalized Anxiety F 41.1 MDD, recurrent, moderate F33.1 |
| Formulation of Plan (i.e. Treatment/ Interventions, Differential diagnosis, Medications, Non-pharmacological treatment, Follow-up): | Continue fluoxetine 30mg po qd, for depression, anxiety Continue propanolol 20mg po bid for anxiety Continue trazadoone 75mg po qhs for sleep Reviewed medication management and patient agrees with continuing these medications, Patient will continue with her therapist once a week (trauma certified therapist) Patient eating a vegan diet and no processed sugars patient exercising 3-4x a week, will continue Patient to follow up in one month and sooner if needed |
| Time with patients (in minutes): | 45 |
| Consult with preceptor (in minutes): | 45 |
| Patient Interaction: | In Person |
PMHNP Case Log
| Date: | 11/08/2022 |
| Rotation Type: | NL 812 Family Psychiatric Nursing III |
| Comments: | |
| Patient Age: | 32 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| SOAP Note: | S " I am feeling so much better since I decreased the lexapro" O: Patient smiling, cheerful, alert, calm A: Patient is improving P: Keep patient on Lexapro, not transition to Effexor as previously discussed, patient will continue with Latuda |
| Age: | 18-49 yrs: |
| Gender: | Female |
| Race: | White Non-Hispanic |
| Insurance: | Self Pay |
| Referral: | None |
| Client Presentation: | Alert, cheerful, smiling, make up on, appropriately dressed, answers questions appropriately, hair done, calm, relaxed, indicates that anxiety is much better and she has not had any |
| DSM 5 Identifiers: | MDD (severe) 296.23, (F32.2) , now in remission 296.26 (F32.5) with peripartum onset |
| Formulation of Plan (i.e. Treatment/ Interventions, Differential diagnosis, Medications, Non-pharmacological treatment, Follow-up): | Continue on Lexapro 10mg po qd, Continue with Latuda 20mg po qd, reminded patient to take the Latuda with 350cal/day Patient continuing to meet with her therapist 1xweek Patient still in pp support group Encouraged patient to exercise 3x/week |
| Time with patients (in minutes): | 30 |
| Consult with preceptor (in minutes): | 30 |
| Patient Interaction: | In Person |
PMHNP Case Log
| Date: | 11/08/2022 |
| Rotation Type: | NL 812 Family Psychiatric Nursing III |
| Comments: | |
| Patient Age: | 32 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| SOAP Note: | S " I am feeling so much better since I decreased the lexapro" O: Patient smiling, cheerful, alert, calm A: Patient is improving P: Keep patient on Lexapro, not transition to Effexor as previously discussed, patient will continue with Latuda |
| Age: | 18-49 yrs: |
| Gender: | Female |
| Race: | White Non-Hispanic |
| Insurance: | Self Pay |
| Referral: | None |
| Client Presentation: | Alert, cheerful, smiling, make up on, appropriately dressed, answers questions appropriately, hair done, calm, relaxed, indicates that anxiety is much better and she has not had any |
| DSM 5 Identifiers: | MDD (severe) 296.23, (F32.2) , now in remission 296.26 (F32.5) with peripartum onset |
| Formulation of Plan (i.e. Treatment/ Interventions, Differential diagnosis, Medications, Non-pharmacological treatment, Follow-up): | Continue on Lexapro 10mg po qd, Continue with Latuda 20mg po qd, reminded patient to take the Latuda with 350cal/day Patient continuing to meet with her therapist 1xweek Patient still in pp support group Encouraged patient to exercise 3x/week |
| Time with patients (in minutes): | 30 |
| Consult with preceptor (in minutes): | 30 |
| Patient Interaction: | In Person |
PMHNP Case Log
| Date: | 11/08/2022 |
| Rotation Type: | NL 812 Family Psychiatric Nursing III |
| Comments: | |
| Patient Age: | 51 Years |
| Patient Sex: | F |
| SOAP Note: | S: I need help with my ADD- I cannot manage my life O: talkative, cheerful, friendly, tangential speaking, fidgety, alert, oriented x3, appropriately dressed for season A: ADHD with testing would like medication P: Review testing, discuss medication options and lifestyle with patient |
| Age: | 50-64 yrs: |
| Gender: | Female |
| Race: | White Non-Hispanic |
| Insurance: | Self Pay |
| Referral: | None |
| Client Presentation: | 51 year old white female, looks stated age, alert, orientedx3, appropriately dressed, cheerful, smiling, very talkative, often goes into tangents during conversation, make up on, moves in seat frequently, fidgets with hands, talks excessively |
| DSM 5 Identifiers: | DSM 314.01 (F90.0) Difficulty paying attention, impulsiveness, restlessness, loses things often, forgets things, inappropriate interruptions |
| Formulation of Plan (i.e. Treatment/ Interventions, Differential diagnosis, Medications, Non-pharmacological treatment, Follow-up): | Patient to start Adderall 5mg po bid. Patient instructed to take blood pressure in the am to assess and keep record, pt to buy a blood pressure cuff Discussed with patient the increase in heart rate, headache, insomnia, nervousness Patient is considering behavior therapy and joining an adult ADHD group Have patient return to office in one month and call with any issues |
| Time with patients (in minutes): | 60 |
| Consult with preceptor (in minutes): | 60 |
| Patient Interaction: | In Person |
PMHNP Case Log
| Date: | 10/25/2022 |
| Rotation Type: | NL 812 Family Psychiatric Nursing III |
| Comments: | |
| Patient Age: | 34 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| SOAP Note: | S: I can't focus, I have lost 70 lb, I have no appetite, I cry every day" O: thin, nervous, clean, appropriately dressed, fidgeting with hands, answers questions appropriately, often forgets in the middle of the sentence what she is talking about, frequent crying during session, answers intelligently, makes eye contact, discusses how her wife has left her almost a year ago, discusses the custody battle, discusses how hard things have been for her, has many acts of ocd- checking to make sure things are where they need to be, thinks she would be better off not around but denies SI or a plan, Denies hallucinations or auditory issues, lacks ability to focus, A:Generalized anxiety disorder, mood disorder, obsessive compulsive disorder, P: Order medications, discuss psychotherapy and other management, ensure safety |
| Age: | 18-49 yrs: |
| Gender: | Female |
| Race: | White Non-Hispanic |
| Insurance: | Self Pay |
| Referral: | None |
| Client Presentation: | patient presents tearful, appropriately dressed, clean, tidy, on time, anxious, makes eye contact, speaks fast with good modulation. Alert and oriented x3, patient reports having to have everything organized the night before, patient reports she loses things often and likes to be organized so she does not lose anything. Patient denies SI or homicidal thoughts. Patient does not want to get up out of bed, but does to take care of her kids. Patient is in the middle of a legal suit with her wife and she is getting a divorce. Patient denies any episodes of mania, or hypomania. Patient has taken many medications in the past and does not recall what they are. Patient has a hard time focusing and often forgets what she is doing. PHQ-22, GAD 7- 20. Patient does report to being depressed, sad, and anxious. She has checking behaviors and some obsessive thinking. |
| DSM 5 Identifiers: | Generalized Anxiety Disorder 300.02(F41.1) Mood Disorder F31.1 Obsessive Compulsive disorder 300.3 (F42) |
| Formulation of Plan (i.e. Treatment/ Interventions, Differential diagnosis, Medications, Non-pharmacological treatment, Follow-up): | 1. Obtain medication records for a more detailed look at previous medications 2. Zoloft 25mg po qd 3.Instructed on signs of hypomania and what to look for, to call immediately if signs/symptoms occur 4.contact a therapist and start therapy 5. Reviewed side effects of Zoloft, esp gi upset, patient has taken before and remembers tolerating well, encouraged to take even if GI issues occur, instructed that this will pass 6. Encouraged healthy diet, no refined sugars, no caffeine, encouraged not to drink alcohol, patient does Vape, encouraged to abstain from marijuana, 7. Exercise encouraged 3x week, something to get heart rate up, 8. sleep hygiene discussed 9. RTO in one week with records |
| 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 812 Family Psychiatric Nursing III |
| Comments: | |
| Patient Age: | 24 Years |
| Patient Sex: | F |
| SOAP Note: | S: I really like the 40mg of Prozac O: Alert, oriented, upbeat, smiling, cheerful, cooperative, pleasant A:Stable on medication P: Refill medication, discuss patient update |
| Age: | 18-49 yrs: |
| Gender: | Female |
| Race: | White Non-Hispanic |
| Insurance: | PPO |
| Referral: | None |
| Client Presentation: | Clean, tidy, hair done, makeup on, punctual, nails manicured, well dressed, friendly, talkative, calm, appropriate with questions, articulate, makes eye contact, speech regular rate and appropriate speed, alert, oriented x3, denies SI/homicidal thoughts, able to sit still, focus good, denies binge eating or anorexia, able to concentrate, sleeping 8 hours a night without nightmares or frequent awakenings, planning to move to New Jersey with her boyfriend, just had a good performance review |
| DSM 5 Identifiers: | Major Depressive Disorder, in full remission, single episode 296.26 (F32.5) |
| Formulation of Plan (i.e. Treatment/ Interventions, Differential diagnosis, Medications, Non-pharmacological treatment, Follow-up): | Continue with Prozac 40mg po qd, discussed continuing therapy and working on trauma related issues with therapist, patient goes once a week, client likes the therapist and is reporting good results, patient is not exercising and would like to restart this for her mental health, discussed finding a balance between over exercising and staying healthy, client to aim for 30 minutes of cardio 3x a week and yoga 2x a week, patient eating a plant based diet, avoiding refined sugars, getting a massage every 2 weeks for stress, patient discussed sleep hygiene and the implementation of white noise and how it is helping, patient to RTO in two 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 812 Family Psychiatric Nursing III |
| Comments: | |
| Patient Age: | 32 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| SOAP Note: | S: I just feel anxious all the time, not as sad, but anxious O: patient talking fast, repeating herself, occasional crying, unable to stop ruminating thoughts A: Anxiety P: adjunct with another medication since the depression is improved to aid with anxiety |
| Age: | 18-49 yrs: |
| Gender: | Female |
| Race: | White Non-Hispanic |
| Insurance: | PPO |
| Referral: | None |
| Client Presentation: | clean, dressed appropriately for fall, cool weather, hair brushed and pulled back, makeup on, prompt, alert, oriented x3, appropriate, making eye contact, fidgeting with fingers, shaking knee frequently, speech fast, intelligent, able to communicate concerns, has had trouble focusing lately, sleeping ok, waking up at night worried that she did not complete her tasks during the day, worried about the next day, taking Zoloft and her mood has improved, denies SI or homicidal thoughts, eating is ok, has had decreased appetite, energy level improved, working out three-four times a week walking/running |
| DSM 5 Identifiers: | MDD, moderate, recurrent 296.32 (F33.1) Generalized Anxiety Disorder 300.02 (F41.1) |
| Formulation of Plan (i.e. Treatment/ Interventions, Differential diagnosis, Medications, Non-pharmacological treatment, Follow-up): | Continue with Sertaline 100mg po qd Augment with Buspar , initial dose 15mg po bid for 7 days, will see patient back in one week to see how patient is tolerating. Will increase medication 5mg/day after until patient has desired efficacy, (max dose is 60mg/day). Advised patient that absorption is affected by food and she should be consistent with how she takes the med, medication does not have many side effects but she may see dizziness headache, nervousness, sedation, excitement, nausea, restlessness. Side effects will subside. Stressed the importance of taking the medication twice a day every day. Patient is to increase her therapy to once a week from every other to see if this aids with anxiety. Patient to keep a diary to see what triggers her anxiety. Diet to be consistent clean eating and avoid refined sugars. Discussed alcohol and how drinking may intensify her anxiety. Patient will continue with her exercise program. Patient is also looking into taking yoga and actively pursing this. Will see patient in a week and see how medication is being tolerated. Will increase the medication at that time. Patient agrees with plan of care. |
| Time with patients (in minutes): | 60 |
| Consult with preceptor (in minutes): | 60 |
| Patient Interaction: | In Person |
PMHNP Case Log
| Date: | 10/04/2022 |
| Rotation Type: | NL 812 Family Psychiatric Nursing III |
| Comments: | Group |
| Patient Age: | 45 Years |
| Patient Sex: | M |
| Patient Ethnicity: | White |
| SOAP Note: | Patient is 45 yo male, alert, confused, unable to make much sense during group discussion. Morning group and new patients were introduced. This client thinks he is in Texas and he knows people in the group. Rules of the group reviewed and client interrupts frequently asking others if he met them in Texas. Patient redirected. This patient is wearing a hospital gown and is unshaven and disheveled. Patient came in the night before. Patient without tics or tremors. Speech normal rate. Patient knows his name but not what day it is. No SI or homicidal comments. Minimal eye contact. Poor insight and judgment. |
| Age: | 18-49 yrs: |
| Gender: | Male |
| Race: | White Non-Hispanic |
| Insurance: | Medicaid |
| Referral: | Unmarked |
| Client Presentation: | Disheveled, unshaven, wearing hospital gown, hair dirty and sticking up, food around mouth, talkative, repeats questions, asks individuals if he knows them from Texas, does not remember what he just said, unable to answer questions appropriately, calm, sitting and talking to himself at times, thought process not goal directed, incoherent at times, does not indicate SI/homicidal intent, poor insight, difficulty with conversation unless he is asking a question, |
| DSM 5 Identifiers: | Schizoaffective Disorder 295.70 (F25.0) Bipolar type First episode, currently in partial remission |
| Formulation of Plan (i.e. Treatment/ Interventions, Differential diagnosis, Medications, Non-pharmacological treatment, Follow-up): | Plan to meet with Psychiatrist today, medication plan to be determined, attend groups as indicated, assist with sleep with medication as needed, meet with wife separately (social worker/therapist), include in activities as tolerated |
| Time with patients (in minutes): | 60 |
| Consult with preceptor (in minutes): | 60 |
| Patient Interaction: | In Person |
PMHNP Case Log
| Date: | 10/06/2022 |
| Rotation Type: | NL 812 Family Psychiatric Nursing III |
| Comments: | Group |
| Patient Age: | 36 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| SOAP Note: | 36 year old female, clean, wearing appropriate clothing, hair is long and brushed, pale, alert, apologizes frequently, tearful, sad, oriented to person, place, and day. Hands tremble, gait normal, makes eye contact, looks down frequently during conversation, talks slow, appropriate vocabulary, tight smile at times, memory intact, good judgment, ruminates frequently, group today discussing goals for day, this client goal is to make an appointment with her social worker and obtain work papers for absence. Sleeping well at night, no nightmares, Lunesta is helping. Appetite fair. |
| Age: | 18-49 yrs: |
| Gender: | Female |
| Race: | White Non-Hispanic |
| Insurance: | Private |
| Referral: | Unmarked |
| Client Presentation: | alert, oriented x3, clean, appropriately dressed, slightly older appearing than stated age, hair long and straight, brushed, clean, pale, dentition issues (crooked teeth), able to maintain conversation, frequent apologies and ruminations, some disassociation, able to recall well, above average vocabulary, slight shaking of hands, no tics, able to ambulate without issues, gait steady, makes eye contact, does not smile, sad, redirects self back to subject matter at hand, participates in group, denies SI or homicidal thoughts, skin picking is less, some excoriated areas on forehead and arms, no new areas reported, patient not feeling the urge to pick her skin |
| DSM 5 Identifiers: | Obsessive-Compulsive Disorder 300.3 (F42)with good insight Posttraumatic Stress Disorder 309.81 (F43.10) |
| Formulation of Plan (i.e. Treatment/ Interventions, Differential diagnosis, Medications, Non-pharmacological treatment, Follow-up): | Continue with medications: Clomipramine 100mg po, Lunesta 3mg po qhs, patient agrees with this medication plan Continue with journaling and mindfulness, patient wants to attend Yoga class this evening. Patient reports she is feeling better and looks forward to going home to see her son. Will start IOP upon discharge |
| Time with patients (in minutes): | 60 |
| Consult with preceptor (in minutes): | 60 |
| Patient Interaction: | In Person |
| Clinical Notes: | patient meds: Clomipramine 100mg po qd, Lunesta 3mg po qhs, pt attending groups, plan to see therapist when discharged and attend IOP 3x week, denies SI or homicidal thoughts, appetite ok, no nausea or vomiting, decrease in skin picking, trying to journal, plans on joining a new mother support group when she discharges, (baby is 9 months), her mom is going to live with her for a while. Patient agrees with plan of care, husband supportive |
PMHNP Case Log
| Date: | 10/04/2022 |
| Rotation Type: | NL 812 Family Psychiatric Nursing III |
| Comments: | Group |
| Patient Age: | 26 Years |
| Patient Sex: | M |
| Patient Ethnicity: | Black or African American |
| SOAP Note: | Patient is a 26 year old male. Alert, oriented x3, participates in group discussion. Group today is on gratitude. Group leader (therapist) discussed gratitude and gave examples. Everyone in the group indicated something they were grateful for. This patient said he was grateful for his dog. This group was in patient and lots of people were medicated. |
| Age: | 18-49 yrs: |
| Gender: | Male |
| Race: | Black |
| Insurance: | Private |
| Referral: | Unmarked |
| Client Presentation: | Clean, unshaven, scruffy beard, hair is clean and brushed, clothing appropriate, sweatpants and t-shirt, talking appropriately during group and participating, maintains eye contact, educated conversation, speech normal rate, thought process clear and coherent, no shaking observed or tremors, no tics, walking and sitting appropriately, infrequent smiles, seems forlorn, sad, disassociates at times, good recall, no SI or homicidal thoughts, reports he is still depressed |
| DSM 5 Identifiers: | MDD, severe, F33.2 |
| Formulation of Plan (i.e. Treatment/ Interventions, Differential diagnosis, Medications, Non-pharmacological treatment, Follow-up): | Medications: Venlafaxine 150mg po qd Buspirone 5mg po qd Participate in groups, encourage patient to use relaxation techniques if feeling anxious, patient to be discharged 10/6 and attend IOP possibly. Patient agrees with plan of care, is not suicidal, feels that this is a good plan. Agrees with medications. Discussed adding Hydroxyzine with provider this am for anxiety/sleep. Patient will inform provider if he would like to take this medication. |
| Time with patients (in minutes): | 60 |
| Consult with preceptor (in minutes): | 45 |
| Patient Interaction: | In Person |
PMHNP Case Log
| Date: | 09/08/2022 |
| Rotation Type: | NL 812 Family Psychiatric Nursing III |
| Comments: | |
| Patient Age: | 65 Years |
| Patient Sex: | M |
| Patient Ethnicity: | White |
| SOAP Note: | S"I am a little irritable" "My skin is dry around my eye""I don't need to check doors as much since I started on the medication" O:clean shaven, appropriately dressed, neat, alert, intense, stern look on face, irritable, answers questions tersely, makes good eye contact, challenges questions and information, does answer clearly when understands the "why", calm, not fidgeting, reports dry patch around his eye, has not had a physical for two years, indicates that 9pm he gets irritable A: stable, tolerating lamictal P: increase lamictal, encourage pt to get physical |
| Age: | >=65 yrs: |
| Gender: | Male |
| Race: | White Non-Hispanic |
| Insurance: | PPO |
| Client Presentation: | Alert, well groomed, professionally dressed, clean shaven, intentional answers provided to questions, irritable at moments during interview, makes good eye contact, no fidgeting or distractibility, denies SI or any homicidal intentions, appropriate for appointment, asking receptionist at one minute past the time of appointment when provider will be starting his appointment |
| DSM 5 Identifiers: | Bipolar 2 Disorder (F31.81) |
| Formulation of Plan (i.e. Treatment/ Interventions, Differential diagnosis, Medications, Non-pharmacological treatment, Follow-up): | Differential diagnosis ; Thyroid insufficiency Treatment: Increase lamictal to 100mg po qd, have patient be seen by dermatology for dry skin patch, have internal medicine MD do physical and assess for thyroid condition (dry skin), reviewed signs and symptoms of Steven Johnson syndrome. Encouraged patient to exercise at least three times/week. Try to reduce refined sugar in diet, mindfulness therapy discussed, continue with psychotherapy, wife and him to do couples counseling to assist with strengthening their relationship. Attending support group at church for men every week. Sleeping fine - no issues. Will see this patient back in two weeks for f/u and to increase lamotrigine if patient is tolerating well and skin clear from dermatology. |
| Time with patients (in minutes): | 30 |
PMHNP Case Log
| Date: | 09/06/2022 |
| Rotation Type: | NL 812 Family Psychiatric Nursing III |
| Comments: | |
| Patient Age: | 32 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| SOAP Note: | S"I am having a lot of trouble sleeping" "I keep waking up and thinking my daughter is in the cupboard"."Is the lexapro causing this?" "I just had a sleep study and it was normal" O:dressed appropriately, clean, furrowed brow, cooperative, thoughtful, intelligent responses to questions, pulling hair during the interview, pleasant, relaxed, smiles intermittently A: SSRI is causing insomnia P:Discuss with patient adding trazodone to medication regime, discuss changing medication to another SSRI |
| Age: | 18-49 yrs: |
| Gender: | Female |
| Race: | White Non-Hispanic |
| Insurance: | Self Pay |
| Client Presentation: | alert, orientedx3, clean, neat, casually dressed, appropriate eye contact, answers questions appropriately and intelligently, concerned facial expressions, smiles intermittently, furrowed brow at times, friendly and cooperative |
| DSM 5 Identifiers: | Anxiety F41.9 Depression F32.9 |
| Formulation of Plan (i.e. Treatment/ Interventions, Differential diagnosis, Medications, Non-pharmacological treatment, Follow-up): | Discussion about changing time when she takes Lexapro. Discussion about adding tradazone to help with sleep. Patient wants to discontinue Lexapro and start Zoloft. Patient currently taking 10mg of Lexapro. Will have patient take 5mg of Lexapro for three days and then start Zoloft 25mg po qd. Discussed side effects of Zoloft to include gi upset, sexual dysfunction, sweating, dry mouth, headache, dizziness, insomnia, discussion regarding how medication may take 6-8 weeks to work.If tolerated can increase to 50mg po qd after 7 days. Discussion about sleep hygiene, stop consumption of caffeine early in the day, sleep app, Lavender bath salts by Dr. Teals, CBTI app to assist with sleep, encouraged diet without refined sugar, encouraged exercise 3xweek and to get Vitamin D daily |
| Time with patients (in minutes): | 30 |
PMHNP Case Log
| Date: | 07/12/2022 |
| Rotation Type: | NL 810 Family Psychiatric Nursing II |
| Comments: | |
| Patient Age: | 10 Years |
| Patient Sex: | M |
| SOAP Note: | S: What am I here for anyway? O: fidgety, talkative, constantly in motion, interrupts, smiles, happy, alert shoes untied, food on his face A: client here for ADHD assessment P: interview parents and child, recommend testing for ADHD, Refer to MINDWORDS for thorough testing and evaluation, referral to nutritionist for evaluation of diet |
| Age: | 5-11 yrs: |
| Gender: | Male |
| Race: | White Non-Hispanic |
| Insurance: | Private |
| Client Presentation: | Alert, cheerful, talkative, interrupts frequently, moving all the time, picking at little toy in his hand, unable to stay on one topic, shoes untied |
| DSM 5 Identifiers: | Attention-Deficit/Hyperactivity Disorder 314.01 Both Criterion A1 (inattention) and Criterion A2 have been met for the past six months |
| Formulation of Plan (i.e. Treatment/ Interventions, Differential diagnosis, Medications, Non-pharmacological treatment, Follow-up): | Parents to make appointments at MINDWORKS for evaluation of formal diagnosis and see where strengths/deficits are. Parents to keep a food log and make an appointment for nutrition consult. See what diet looks like/make recommendations. Return to this office after evaluations/recommendations are made for medication management if desired. |
| Time with patients (in minutes): | 60 |
PMHNP Case Log
| Date: | 07/12/2022 |
| Rotation Type: | NL 810 Family Psychiatric Nursing II |
| Comments: | |
| Patient Age: | 11 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| SOAP Note: | S: I don't know why I pull on my eyelashes, it makes me feel better. People make fun of me. O: client without eyelashes and eyebrows, obese, alert, flat affect, appropriate answers to questions, makes eye contact, fidgets with hands A: Trichtotillomania P: Start Zoloft and therapy |
| Age: | 5-11 yrs: |
| Gender: | Female |
| Race: | White Non-Hispanic |
| Insurance: | Self Pay |
| Client Presentation: | Alert, obese, fair skin, quiet, no eyebrows or eyelashes, cooperative, pleasant, fidgeting with hands |
| DSM 5 Identifiers: | Obsessive-Compulsive Disorder 300.3 |
| Formulation of Plan (i.e. Treatment/ Interventions, Differential diagnosis, Medications, Non-pharmacological treatment, Follow-up): | Zoloft 25 mg po and x7 days, Zoloft 50 mg po qd on day 8 and return to office in 14 days. Start therapy for obsessions/compulsions (trichtotillomania) Recommend CBT- names gives, client likes yoga, pt to do with mom 3x a week. Nutrition referral given for BMI (41%) |
| Time with patients (in minutes): | 60 |
PMHNP Case Log
| Date: | 06/23/2022 |
| Rotation Type: | NL 810 Family Psychiatric Nursing II |
| Comments: | |
| Patient Age: | 17 Years |
| Patient Sex: | F |
| SOAP Note: | S: I can't seem to do my work and I keep losing things O: Pleasant, cooperative, alert, oriented x3, talkative, accompanied by mother, denies any mood instability, SI, erratic behavior A: ADHD not managed P: Start patient on ADHD medication if patient agrees |
| Age: | 12-17 yrs: |
| Gender: | Female |
| Race: | White Non-Hispanic |
| Insurance: | PPO |
| Client Presentation: | smiling, fidgeting, able to organize thoughts, speech coherent, alert, appropriately dressed, hair brushed, interacts with mother appropriately, polite, able to articulate that she can't seem to do her work at her job and she is losing everything and "feels scattered", doing well on Geodon, has gained about 50lb, has appetite, not exercising, binge eating periodically, pt and mother report that patient received a diagnosis of ADHD at age 11 and was on Adderal, not currently in therapy |
| DSM 5 Identifiers: | Bipolar 1 296.89 (F31.81) ADHD 314.00 (F90.0) |
| Formulation of Plan (i.e. Treatment/ Interventions, Differential diagnosis, Medications, Non-pharmacological treatment, Follow-up): | Start pt on Adderal Xr 10mg po qd, continue on Geodon 150 mg po qd, make appointment with therapist for psychological support (has therapist she likes from previous years), start walking 3-5x a week for 45 min a day, Take Adderal after eating breakfast as appetite may decrease, report any SI to provider and call 911 for any emergencies, patient feels safe and stable at this time, mother in agreement with plan of care, return to office for f/u in 4 weeks and sooner if needed, Rx for 30 tabs of Adderal sent to pt pharmacy |
| Time with patients (in minutes): | 60 |
PMHNP Case Log
| Date: | 06/09/2022 |
| Rotation Type: | NL 810 Family Psychiatric Nursing II |
| Comments: | |
| Patient Age: | 16 Years |
| Patient Sex: | F |
| Patient Ethnicity: | Black or African American |
| SOAP Note: | S: I am feeling good, I stopped my medication O: Alert, oriented x3, dressed appropriately, polite A: teen stopped meds without discussing with provider, stable P:discuss importance of continuing on medication if replapse occurs |
| Age: | 12-17 yrs: |
| Gender: | Female |
| Race: | Black |
| Insurance: | PPO |
| Client Presentation: | alert, cooperative, pleasant, smiling, engaged, outgoing, talkative |
| DSM 5 Identifiers: | Anxiety ICD10-F41.9 |
| Formulation of Plan (i.e. Treatment/ Interventions, Differential diagnosis, Medications, Non-pharmacological treatment, Follow-up): | Patient was taking 20mg fluoxetine qd, pt not interested in taking as she is feeling better and medication made her feel flat, last took medication two weeks ago, pt denies SI, appetite good, exercising 2-3x a week for 30 minutes, grades good, has summer job, plan to continue to monitor patient, patient to call if she experiences depression/anxiety, continue to meet with therapist every other week. Follow up in one month |
| Time with patients (in minutes): | 45 |
PMHNP Case Log
| Date: | 04/11/2022 |
| Rotation Type: | NL 801 Family Psychiatric Nursing I- Advance Mental Health Assessment Across Lifespan |
| Comments: | |
| Patient Age: | 60 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| SOAP Note: | S: I feel good, three weeks left of the probation O: Alert, smiling, good eye contact, laughing, cheerful A: Stable, Alert, doing well P: Continue on medication, therapy once a week, exercise three times a week for 30 min, relaxing |
| Age: | 50-64 yrs: |
| Gender: | Female |
| Race: | White Non-Hispanic |
| Insurance: | Self Pay |
| Client Presentation: | well dressed, cheerful, alert, smiling, good eye contact, pleasant, cooperative, agreeable |
| DSM 5 Identifiers: | ADHD F90.0 MDD F32.0 |
| Formulation of Plan (i.e. Treatment/ Interventions, Differential diagnosis, Medications, Non-pharmacological treatment, Follow-up): | Continue on medications, adderal 15 mg po qd, wellbutrin 300mg po qd, restless leg syndrome is improved, meditation, boundary work with therapist, f/u in 2 months, try to get in bed at a decent hour and not stay up so late |
| Time with patients (in minutes): | 35 |
PMHNP Case Log
| Date: | 05/31/2022 |
| Rotation Type: | NL 810 Family Psychiatric Nursing II |
| Comments: | |
| Patient Age: | 15 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| SOAP Note: | "I don't like using my pass to get out of class because I have to sit in the office" Mom reports pt has had a 20lb weight gain since 2019 starting zoloft O: alert, clean, articulate, dressed, appropriate, cooperative, accompanied by mom and dad A:Teenager presents stable for medication managaement P: Discuss medication with patient and parents, decrease zoloft as patient mom says it is making her gain weight |
| Age: | 12-17 yrs: |
| Gender: | Female |
| Race: | White Non-Hispanic |
| Insurance: | PPO |
| Client Presentation: | alert, oriented, pleasant, talkative, organized, appropriate, denies suicidal ideation or attempts, no interest in selfharm, passing classes, good grades |
| DSM 5 Identifiers: | ADHD f90.2 Social anxiety f40.10 |
| Formulation of Plan (i.e. Treatment/ Interventions, Differential diagnosis, Medications, Non-pharmacological treatment, Follow-up): | Plan to decrease Zoloft to 125 from 200mg, pt will take 175 for two days then 150 for 2 days, then go to 125. Discussed dosage changes with patient, Patient to exercise 3x a week, continue with therapy once a week and teen group every week, plan to volunteer this summer at animal shelter one time a week, follow up in two months unless sooner needed |
| Time with patients (in minutes): | 45 |
PMHNP Case Log
| Date: | 05/31/2022 |
| Rotation Type: | NL 810 Family Psychiatric Nursing II |
| Comments: | |
| Patient Age: | 17 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| SOAP Note: | S: "I am doing good" "I want to talk about stopping my medicationfor the summer" O: yawning, smiling, alert, talkative, appropriate, clean A: teenager just graduated from high school P: restart wellbutrin in the fall per pt request |
| Age: | 12-17 yrs: |
| Gender: | Female |
| Race: | White Non-Hispanic |
| Insurance: | PPO |
| Client Presentation: | Alert, oriented, clean, dressed in pajama bottoms and t-shirt, smiling, hair sticking up in areas, accompanied by mother, friendly, cooperative, verbally articulate |
| DSM 5 Identifiers: | F90.2 ADHD |
| Formulation of Plan (i.e. Treatment/ Interventions, Differential diagnosis, Medications, Non-pharmacological treatment, Follow-up): | pt reports wanting to stop Wellbutrin, currently taking 300mg po qd, suggested a taper and pt reports that she has already not been taking for one and half weeks. Pt in good spirits, follow up scheduled for August, pt to call if she wants to restart sooner or has any questions, pt reports no issues with stopping the medications. Will continue to exercise 3x a week and see her therapist every other week. |
| Time with patients (in minutes): | 45 |
PMHNP Case Log
| Date: | 03/29/2022 |
| Rotation Type: | NL 801 Family Psychiatric Nursing I- Advance Mental Health Assessment Across Lifespan |
| Comments: | |
| Patient Age: | 25 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| SOAP Note: | S: Things are about the same, I started Accutane and my skin is amazing, I am going through so much that I am not depressed with the Accutane, I am numb and sad about the loss of my aunt/uncle, I am having lots of nightmares and body shakes when I think about them O:Alert, skin clear, well dressed, calm, tearful when speaking about loss of aunt/uncle, denies suicidal thoughts, able to sleep, not feeling rested due to nightmares, appetite good A:coping with loss of aunt/uncle, working through the traumatic loss of relatives, does not want to keep taking the propranolol, using xanax for anxiety, taking 2x a week, doing therapy biweekly, working f/t P: Discontinue the propanolol, continue biweekly therapy. Continue on Sertraline, RTO in 2 months |
| Age: | 18-49 yrs: |
| Gender: | Female |
| Race: | White Non-Hispanic |
| Insurance: | PPO |
| Client Presentation: | calm, good eye contact, alert, tearful when speaking about loss of family members in tragic death |
| DSM 5 Identifiers: | Generalized Anxiety Disorder F41.1 Panic Disorder F41.0 Major Depressive Disorder F33.0 Normal Grief Reaction F43.2 |
| Formulation of Plan (i.e. Treatment/ Interventions, Differential diagnosis, Medications, Non-pharmacological treatment, Follow-up): | Continue with Sertaline 150 mg po qd, xanax .5prn po prn anxiety, continue with biweekly therapy, maintain a good diet, exercise 30 min 3-4 x a week. |
| Time with patients (in minutes): | 30 |
PMHNP Case Log
| Date: | 03/21/2022 |
| Rotation Type: | NL 801 Family Psychiatric Nursing I- Advance Mental Health Assessment Across Lifespan |
| Comments: | |
| Patient Age: | 34 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| SOAP Note: | Subjective: reports mood is good, frequent night sweats, increase in bowel movements, not diarrhea, occasional distractability, sleeping well with seroquel every night, occasionally using Ativan for anxiety, appetite good, breast feeding at night only, husband at home with the baby now on paternity leave O: Alert, oriented, well groomed, maintained good eye contact, appropriate A: depression manageable, stable P: Continue on sertaline 150mg, Ativan prn, and Seroquel 50mg-100mg po qhs for sleep |
| Age: | 18-49 yrs: |
| Gender: | Female |
| Race: | White Non-Hispanic |
| Insurance: | PPO |
| Client Presentation: | Alert, oriented x3, well groomed, atttentive, pleasant, smiling. Questioned if the meds she is taking would make her sweat and have more frequent stool. Denies suicidal ideation and self harm. |
| DSM 5 Identifiers: | MDD 32.9 |
| Formulation of Plan (i.e. Treatment/ Interventions, Differential diagnosis, Medications, Non-pharmacological treatment, Follow-up): | Continue with psychotherapy once a week, refill prescriptions, reviewed potential for weight gain with quetiapine (not expected with lower doses), discussed frequency of stool and sweating as side effects of SSRI. |
| Time with patients (in minutes): | 30 |
PMHNP Case Log
| Date: | 02/28/2022 |
| 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: | S: pt presents for evaluation of pp depression O: pt 6 weeks pp, alert, sad, eyes red, occ. tears, dressed, messy hair, oriented x3, calm, good eye contact denies SI, does not have plan, on Zyprexa at delivery, now on 5mg abilify A: pp depression , Edinburgh 21/30, P: Discussed plan with patient, patient will continue with current psychiatrist, just started on Abilify, pt to get book good moms have scary thoughts, psychotherapy x1 week |
| Age: | 18-49 yrs: |
| Gender: | Female |
| Race: | White Non-Hispanic |
| Insurance: | Self Pay |
| Client Presentation: | 19 yo, pleasant, calm, oriented, tearful, dressed, pt reports she feels sad and is not bonding with her baby |
| DSM 5 Identifiers: | Bipolar 1 disorder (mod) 296.42, (F31.12) MDD 296.32 (F33.1) |
| Formulation of Plan (i.e. Treatment/ Interventions, Differential diagnosis, Medications, Non-pharmacological treatment, Follow-up): | Pt is on Medicaid and had a provider. Self-pay for this appointment. Referral from a lactation consultant for the perinatal project. Pt just started Abilify 5 days ago. Discontinued Zyprexa. Pt denies SI, pt feels safe, will buy the book good moms have scary thoughts. Sees a psychotherapist 1x a week. Will have dad feed the baby at night so mom can sleep 8 hours. PP support group information given, supportive psychotherapy given. Pt to return in 30 days for f/u and to call if she feels a change in thoughts. |
| Time with patients (in minutes): | 45 |
PMHNP Case Log
| Date: | 02/22/2022 |
| Rotation Type: | NL 801 Family Psychiatric Nursing I- Advance Mental Health Assessment Across Lifespan |
| Comments: | |
| Patient Age: | 27 Years |
| Patient Sex: | F |
| Patient Ethnicity: | Hispanic or Latino |
| SOAP Note: | S:"I feel much better with the increase of Lamictal to 350", I am not as sad, or crying O:alert, oriented, smiling, calm, speech even, denies suicidal ideation A:tolerating Lamictal without issues (increase) P:see patient in one month, review suicide precautions |
| Age: | 18-49 yrs: |
| Gender: | Female |
| Race: | Hispanic |
| Insurance: | PPO |
| Client Presentation: | 27 year old female, alert, clean, dressed neatly, speech even and moderate, thoughts organized, good eye contact,calm, smiling |
| DSM 5 Identifiers: | Major depressive disorder 296.32 (F33.1) |
| Formulation of Plan (i.e. Treatment/ Interventions, Differential diagnosis, Medications, Non-pharmacological treatment, Follow-up): | Continue with Lamictal 350mg po qd and Prozac 80mg po qd, continue psychotherapy qweek, light for depression, exercise 30 min q3-4 week, f/u 4 weeks |
| Time with patients (in minutes): | 45 |
PMHNP Case Log
| Date: | 02/14/2022 |
| Rotation Type: | NL 801 Family Psychiatric Nursing I- Advance Mental Health Assessment Across Lifespan |
| Comments: | |
| Patient Age: | 30 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| SOAP Note: | S: I am not going to go back to work, I am feeling better but I am going to stay home with the baby. O: Alert, oriented, clean presenting, organized speech, purposeful conversation, denies hallucinations, denies self harm or harming baby, able to get up in the am and start her day, no more thoughts of smothering her baby A:post partum depression managed with medication/therapy, pt stable P: continue with medication, see pt in two months unless needed sooner |
| Age: | 18-49 yrs: |
| Gender: | Female |
| Race: | White Non-Hispanic |
| Insurance: | PPO |
| Client Presentation: | alert, neatly dressed, intelligent, fluid speech with appropriate pausing and dialogue, attentive, calm, no tears |
| DSM 5 Identifiers: | Post partum depression F53, 648.40 Anxiety F41.9, 300.00 Other mental disorder complicating the puerperium 099.345, 648.44 |
| Formulation of Plan (i.e. Treatment/ Interventions, Differential diagnosis, Medications, Non-pharmacological treatment, Follow-up): | continue with prozac 30mg po qd, Wellbutrin 150mg po qd, Melatonin for sleep prn, refill given for 2 months, return to office in 2 months unless sooner needed, pt to f/u with her therapist qweek, continue healthy diet and exercise, 8 hours rest a night |
| Time with patients (in minutes): | 45 |
PMHNP Case Log
| Date: | 02/14/2022 |
| Rotation Type: | NL 801 Family Psychiatric Nursing I- Advance Mental Health Assessment Across Lifespan |
| Comments: | |
| Patient Age: | 32 Years |
| Patient Sex: | F |
| Patient Ethnicity: | Hispanic or Latino |
| SOAP Note: | S: states "I don't need the Ativan at night anymore, the Seroquel is doing the job", I am doing much better. O:S: Alert and Oriented x3, calm, neatly dressed, cooperative, appropriate, speech normal, concentration good, denies suicidal ideation, denies harming self or infant A:post partum depression managed with medication, pt off benzodiazapines, resting with seroquel, returning to work in three weeks, pt able to do so (per self) P: Continue with 150 of sertaline po qd, 100mg seroquel at hs, pt to continue therapy every other week, exercise 30 min 3-4x week, continue with healthy diet |
| Age: | 18-49 yrs: |
| Gender: | Female |
| Race: | Hispanic |
| Insurance: | PPO |
| Client Presentation: | calm, quiet, alert and oriented x3, worried about going back to work, good judgment, has goals, states medication is helping and she is not needing the Ativan at night, |
| DSM 5 Identifiers: | major depressive disorder, recurrent episode, moderate 296.32 (F33.1). Post partum depression 648.40 (F53.0) |
| Formulation of Plan (i.e. Treatment/ Interventions, Differential diagnosis, Medications, Non-pharmacological treatment, Follow-up): | Refill medication for two months,encourage exercise/walking 3-4x week, continue with therapy every other week unless more is needed, 8 hours rest a night, healthy diet, increase calories 500/day while breast feeding, call with any problems, return to office in 2 months |
| Time with patients (in minutes): | 45 |
PMHNP Case Log
| Date: | 02/08/2022 |
| Rotation Type: | NL 801 Family Psychiatric Nursing I- Advance Mental Health Assessment Across Lifespan |
| Comments: | |
| Patient Age: | 18 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| SOAP Note: | S: pt reports she is going to a PHP program to get her eating under control, pt reports she has a ten year history of ARFID, (not ever disclosed in previous sessions), no change in weight, pt reports she is going to go to college and needs to learn how to eat around others, reports she has a bad relationship with food, denies binging or starving, sleeping at night with seroquel, has not needed vistaril, mood stable O: alert, oriented x 3, appropriate, normal speech, maintains good eye contact A: ARFID flare up, depression contained with Wellbutrin, able to perform school work and job P:PHP at the Center for Discovery start 2/14 for 4-6 weeks, continue on Wellbutrin 300 XL po qd Seroquel 200mg po @hs for sleep |
| Age: | 18-49 yrs: |
| Gender: | Female |
| Race: | White Non-Hispanic |
| Insurance: | PPO |
| Client Presentation: | alert, cooperative, neat, appropriate behavior, average intelligence, normal speech, affect flat, denies suicidal ideation, good judgment and insight |
| DSM 5 Identifiers: | Major Depression F 32.2 Generalized Anxiety F 41.1 |
| Formulation of Plan (i.e. Treatment/ Interventions, Differential diagnosis, Medications, Non-pharmacological treatment, Follow-up): | going to PHP, will meet with MD once released (office policy) then return to this provider, communication form signed for HIPPA with Center for Discovery, meds renewed |
| Time with patients (in minutes): | 60 |
PMHNP Case Log
| Date: | 01/31/2022 |
| Rotation Type: | NL 801 Family Psychiatric Nursing I- Advance Mental Health Assessment Across Lifespan |
| Comments: | |
| Patient Age: | 33 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| SOAP Note: | S: I am very sad, I can't sing or hum to the baby. I am not sleeping enough, I don't feel like eating. I am overwhelmed and cry frequently, gave birth vaginally 2 months ago to healthy son, breastfeeding,on sertaline 100mg and quetiapine 50mg at bedtime, waking and taking .5 ativan to get back to sleep, OB started her on zoloft 100mg six weeks ago O: tearful, nose red, quiet, apprehensive at times, good concentration, above average intelligence, normal speech tone and rate, denies headaches, hallucinations, cooperative, denies wanting to harm herself or her baby, denies suicidal ideation, does not have a plan A: post partum depression, anxious, worried about baby and doing the right things for baby, baby gaining weight, tongue tie clipped on baby and baby eating improved, supportive husband and family, on maternity leave P: Increase zoloft and quetiapine, encourage patient to try increased quetiapine instead of ativan when she wakes up at night, encourage patient to take walk every day for 30 min, |
| Age: | 18-49 yrs: |
| Gender: | Female |
| Race: | White Non-Hispanic |
| Insurance: | PPO |
| Client Presentation: | neat, appropriate, cooperative, alert, oriented, mood congruent with depression, flat affect |
| DSM 5 Identifiers: | Post partum depression F53.0, 648.40 Anxiety F41.9, 300.00 Other mental disorder complicating the puerperium, 099.345, 648.44 |
| Formulation of Plan (i.e. Treatment/ Interventions, Differential diagnosis, Medications, Non-pharmacological treatment, Follow-up): | Increase Sertaline 150mg po qam Increase Quetiapine 100mg po @hs, try to not take in the night and see if increased quetiapine helps Lorazepam 0.5mg prn as needed, Referral for psychotherapy Recommended book- good moms have scary thoughts Follow-up two weeks |
| Time with patients (in minutes): | 60 |
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