case study

Apr 11 at 4:27 PM

Therapy Progress Note

Date: 03/28/18 : 10:02am

Session started: 900am

Date:

 

03/28/18

Seen: Individual 

Mental Status Exam-

Suicidal Ideations: denied

Homicidal Ideations: denied

Alcohol Use: denied 

Substance Use: clean x 10 years

Domestic Violence: denied 

Appearance:  neat

Physiological Signs: tearful at times

Manner and Attitude: Accessible 

Orientation: alert and oriented to person, place, time, and circumstance 

Verbal: Appropriate 

Thought Content: some ruminating 

Current Symptoms/Topic/Stressors: Pt states that she has been feeling manic-y for past few days, c/o racing thoughts and agitation.  She is under a lot of stress at work with her promotion.  She has also been inconsistent with Prozac and was told by med pro that this may contribute to agitating as well.  Overall, pt has been better at being less reactive and thoughts are skewing more positive.  Pt agrees to regulate med dosage and practice mindfulness when feeling reactive.  

Treatment Goals in General and/or This Session:  CBT for depression/anxiety;  substance abuse and relapse prevention

Homework Completed from Last Session:  yes

Helpful Towards Tx Goals: yes

Interventions: Provided Support, Behavioral, Psychoeducational, Solution Focus, Cognitive 

Client’s Response to Interventions:  open

Level of Client Functioning or Participation/Motivation: high  

Progress->Current Treatment Effective:  

Plan for Treatment:  Individual therapy bi-weekly to decrease depression/anxiety by 3 points on 10 point scale; Address substance use and relapse prevention

Homework Assignment: Practice Target Behaviour(s) 

Misc: 

Diagnosis: bipolar II; anxiety 

ICD-10:

 Diagnosis: Bipolar 2 disorder : ICD9 = 296.89 / ICD10 = F31.81 / SNOMED = 83225003

Major Problem: Anxiety depression : ICD9 = 300.4 / ICD10 = F41.8 / SNOMED = 231504006

Change in Diagnosis:   no

Session Ended: 1000am

Follow-up:  

Authorizations:  

 

Date: 03/06/18 : 12:47pm

Therapy Progress Note

Session started:900am 

Date:  03/06/18

Services Provided: 90834

Seen: Individual 
Mental Status Exam-
Suicidal Ideations: denied
Homicidal Ideations: denied
Alcohol Use: denied 
Substance Use: clean x 10 years
Domestic Violence: denied 
Appearance:  neat
Physiological Signs: tearful at times
Manner and Attitude: Accessible 
Orientation: alert and oriented to person, place, time, and circumstance 
Verbal: Appropriate 
Thought Content: some ruminating 

Current Symptoms/Topic/Stressors: Pt remains clean and free of diet pills and was praised for this.  Pt is struggling with fatigue but also knows that it has not been very long since she quit pills, and also she has been undera  lot of work stress.  Aside from sleepiness and stress, pt is doing very well.  She is more calm, less reactive, and generally happier.  Writer pointed out the change in pt’s attitude that was clear in her choice of language.  Pt is now able to effectively assess urgency of situations and respond accordingly as opposed to reacting.  Pt feels good and is proud of accomplishments.  

Treatment Goals in General and/or This Session:  CBT for depression/anxiety;  substance abuse and relapse prevention

Homework Completed from Last Session:  yes

Helpful Towards Tx Goals: yes
Interventions: Provided Support, Behavioral, Psychoeducational, Solution Focus, Cognitive 
Client’s Response to Interventions:  open
Level of Client Functioning or Participation/Motivation: high  
Progress->Current Treatment Effective:  
Plan for Treatment:  Individual therapy bi-weekly to decrease depression/anxiety by 3 points on 10 point scale; Address substance use and relapse prevention
Homework Assignment: Practice Target Behaviour(s) 
Misc: 
Diagnosis: bipolar II; anxiety 
ICD-10:
 Diagnosis: Bipolar 2 disorder : ICD9 = 296.89 / ICD10 = F31.81 / SNOMED = 83225003
Major Problem: Anxiety depression : ICD9 = 300.4 / ICD10 = F41.8 / SNOMED = 231504006

Change in Diagnosis:   no

Session Ended: 945am

Follow-up:  
Authorizations:  
 

Rx: PROZAC 20MG 1 Capsule once each day , 30, Ref: 0

03/06/2018 03:26PM

Date: 03/28/18 : 10:02am
Therapy Progress Note
Session started: 900am
Mental Status Exam-
Suicidal Ideations: denied
Homicidal Ideations: denied
Alcohol Use: denied 
Substance Use: clean x 10 years
Domestic Violence: denied 
Appearance:  neat
Physiological Signs: tearful at times
Manner and Attitude: Accessible 
Orientation: alert and oriented to person, place, time, and circumstance 
Verbal: Appropriate 
Thought Content: some ruminating 

Current Symptoms/Topic/Stressors: Pt states that she has been feeling manic-y for past few days, c/o racing thoughts and agitation.  She is under a lot of stress at work with her promotion.  She has also been inconsistent with Prozac and was told by med pro that this may contribute to agitatin as well.  Overall, pt has been better at being less reactive and thoughts are skewing more positive.  Pt agrees to regulate med dosage and practice mindfulness when feeling reactive.  

Treatment Goals in General and/or This Session:  CBT for depression/anxiety;  substance abuse and relapse prevention
Homework Completed from Last Session:  yes
Helpful Towards Tx Goals: yes
Interventions: Provided Support, Behavioral, Psychoeducational, Solution Focus, Cognitive 
Client’s Response to Interventions:  open
Level of Client Functioning or Participation/Motivation: high  
Progress->Current Treatment Effective:  
Plan for Treatment:  Individual therapy bi-weekly to decrease depression/anxiety by 3 points on 10 point scale; Address substance use and relapse prevention
Homework Assignment: Practice Target Behaviour(s) 
Misc: 
Diagnosis: bipolar II; anxiety 
ICD-10:
 Diagnosis: Bipolar 2 disorder : ICD9 = 296.89 / ICD10 = F31.81 / SNOMED = 83225003
Major Problem: Anxiety depression : ICD9 = 300.4 / ICD10 = F41.8 / SNOMED = 231504006

Change in Diagnosis:   no
Session Ended: 1000am
Follow-up:  
Authorizations:  
 

Mental Status Exam-
Suicidal Ideations: denied
Homicidal Ideations: denied
Alcohol Use: denied 
Substance Use: clean x 10 years
Domestic Violence: denied 
Appearance:  neat
Physiological Signs: tearful at times
Manner and Attitude: Accessible 
Orientation: alert and oriented to person, place, time, and circumstance 
Verbal: Appropriate 
Thought Content: some ruminating 

Current Symptoms/Topic/Stressors: Pt is dealing with a lot of drama at work, which makes her anxious.  However, she appreciates the money she makes and could not make that much elsewhere.  She is moving at end of January and hopes this will allow her to meet more people.  She has found herself recently looking up ex BF and making herself miserable.  Pt knows she needs a change but cannot bring herself to make changes.  Pt has plan to quit diet pills over Xmas and is going to beach and looking forward to it.  

Treatment Goals in General and/or This Session:  CBT for depression/anxiety;  substance abuse and relapse prevention
Homework Completed from Last Session:  yes
Helpful Towards Tx Goals: yes
Interventions: Provided Support, Behavioral, Psychoeducational, Solution Focus, Cognitive 
Client’s Response to Interventions:  open
Level of Client Functioning or Participation/Motivation: high  
Progress->Current Treatment Effective:  
Plan for Treatment:  Individual therapy bi-weekly to decrease depression/anxiety by 3 points on 10 point scale; Address substance use and relapse prevention
Homework Assignment: Practice Target Behaviour(s) 
Misc: 
Diagnosis: bipolar II; anxiety 
ICD-10:
 Diagnosis: Bipolar 2 disorder : ICD9 = 296.89 / ICD10 = F31.81 / SNOMED = 83225003
Major Problem: Anxiety depression : ICD9 = 300.4 / ICD10 = F41.8 / SNOMED = 231504006

 

12/15/2017 05:06PM

Mental Status Exam-
Suicidal Ideations: denied
Homicidal Ideations: denied
Alcohol Use: denied 
Substance Use: clean x 10 years
Domestic Violence: denied 
Appearance:  neat
Physiological Signs: tearful at times
Manner and Attitude: Accessible 
Orientation: alert and oriented to person, place, time, and circumstance 
Verbal: Appropriate 
Thought Content: some ruminating 

Current Symptoms/Topic/Stressors: Pt reports that she feels like she is doing slightly better.  She has a lot of drama at work and was getting very frustrated but was then offered a new position thaat would be a huge leap for her and feels good about that although she is not sure if she wants the job.  She has also weeded out some “friends” who caused a lot of distress.  She is moving downtown soon and is excited about it.  She agrees to start more self care such as yoga class so as to meet ppl whom she may befriend.

Treatment Goals in General and/or This Session:  CBT for depression/anxiety;  substance abuse and relapse prevention
Homework Completed from Last Session:  yes
Helpful Towards Tx Goals: yes
Interventions: Provided Support, Behavioral, Psychoeducational, Solution Focus, Cognitive 
Client’s Response to Interventions:  open
Level of Client Functioning or Participation/Motivation: high  
Progress->Current Treatment Effective:  
Plan for Treatment:  Individual therapy bi-weekly to decrease depression/anxiety by 3 points on 10 point scale; Address substance use and relapse prevention
Homework Assignment: Practice Target Behaviour(s) 
Misc: 
Diagnosis: bipolar II; anxiety 
ICD-10:
 Diagnosis: Bipolar 2 disorder : ICD9 = 296.89 / ICD10 = F31.81 / SNOMED = 83225003
Major Problem: Anxiety depression : ICD9 = 300.4 / ICD10 = F41.8 / SNOMED = 231504006

Change in Diagnosis:   no

Session Ended: 0945am

Follow-up:  

Date: 10/25/17 : 10:09am

Session started: 900am 

Mental Status Exam-
Suicidal Ideations: denied
Homicidal Ideations: denied
Alcohol Use: denied 
Substance Use: clean x 10 years
Domestic Violence: denied 
Appearance:  neat
Physiological Signs: tearful at times
Manner and Attitude: Accessible 
Orientation: alert and oriented to person, place, time, and circumstance 
Verbal: Appropriate 

Thought Content: Ruminating 

Current Symptoms/Topic/Stressors: Pt reports that she has decided to move out and is waiting on a unit to open in bldg downtown.  When asked what would be different aside from where she lives, pt states “I will go to more sporting events and other things around the city.”  Pt was encouraged to do these things now.  Pt questions if she will ever find someone for long term relationship because she is accustomed to feeling “less than” due to family experiences.  Pt admits that she has not put forth any effort to meetr ppl.  Pt agrees to go to Halloween party this weekend.  

Treatment Goals in General and/or This Session:  CBT for depression/anxiety;  substance abuse and relapse prevention
Homework Completed from Last Session:  yes
Helpful Towards Tx Goals: yes
Interventions: Provided Support, Behavioral, Psychoeducational, Solution Focus, Cognitive 
Client’s Response to Interventions:  open
Level of Client Functioning or Participation/Motivation: high  
Progress->Current Treatment Effective:  
Plan for Treatment:  Individual therapy bi-weekly to decrease depression/anxiety by 3 points on 10 point scale; Address substance use and relapse prevention
Homework Assignment: Practice Target Behaviour(s) 
Misc: 
Diagnosis: bipolar II; anxiety 
ICD-10:
 Diagnosis: Bipolar 2 disorder : ICD9 = 296.89 / ICD10 = F31.81 / SNOMED = 83225003
Major Problem: Anxiety depression : ICD9 = 300.4 / ICD10 = F41.8 / SNOMED = 231504006

Mental Status Exam-
Suicidal Ideations: denied
Homicidal Ideations: denied
Alcohol Use: denied 
Substance Use: clean x 10 years
Domestic Violence: denied 
Appearance:  neat
Physiological Signs: tearful at times
Manner and Attitude: Accessible 
Orientation: alert and oriented to person, place, time, and circumstance 
Verbal: Appropriate 
Thought Content: Ruminating 

Current Symptoms/Topic/Stressors: Pt reports that she continues to debate whether or not to move out of current living situation.  She is not happy there but also knows that she may not be happy just vecause she moves.  Pt enjoys living alone but doesnt want to isolate herself.  Mood has been ok, still having issues with family.  Discussed healthy/unhealthy attachments and discussed addiction as an attachment disorder.  Pt has always had a sense of not quite belonging since childhood, as her parents remarried and each had kids with their second spouses and they all remain family units.  Pt wants to get married and have her own family but is not living a lifestyle conducive to meeting quality people.  She has recently taken a position with AA that takes up a lot of free time but rest of time is spent working.

Treatment Goals in General and/or This Session:  CBT for depression/anxiety; substance abuse and relapse prevention

Homework Completed from Last Session:  yes
Helpful Towards Tx Goals: yes
Interventions: Provided Support, Behavioral, Psychoeducational, Solution Focus, Cognitive 
Client’s Response to Interventions:  open
Level of Client Functioning or Participation/Motivation: high  
Progress->Current Treatment Effective:  
Plan for Treatment:  Individual therapy bi-weekly to decrease depression/anxiety by 3 points on 10 point scale; Address substance use and relapse prevention
Homework Assignment: Practice Target Behaviour(s) 
Misc: 
Diagnosis: bipolar II; anxiety 
ICD-10:
 Diagnosis: Bipolar 2 disorder : ICD9 = 296.89 / ICD10 = F31.81 / SNOMED = 83225003

Major Problem: Anxiety depression : ICD9 = 300.4 / ICD10 = F41.8 / SNOMED = 231504006 

Mental Status Exam-
Suicidal Ideations: denied
Homicidal Ideations: denied
Alcohol Use: denied 
Substance Use: clean x 10 years
Domestic Violence: denied 
Appearance:  neat
Physiological Signs: tearful at times
Manner and Attitude: Accessible 
Orientation: alert and oriented to person, place, time, and circumstance 
Verbal: Appropriate 

Thought Content: Ruminating but better than last session

Current Symptoms/Topic/Stressors: Pt reports that she has had a ‘very dramatic’ past few weeks.  After last session, she and roommates continues to argue and the aggressiveness increased to the ppint of name calling a screaming and pt was very upset.  She made the decision to get rid of her dog, as most of recent stress was due to problems with caring for the dog.  Pt was very sad to make this decision but dog went to family with large yard and other dogs and will have much better quality of life.  However, when she told her mother, mother responded by telling her that she “should never have kids because she would just abandon them and put them up for adoption”etc etc.  Pt was devastated but now that she has had time to process she sees that mother was projecting onto her, and that she is differentiated enough to know that they can see things completely differently and that is ok.  She is being cordial to roommates also but feels only safe and happy place for her is at work, where she is loved by co-workers and valued for work she does.  Pt understands that she needs health ppl in her life who build her up instead of beating her down.  She is looking for place to live that is closer to work and has options for more socializing. She recently took state level position for AA  and is looking forward to it.

Treatment Goals in General and/or This Session:  CBT for depression/anxiety;  substance abuse and relapse prevention
Homework Completed from Last Session:  yes
Helpful Towards Tx Goals: yes
Interventions: Provided Support, Behavioral, Psychoeducational, Solution Focus, Cognitive 
Client’s Response to Interventions:  open
Level of Client Functioning or Participation/Motivation: high  
Progress->Current Treatment Effective:  
Plan for Treatment:  Individual therapy bi-weekly to decrease depression/anxiety by 3 points on 10 point scale; Address substance use and relapse prevention
Homework Assignment: Practice Target Behaviour(s) 
Misc: 
Diagnosis: bipolar II; anxiety 
ICD-10:
 Diagnosis: Bipolar 2 disorder : ICD9 = 296.89 / ICD10 = F31.81 / SNOMED = 83225003
Major Problem: Anxiety depression : ICD9 = 300.4 / ICD10 = F41.8 / SNOMED = 231504006

Mental Status Exam-
Suicidal Ideations: denied
Homicidal Ideations: denied
Alcohol Use: denied 
Substance Use: clean x 10 years
Domestic Violence: denied 
Appearance:  neat
Physiological Signs: tearful at times
Manner and Attitude: Accessible 
Orientation: alert and oriented to person, place, time, and circumstance 
Verbal: Appropriate 
Thought Content: Ruminating but better than last session

Current Symptoms/Topic/Stressors: Pt reports that she was taken off of new med that made her feel weird.  She is now only taking Wellbutrin and Lamictal and feels better and more clear-headed than she has in a long time.  She plans to move due to dysfunction of roommate situation that threatens her sobriety.  She is busy at work but otherwise feeling pretty good and spending more time with friends and socializing.  Pt is proud of how she has handled recent events and was encouraged to keep it up and avoid idle time which tends to be bad for her.

Treatment Goals in General and/or This Session:  CBT for depression/anxiety;  substance abuse and relapse prevention
Homework Completed from Last Session:  yes
Helpful Towards Tx Goals: yes
Interventions: Provided Support, Behavioral, Psychoeducational, Solution Focus, Cognitive 
Client’s Response to Interventions:  open
Level of Client Functioning or Participation/Motivation: high  
Progress->Current Treatment Effective:  
Plan for Treatment:  Individual therapy bi-weekly to decrease depression/anxiety by 3 points on 10 point scale; Address substance use and relapse prevention
Homework Assignment: Practice Target Behaviour(s) 
Misc: 
Diagnosis: bipolar II; anxiety 
ICD-10:
 Diagnosis: Bipolar 2 disorder : ICD9 = 296.89 / ICD10 = F31.81 / SNOMED = 83225003
Major Problem: Anxiety depression : ICD9 = 300.4 / ICD10 = F41.8 / SNOMED = 231504006

Date:  10/25/17

Seen: Individual 
Mental Status Exam-
Suicidal Ideations: denied
Homicidal Ideations: denied
Alcohol Use: denied 
Substance Use: clean x 10 years
Domestic Violence: denied 
Appearance:  neat
Physiological Signs: tearful at times
Manner and Attitude: Accessible 
Orientation: alert and oriented to person, place, time, and circumstance 
Verbal: Appropriate 
Thought Content: Ruminating 
Current Symptoms/Topic/Stressors: Pt reports that she has decided to move out and is waiting on a unit to open in bldg downtown.  When asked what would be different aside from where she lives, pt states “I will go to more sporting events and other things around the city.”  Pt was encouraged to do these things now.  Pt questions if she will ever find someone for long term relationship because she is accustomed to feeling “less than” due to family experiences.  Pt admits that she has not put forth any effort to meetr ppl.  Pt agrees to go to Halloween party this weekend.  
Treatment Goals in General and/or This Session:  CBT for depression/anxiety;  substance abuse and relapse prevention
Homework Completed from Last Session:  yes
Helpful Towards Tx Goals: yes
Interventions: Provided Support, Behavioral, Psychoeducational, Solution Focus, Cognitive 
Client’s Response to Interventions:  open
Level of Client Functioning or Participation/Motivation: high  
Progress->Current Treatment Effective:  
Plan for Treatment:  Individual therapy bi-weekly to decrease depression/anxiety by 3 points on 10 point scale; Address substance use and relapse prevention
Homework Assignment: Practice Target Behaviour(s) 
Misc: 
Diagnosis: bipolar II; anxiety 
ICD-10:
 Diagnosis: Bipolar 2 disorder : ICD9 = 296.89 / ICD10 = F31.81 / SNOMED = 83225003
Major Problem: Anxiety depression : ICD9 = 300.4 / ICD10 = F41.8 / SNOMED = 231504006

Change in Diagnosis:   no
Session Ended: 1000am
Follow-up:  
Authorizations:  
 

Seen: Individual 
Mental Status Exam-
Suicidal Ideations: denied
Homicidal Ideations: denied
Alcohol Use: denied 
Substance Use: clean x 10 years
Domestic Violence: denied 
Appearance:  neat
Physiological Signs: tearful at times
Manner and Attitude: Accessible 
Orientation: alert and oriented to person, place, time, and circumstance 
Verbal: Appropriate 
Thought Content: some ruminating 
Current Symptoms/Topic/Stressors: Pt reports that she feels like she is doing slightly better.  She has a lot of drama at work and was getting very frustrated but was then offered a new position thaat would be a huge leap for her and feels good about that although she is not sure if she wants the job.  She has also weeded out some “friends” who caused a lot of distress.  She is moving downtown soon and is excited about it.  She agrees to start more self care such as yoga class so as to meet ppl whom she may befriend.
Treatment Goals in General and/or This Session:  CBT for depression/anxiety;  substance abuse and relapse prevention
Homework Completed from Last Session:  yes
Helpful Towards Tx Goals: yes
Interventions: Provided Support, Behavioral, Psychoeducational, Solution Focus, Cognitive 
Client’s Response to Interventions:  open
Level of Client Functioning or Participation/Motivation: high  
Progress->Current Treatment Effective:  
Plan for Treatment:  Individual therapy bi-weekly to decrease depression/anxiety by 3 points on 10 point scale; Address substance use and relapse prevention
Homework Assignment: Practice Target Behaviour(s) 
Misc: 
Diagnosis: bipolar II; anxiety 
ICD-10:
 Diagnosis: Bipolar 2 disorder : ICD9 = 296.89 / ICD10 = F31.81 / SNOMED = 83225003
Major Problem: Anxiety depression : ICD9 = 300.4 / ICD10 = F41.8 / SNOMED = 231504006

Change in Diagnosis:   no
Session Ended: 0945am
Follow-up:  
Authorizations:  
 

Session started: 930am

Date:  01/10/18

Seen: Individual 
Mental Status Exam-
Suicidal Ideations: denied
Homicidal Ideations: denied
Alcohol Use: denied 
Substance Use: clean x 10 years
Domestic Violence: denied 
Appearance:  neat
Physiological Signs: tearful at times
Manner and Attitude: Accessible 
Orientation: alert and oriented to person, place, time, and circumstance 
Verbal: Appropriate 
Thought Content: some ruminating 

Current Symptoms/Topic/Stressors: Pt was able to stop taking diet pills and was doing ok until RTW, where she was having great trouble focusing.  Pt is also terrified of gaining weight b/c it will tempt her to go back on pills.  Pt expressed concern to PCP and was started on weight loss meds but apparently pt was taking too much serotonin so still was not functioning well.  Meds have been adjusted and now pt feels confident that she is on the right path.  Pt is moving in a month and recently received a promotion at work so is excited for next phase in her life.  

Treatment Goals in General and/or This Session:  CBT for depression/anxiety;  substance abuse and relapse prevention
Homework Completed from Last Session:  yes
Helpful Towards Tx Goals: yes
Interventions: Provided Support, Behavioral, Psychoeducational, Solution Focus, Cognitive 
Client’s Response to Interventions:  open
Level of Client Functioning or Participation/Motivation: high  
Progress->Current Treatment Effective:  
Plan for Treatment:  Individual therapy bi-weekly to decrease depression/anxiety by 3 points on 10 point scale; Address substance use and relapse prevention
Homework Assignment: Practice Target Behaviour(s) 
Misc: 
Diagnosis: bipolar II; anxiety 
ICD-10:
 Diagnosis: Bipolar 2 disorder : ICD9 = 296.89 / ICD10 = F31.81 / SNOMED = 83225003
Major Problem: Anxiety depression : ICD9 = 300.4 / ICD10 = F41.8 / SNOMED = 231504006
Mental Status Exam-
Suicidal Ideations: denied
Homicidal Ideations: denied
Alcohol Use: denied 
Substance Use: clean x 10 years
Domestic Violence: denied 
Appearance:  neat
Physiological Signs: tearful at times
Manner and Attitude: Accessible 
Orientation: alert and oriented to person, place, time, and circumstance 
Verbal: Appropriate 
Thought Content: some ruminating 

Current Symptoms/Topic/Stressors: Pt remains clean and free of diet pills and was praised for this.  Pt got recent promotion at work and although she is not the “superstar” that she was while on pills, she is finally starting to feel more normal, less reactive.  Pt finds herself looking for drama and chaos despite all going well.  Pt will try and practice mindfulness and gratitude to help her take focus off of negative feelings.

Treatment Goals in General and/or This Session:  CBT for depression/anxiety;  substance abuse and relapse prevention
Homework Completed from Last Session:  yes
Helpful Towards Tx Goals: yes
Interventions: Provided Support, Behavioral, Psychoeducational, Solution Focus, Cognitive 
Client’s Response to Interventions:  open
Level of Client Functioning or Participation/Motivation: high  
Progress->Current Treatment Effective:  
Plan for Treatment:  Individual therapy bi-weekly to decrease depression/anxiety by 3 points on 10 point scale; Address substance use and relapse prevention
Homework Assignment: Practice Target Behaviour(s) 
Misc: 
Diagnosis: bipolar II; anxiety 
ICD-10:
 Diagnosis: Bipolar 2 disorder : ICD9 = 296.89 / ICD10 = F31.81 / SNOMED = 83225003
Major Problem: Anxiety depression : ICD9 = 300.4 / ICD10 = F41.8 / SNOMED = 231504006

Date: 03/06/18 : 12:47pm
Session started:900am 
Mental Status Exam-
Suicidal Ideations: denied
Homicidal Ideations: denied
Alcohol Use: denied 
Substance Use: clean x 10 years
Domestic Violence: denied 
Appearance:  neat
Physiological Signs: tearful at times
Manner and Attitude: Accessible 
Orientation: alert and oriented to person, place, time, and circumstance 
Verbal: Appropriate 
Thought Content: some ruminating 
Current Symptoms/Topic/Stressors: Pt remains clean and free of diet pills and was praised for this.  Pt is struggling with fatigue but also knows that it has not been very long since she quit pills, and also she has been undera  lot of work stress.  Aside from sleepiness and stress, pt is doing very well.  She is more calm, less reactive, and generally happier.  Writer pointed out the change in pt’s attitude that was clear in her choice of language.  Pt is now able to effectively assess urgency of situations and respond accordingly as opposed to reacting.  Pt feels good and is proud of accomplishments.  
Treatment Goals in General and/or This Session:  CBT for depression/anxiety;  substance abuse and relapse prevention
Homework Completed from Last Session:  yes
Helpful Towards Tx Goals: yes
Interventions: Provided Support, Behavioral, Psychoeducational, Solution Focus, Cognitive 
Client’s Response to Interventions:  open
Level of Client Functioning or Participation/Motivation: high  
Progress->Current Treatment Effective:  
Plan for Treatment:  Individual therapy bi-weekly to decrease depression/anxiety by 3 points on 10 point scale; Address substance use and relapse prevention
Homework Assignment: Practice Target Behaviour(s) 
Misc: 
Diagnosis: bipolar II; anxiety 
ICD-10:
 Diagnosis: Bipolar 2 disorder : ICD9 = 296.89 / ICD10 = F31.81 / SNOMED = 83225003
Major Problem: Anxiety depression : ICD9 = 300.4 / ICD10 = F41.8 / SNOMED = 231504006

Rx: PROZAC 20MG 1 Capsule once each day , 30, Ref: 0

Seen: Individual 
Mental Status Exam-
Suicidal Ideations: denied
Homicidal Ideations: denied
Alcohol Use: denied 
Substance Use: clean x 10 years
Domestic Violence: denied 
Appearance:  neat
Physiological Signs: tearful at times
Manner and Attitude: Accessible 
Orientation: alert and oriented to person, place, time, and circumstance 
Verbal: Appropriate 
Thought Content: some ruminating 
Current Symptoms/Topic/Stressors: Pt remains clean and free of diet pills and was praised for this.  Pt is struggling with fatigue but also knows that it has not been very long since she quit pills, and also she has been undera  lot of work stress.  Aside from sleepiness and stress, pt is doing very well.  She is more calm, less reactive, and generally happier.  Writer pointed out the change in pt’s attitude that was clear in her choice of language.  Pt is now able to effectively assess urgency of situations and respond accordingly as opposed to reacting.  Pt feels good and is proud of accomplishments.  
Treatment Goals in General and/or This Session:  CBT for depression/anxiety;  substance abuse and relapse prevention
Homework Completed from Last Session:  yes
Helpful Towards Tx Goals: yes
Interventions: Provided Support, Behavioral, Psychoeducational, Solution Focus, Cognitive 
Client’s Response to Interventions:  open
Level of Client Functioning or Participation/Motivation: high  
Progress->Current Treatment Effective:  
Plan for Treatment:  Individual therapy bi-weekly to decrease depression/anxiety by 3 points on 10 point scale; Address substance use and relapse prevention
Homework Assignment: Practice Target Behaviour(s) 
Misc: 
Diagnosis: bipolar II; anxiety 
ICD-10:
 Diagnosis: Bipolar 2 disorder : ICD9 = 296.89 / ICD10 = F31.81 / SNOMED = 83225003
Major Problem: Anxiety depression : ICD9 = 300.4 / ICD10 = F41.8 / SNOMED = 231504006

Rx: PROZAC 20MG 1 Capsule once each day , 30, Ref: 0

Seen: Individual 
Mental Status Exam-
Suicidal Ideations: denied
Homicidal Ideations: denied
Alcohol Use: denied 
Substance Use: clean x 10 years
Domestic Violence: denied 
Appearance:  neat
Physiological Signs: tearful at times
Manner and Attitude: Accessible 
Orientation: alert and oriented to person, place, time, and circumstance 
Verbal: Appropriate 
Thought Content: some ruminating 
Current Symptoms/Topic/Stressors: Pt remains clean and free of diet pills and was praised for this.  Pt is struggling with fatigue but also knows that it has not been very long since she quit pills, and also she has been undera  lot of work stress.  Aside from sleepiness and stress, pt is doing very well.  She is more calm, less reactive, and generally happier.  Writer pointed out the change in pt’s attitude that was clear in her choice of language.  Pt is now able to effectively assess urgency of situations and respond accordingly as opposed to reacting.  Pt feels good and is proud of accomplishments.  
Treatment Goals in General and/or This Session:  CBT for depression/anxiety;  substance abuse and relapse prevention
Homework Completed from Last Session:  yes
Helpful Towards Tx Goals: yes
Interventions: Provided Support, Behavioral, Psychoeducational, Solution Focus, Cognitive 
Client’s Response to Interventions:  open
Level of Client Functioning or Participation/Motivation: high  
Progress->Current Treatment Effective:  
Plan for Treatment:  Individual therapy bi-weekly to decrease depression/anxiety by 3 points on 10 point scale; Address substance use and relapse prevention
Homework Assignment: Practice Target Behaviour(s) 
Misc: 
Diagnosis: bipolar II; anxiety 
ICD-10:
 Diagnosis: Bipolar 2 disorder : ICD9 = 296.89 / ICD10 = F31.81 / SNOMED = 83225003
Major Problem: Anxiety depression : ICD9 = 300.4 / ICD10 = F41.8 / SNOMED = 231504006

Rx: PROZAC 20MG 1 Capsule once each day , 30, Ref: 0

chief complaints 

Date:  07/11/14

Sex:  female

Age:  35 year

Ethnicity: Caucasion

Marital Status:   Single   

Seen:  Individual 

Source of Information: 

Presenting Problem/Chief Complaint:   

She is currently takes

Lamictal 400 mg 1 tab qam

,

Abilify 15 mg qam

,

Prozac 10 mg 1 tab qam

. Feels fine during the day after taking her medications, but every morning she wakes up at 5 am, takes your coffee, and experiences state of hypomania – gets really energetic, hyper, irritable, spends a lot of money (internet-shopping) for about two hours; at 7 am she takes all her meds and her mood completely stabilizes very quickly and she has absolutely no manic/depressive sx during the day. She said that she goes to bed early (at 8 pm) every evening b/c she wants to go back to her manic morning state as soon as it’s possible. She enjoys those two hours of morning manic state and thinks that those are the best two hours of her day. 

History of Presenting Problem:   

Since she became completely sober from her multidrug use (2008).

Cycling Bipolar Dz – two – months period –  manic episode (binges, spending sprees, reckless driving, excessive emotionality, irritability, grandiosity, rapid talking) – lasts for 3 weeks (out of two months), followed by 1 week of mild-moderate depression (appetite fluctuations, fatigue, crying spells, low self-esteem, feeling of worthlessness, denies SI), followed by 1 month of stable mood  (no depressive, manic or anxiety Sx). 

This cycle constantly repeats itself.

Started to get Tx in 2006 in Rehab Center with Lamictal. Got slightly better – less irritable.

Around 2010 started Tx with Lamictal+Abilify combination. All but depressive Sx had subsided. Depression was Tx successfully with addition of SSRI (Zoloft, Prozac). 

Tends to d/c all her meds every 2-3 years (feels urge to be normal without medications). When off her meds – has an acute depressive episode (no SI) for 1 week – when starts to take her meds again. Never had a manic episode when d/c taking meds.

Depression Sx:   Depression, Weight change, Fatigue, Irritability, Crying spells, Worthlessness or inappropriate guilt 

Anxiety Sx:   Irritability 

Panic Sx:  none

Psychiatric History-

Psychiatric Admissions:   no 

Reason/Diagnosis:

Outpatient Treatment:   yes  

Reason/Diagnosis: Bipolar Dz (2010, 2011-2013), Hx of multiple drug dependence (15 yo – 28 yo)

Where:   Atlanta, GA

Suicide Attempts:   no 

Past Psych Meds:   yes  

What meds:   Lamictal 200 mg, Abilify 10mg, 15mg, Topamax, Deplin 15mg, Prozac 10 mg.

Response:   Lamictal+Abilify is a good combination according to Pt (satisfactorily stabilizes her mood – prevents mood swings), Prozac added to this combination helped with Depressive Sx

Substance Abuse:   yes  

What meds:   Meth, Cocaine, Heroin, Cannabis, LCD, Ecstasy – since 15 yo. Sobriety since 28 yo.

Response:   Heroin made her nauseated; Meth, cocaine, Ecstasy  – stimulating effect.

Medical History: 

Past Medical History-  yes 

      Type:   persistent low blood glucose (around 50)

Surgeries-   no

Trauma-   no

Other-   no 

Current Medications:

 

Lamictal 400 mg 1 tab qam,

Abilify 15 mg qam,

Prozac 10 mg 1 tab qam

Biotin

Allergies:  NKDA 

Sleeping Pattern:

Normal hours of Sleep: 8-9 hrs/night, goes to sleep at 8pm, wakes up at 5am, which is NL for her.

Current:  8-9 hrs/night

Rested in the am?   yes 

Midnight awakening:   no 

Difficulty failing asleep:   no

Early morning awakening:   no  

Restless sleeping:   no 

Hypersomnia:   no 

Eating pattern/food issues:

Appetite: varies depending on emotional state – when she is depressed – no appetite at all, periodic sugar cravings/binges

Weight:  stable

Psychosocial History-

Education :  bachelor degree in English

Work History:   full-time 

Past Employment: business development manager – 3 years

Sexual History: Heterosexual

Spiritual, Cultural and Social History: Spiritual

Criminal History: 16 yo – shoplifting, 16 yo – 28 yo – multiple (five) arrests for misdemeanor, 2007 – drug selling (1 month in prison – suffered from Meth withdrawal).

Military Service: none

History of Abuse: were raped when she was 25 yo, didn’t go to the police. No PTSD Sx

Family History: 

Medical:  None

Psych:  Bipolar Dz – mother

History of Abuse-  no 

Childhood History:   Parents divorced when she was 3yo, Mother remarried, she lived with her mother, step-father, half-brother. Step-father was very strict, but not abusive. She leaved home when she was 15 yo (was kicked out by parents, b/c of her constant misconduct and drug use) and afterwards lived with her boyfriend for 6 months. She got pregnant, separated with her boyfriend and came back home. She was accepted back in her family, had an abortion and stayed in parent’s house till college.

 

Risk Assessment-

Suicidal Ideations:   denied    

Access to guns:   no 

Homicidal Ideations:    denied    

Access to guns:   no 

Other Risks or Self Harm:   no 

Mental Status Exam-

Appearance:   dressed appropriately 

Psychomotor Activity:   normal 

Mood:   euthymic

Affect:   appropriate   

Speech:   normal

Thought Process:   organized

Thought Content:   relevant

       Hallucinations: no, since sober 

       Delusions: no 

       Suicidal Ideations:   denied 

       Homicidal Ideations:  denied

Insight:  fair

Judgement:   fair

Oriented:   alert and oriented to person, place, time, and circumstance 

Level of Consciousness: alert 

Memory:   STM impaired, LTM impaired, poor immediate memory, poor recent memory, poor remote memory 

Concentration:   normal  

Attention:   normal 

Sleep:   no problems, 8-9 hrs 

Appetite: varies depending on emotional state – when she is depressed – no appetite at all, periodic sugar cravings/binges

Alcohol Use:   excessive use – concomittant with drug use (15 yo – 28 yo), completely sober since 28 yo.

Substance Use:   in recovery – last use? 2008

                             longest period of sobriety?  7 years of sobriety

Domestic Violence:   denied, lives with her uncle (70 yo).

Intelligence:   average 

Strengths:   good with people, good sense of humor

Challenges:  mood swings

Diagnosis-

Axis I:   296.40

Axis II:   Deferred  

Axis III:  Mild Hypoglycemia 

Axis IV:  Long standing severe SA Issues in the Past. (In Remissionfor the last 8 yrs.) 

Axis V:   GAF=60  

Assessment/Plan- Want to continue with Lamictal, Prozac, and Abilify. RTC 1month.

Referral Given-

Date:  10/21/15

Name:  S. S

Chief Complaint/HPI-  37 yo female who has a history of Bipolar disorder, Binge Eating Disorder, and Polysubstance abuse (Meth, Cocaine, Heroin, Cannabis, LSD, and Ecstasy). She also has a history of anger management problems.  Currently she is back on Phentermine due to her body image issues of feeling fat.  Lamictal only is not stabilizing.  

At her her last visit on 8/3/2015:  She presents today because she has stopped taking all of her medications except the Lamictal. She states that she stopped taking her medications for the past month because she was gaining too much weight. She is now taking her diet pills (Phentermine 37.5mg) and reports only dry mouth with the drug. She is concerned because  her medications make her gain weight. Since being off of the medications she feels very aggitated, depression, lack of ambition, and feels “insane”. She reports no anxiety or panic attacks and no episodes of binge eating. She is dieting and exercising everyday. She is attending AA meetings twice a week and reports that she would like to see a therapist here regularly. 

Mental Status Exam-
Appearance:   dressed appropriately 
Psychomotor Activity:   normal 

Mood:   depressed, agitated for months, irritable

Affect:  anxious  

Speech:   normal

Thought Process:   disorganized and racing rageful and obsessive thoughts

Thought Content:   cant let go of her anger but not acting out like in the past 

       Hallucinations: no 

       Delusions: no 
       Suicidal Ideations:   denied 
       Homicidal Ideations:  denied

Insight:  poor

Judgement:  poor

Oriented:   alert and oriented to person, place, time, and circumstance 
Level of Consciousness: alert 

Memory:   intact 

Concentration:  fair and work gives her distraction from her heade clouded  

Attention:   normal 

Sleep:   9 hrs and no longer RLS

at the last visit: insomnia  Disrupted sleep and she has always been a good sleeper prior to this RLS from coming off abilify

Appetite:  varies  no change w/phentermine

Energy:    increased w/phentermine

at the last visit: no change 

Alcohol Use:   denied

Substance Use:   denied  

Domestic Violence:   denied 

Medications-  

Drug Allergies:  NKDA

Current Medications:

Phentermine 37.5mg (began taken this for the last 2 months)

Lamictal 400 mg 1 tab qam

Past Meds

Contrave gave nausea and d/c’d

Topamax made her dopey

Abilify 15 mg qam

Prozac 20 mg 1 tab qam 

Biotin

FLUOXETINE HCL 20MG 1 every morning 

ARIPIPRAZOLE 15MG 1 daily

VYVANSE 30MG qAM

Diagnosis-

Axis I:   296.62, No known Medical Problems, Binge Eating D/o

Axis IV:  Long standing severe SA Issues in the Past. (In Remission for the last 8 yrs.) 

Axis V:   GAF=60  

Assessment/Plan- Rexulti 0.5-1mg trial and continue other meds for now

At the last visit: Agreed to try Contrave.Refer to Christina for counselling.

Referral Given- 

Counseling/Therapy:    no She would like to see someone

Relapse Prevention/12 Steps/AA:   yes attends 2 times per week

DBT:    no

Other:    no

ICD-10:

Diagnosis: Bipolar I disorder : ICD9 = 296.7 / ICD10 = F31.9 / SNOMED = 371596008

Diagnosis: Binge eating disorder : ICD9 = 307.59 / ICD10 = F50.8 / SNOMED = 439960005

Return to office in:   Sarah has been instructed to return to the office .  

Rx: REXULTI 1MG 1 once each day , 30, Ref: 0

Chief Complaint/HPI-  37 yo female who has a history of Bipolar disorder, Binge Eating Disorder, and Polysubstance abuse (Meth, Cocaine, Heroin, Cannabis, LSD, and Ecstasy). She also has a history of anger management problems. Rexulti helped but she is still obsessing and agitated.  christina davis validated her current depressed w/agitation dx.  

At the last visit:  Currently she is back on Phentermine due to her body image issues of feeling fat.  Lamictal only is not stabilizing.  

Mental Status Exam-

Suicidal Ideations: passive SI at times, none current

Homicidal Ideations: denied
Alcohol Use: denied 

Substance Use: excessive use – how often?  pt takes phentermine diet pills.  Pt stopped antidepressant so that she could take them Pt goes to AA and feels that it is helpful as she has hx of past addiction to multiple substances but clean x 9 years, except for phentermine pills.  Pt’s dosage has been slowly increasing.  

                                       

Domestic Violence: denied 
Appearance:  neat
Physiological Signs: tearful at times
Manner and Attitude: Accessible 
Orientation: alert and oriented to person, place, time, and circumstance 
Verbal: Appropriate 

Thought Content: Ruminating; Rule out obsessions

Current Symptoms/Topic/Stressors:  Pt states that her medication appointment with Dr Antin is tomorrow. She is excited / anxious about this appointment.  When pt first came to therapy, she reported that she did not want to get off of diet pills, mainlyfor issue of weight gain but also for energy.  Pt was willing to stop all other medications, including psychotropics that were helping her mood and quality of life, to continue taking diet pills.  Pt cannot take an SSRI with diet pills due to too much serotonin.  Pt reports and episode of serotonin syndrome recently, which is what made her decide to stop other meds.  Now, however, pt realizes that this lifestyle is not working well for her.  She continues to feel agitated, anxious, and depressed.  Pt has long hx of depression/anxiety and substance abuse.  Pt’s most distressing symptom currently is her inability to control intense emotions that are triggered by her agitated and negative thoughts.  Pt describes moods as “erratic-not mood swings so much as just erratic and suddenly angry or agitated.”  Pt also states, “I am quick to anger and when I do I becomed enraged and literally ‘see red.’  I am also not able to calm myself down.”  Pt also reports obsessive/paranoid thoughts, particularly about the man she is dating.  She will become codependent and clingy and then begin to think he is constantly cheating.  This drives her to do behaviors such as “stalking Facebook” and other things that just make her more anxious.  Pt knows that she has had great success with SSRI’s in past and now reports that she is ready to do something differently.  Her fear is that she will come for med appointment, be open and honest, and that the consequence will be that doctors are unwilling to help her if she refuses to stop diet pills, and therefore will not be helped,.  Pt states that she is now willing to consider meds if they dont make her gain weight or lose energy.  

In session, discussed CBT techniques to cope with uncomfortable negative thoughts.  Coping skills include exercise, mindfulness, distraction, and fear analysis.  

Treatment Goals in General and/or This Session: CBT for depression/anxiety

Homework Completed from Last Session:  yes

Helpful Towards Tx Goals: yes
Interventions: Provided Support, Behavioral, Psychoeducational, Solution Focus, Cognitive 
Client’s Response to Interventions:  open
Level of Client Functioning or Participation/Motivation: high  
Progress->Current Treatment Effective:  

Plan for Treatment:  Individual therapy weekly to decrease depression/anxiety by 3 points on 10 point scale; Address substance use and relapse prevention

Homework Assignment: Practice Target Behaviour(s) 
Misc: 
Diagnosis: bipolar II; anxiety 
ICD-10:
 Diagnosis: Bipolar 2 disorder : ICD9 = 296.89 / ICD10 = F31.81 / SNOMED = 83225003
Major Problem: Anxiety depression : ICD9 = 300.4 / ICD10 = F41.8 / SNOMED = 231504006

Chief Complaint/HPI- 37 yo female who has a history of Bipolar disorder, Binge Eating Disorder, and Polysubstance abuse (Meth, Cocaine, Heroin, Cannabis, LSD, and Ecstasy). She also has a history of anger management  problems. Patient was last seen on 11/04/15. Mood: Pt. stated to be feeling okay. Rated mood on 5/10 on mood scale. Normally is 7/10. 

Depression: Patient hasn’t been feeling any depression since being back on medication. Patient took herself off medications over the summer, but continued to take Lamictal. 

Anxiety: Patient doesn’t think she’s feeling any anxiety. She “doesn’t walk around worried.” She stated that she feels that she obsesses over things such as the man she’s currently dating. 

Panic Attack: She experiences no panic attacks.

Sleep: Patient claims to get 9 hours of sleep every night. In the morning, she feels annoyed until she takes her medication. Doesn’t take any naps during the day. 

Appetite: She’s on 16-20 Phentermine a day. She eats 3 meals a day. States to eat a lot of sugar. She states “when she’s good, she’s extreme, when she’s bad, she’s really bad.” 

Exercise: She walks the dog every morning. Sometimes she runs. 

Polysubstance Abuse: Haven’t taken any illicit drugs since December 14, 2006. 

Anger: She states she’s easily angered. She states that she is impatient. 

Medication: Patient stated no side effects. 

Taking phentermine 16-20 per day

Mental Status Exam-
Appearance:   dressed appropriately 
Psychomotor Activity:   normal 
Mood:   euthymic
Affect:   appropriate   
Speech:   normal
Thought Process:   organized

Thought Content:   obsessions

       Hallucinations: no 
       Delusions: no 
       Suicidal Ideations:   denied 
       Homicidal Ideations:  denied

Insight:   appropriate

Judgement:   good

Oriented:   alert and oriented to person, place, time, and circumstance 
Level of Consciousness: alert 

Memory:   STM impaired, LTM impaired 

Concentration:   normal  
Attention:   normal 

Sleep:   no problems  

Appetite:    no change 

Energy:   no change 

Alcohol Use:   denied
Substance Use:   denied  
Domestic Violence:   denied 
Medications-  

Drug Allergies: NKDA

Current Medications:

Abilify 10mg daily (patient takes 7.5mg daily) 1/4 of 30 mg tab

Phentermine 37.5mg –takes 16-20 tabs daily from multiple MDs at 2 different weight loss med Drs–(began taken this after getting sober May 2007)

Lamictal 400 mg 1 tab qam
Diagnosis-

Axis I:   Bipolar Disorder NOS, Eating Disorder NOS, Polysubstance Abuse

ICD-10:

Diagnosis: Bipolar I disorder : ICD10 = F31.9 / ICD9 = 296.7 / SNOMED = 371596008

 

Assessment/Plan-  Needs to attend 12 step meetings address holistic methods. will allow use of contrave 8/90 qd. anafranil 25 mg qhs for obsessional thinking. DC phentermine.  i requested to talk to her physicians that are prescribing the meds and she deferred. Zofran 4 mg qd prn

Referral Given- 

Relapse Prevention/12 Steps/AA:   yes , once a week

DBT:   no

Other:   no

Return to office in:  has been instructed to return to the office in one month for follow-up.  

Rx: ZOFRAN 4MG Tablet , 30, Ref: 0

Rx: ANAFRANIL 25MG 1 Capsule at bedtime , 30, Ref: 1

 Medication

Current Medications:
Abilify 10mg daily (patient takes 7.5mg daily) 1/4 of 30 mg tab
Phentermine 37.5mg –takes 16-20 tabs daily from multiple MDs at 2 different weight loss med Drs–(began taken this after getting sober May 2007)
Lamictal 400 mg 1 tab qam

Current Medications:

Phentermine 37.5mg  12 tabs Daily 

Lamictal 400 mg  qam( 2 -200mg)

Wellbutrin 300mg qd am

Nekon birth control

Current Medications:

Contrave 1 tablet in the morning daily

Abilify 10mg daily (patient takes 7.5mg daily) 1/4 of 30 mg tab

Phentermine 37.5mg –takes an average of 18 tabs daily from multiple MDs at 2 different weight loss med Drs–(began taken this after getting sober May 2007)

Lamictal 400 mg 1 tab qam
Lamictal 400 mg 1 tab qam,
Abilify 15 mg qam,
Prozac 20 mg 1 tab qam 
Biotin

Phentermine 37.5mg (Stoped 2 months ago.) 

FLUOXETINE HCL 20MG 1 every morning , 90, Ref: 0

ARIPIPRAZOLE 15MG 1 daily , 90, Ref: 0

VYVANSE 30MG 1 EVERY MORNING , 30, Ref: 0