Professional blog

SUBJECTIVE

Chief Complaint: “ER follow up with Dx Dissociative Disorder”.

History of Presenting Illness:  A 14-year-old female African American presents to clinic after she went to the ED for following symptoms: As per ER discharge documentation and referral to see a psychiatrist, she presented to the ER with an acute onset of left-sided body twitching after a minor accident in which she hit her head. Physical exam, laboratory investigations, and imaging studies are normal. Over the next several weeks, she begins experiencing episodes of full-body movements. In the week before the initial symptom onset, her boyfriend (for whom she also worked) broke up with her, and she had a conflict with her parents. She and her boyfriend have since reconciled. There is no reported history of abuse, but there is a family dynamic of high expectations of the patient. Neurologic exam and EEG during a typical episode are normal. Physical exam reveals a healthy, tense woman with normal vital signs and generalized muscular tension. She does not abuse substances, and medical history is unremarkable.

Past Psychiatric History: Denies any past psychiatrist history, no hospitalization

Has been drinking for dinner a glass of red wine and admits drinking only occasionally. Smokes cigarettes.

Denies drinking caffeinated beverages.

Medical History: Past medical history is unremarkable.

Psychiatric Family History:  Her mother had depression/her father history is unremarkable.

Social /Developmental History: Graduated high school. Adulthood: She is currently at enrolled in the community college/taking classes online. She is planning to work as registered nurse once she finish school.

No medical conditions reported.

Allergies:  No known allergies

OBJECTIVE

Mental/Functional: Appearance: tall and medium size she is dressed in attractive outfit.

Mental Status Exam: During interviewing patients, he was becoming noticeably anxious and nervous when describing her symptoms

Appearance: Well groomed

Orientation: Oriented to person, place, time, event/situation

Speech/Language:  Clear; spontaneous, normal rate; normal prosody

Mood: within normal limits

Affect: congruent

Thought Content:  No obsessions/compulsions; no evidence of perceptual disturbances

Insight: Good

Judgment: Good

Suicidality and Homicidality: Denies

ASSESSMENT: DSM-5 Diagnoses:

1) 302.85 (F64.9) Dissociative Disorder

3) 300.01 (F41.0) Panic Disorder

Risk Assessment: The patient denies SI/HI and/or behaviors, intent, and/or plan.  Current protective and risk factors were reviewed, and the patient is not currently at clinically significant risk for suicide/homicide.  The patient acknowledged understanding of emergency resources such as going to the ER or dialing 911 if experiencing suicidal/homicidal ideation.

Vitals: Temp: 97.9 F, BP: 108/58, HR: 60, Pulse Ox: 99, RR: 22, WT 195 pounds, HT: 5”8, BMI: 28.2

PLAN AND RECOMMENDATION:

1) Supportive psychoeducation completed

2) Safety plan discussed: Current protective and risk factors were reviewed, and the patient is not currently at clinically significant risk for suicide/homicide.  The patient acknowledged understanding of emergency resources such as going to the ER or dialing 911 if experiencing suicidal/homicidal ideation. Patient verbalized understanding.

3) Medications: Will start on medications sertraline 50mg orally daily, risks, benefits, alternative to medication explained to patient she verbalized understanding. Patient encourage to start eating, engage her in the therapeutic milieu.

Alprazolam 0.5mg po prn q4hr. Complete: Discussed risks/benefits/alternatives to all treatments listed above, the patient verbalizes understanding. Will bring back the patient in 2 weeks for monitor/and side effects of medications.

Cognitive behavioral therapy (CBT). Applied relaxation, mindfulness/meditation training, sleep hygiene education, exercise, self-help. Goals for the patient as follow: GOAL- – Become capable of handling thoughts and feelings in constructive ways. Supportive psychotherapy and psychoeducation provided. Taught patient relaxation techniques. Objective: Pt. will learn and implement cognitive restructuring, positive self-talk, and behavior activation from 0-1X/day to 4-5X/day to manage depression..

Intervention:- Utilize Cognitive Behavioral Therapy

– Challenge and reframe negative cognitions

– Engage patient in Behavioral Activation

Explain the rationale for the medication recommendations as stated earlier

• Complete baseline EKG, UA (-) for pregnancy, CBC, CMP, LIPID PANEL, Vit B12 levels, TSH, VIT D, TOXICOLOGY SCREENING,
• Overall treatment plan was discussed with the patient. Patient voiced understanding.

Continue to require outpatient treatment and medications.

Risks, benefits, side effects, and alternative treatments regarding prescribed medications were discussed with the patient/family.  Patient expressed understanding and provided informed consent to be on aforementioned medications.

Rechecks with PCP for further evaluation and treatment of medical problems.  Patient voiced understanding.

Patient was advised to immediately return to clinic, call 911, or go to the nearest ER for worsening symptoms, side effects, thoughts of harming others, or any concerns. Patient verbalized understanding.

Next Follow-up:  2 weeks or sooner if needed.