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WK 1 patient log CC. “Fine fine”

HPI: S: “I have been having a lot of flashbacks.” O: SC is a 69-year-old African American female who presents with increased depression and anxiety complaints. She has been having active DID episodes and is seeing a therapist that specializes in DID. She sees her therapist every week, reports depressive episodes with “one alters” and satanic abuse. Endorse AH/VH but denies Suicidal and homicidal ideations. A: DID, Multiple personality disorders. P: Continue Sertraline 125mg daily, Lorazepam 1mg as needed, change Trazodone from 50 mg QHS to 75 mg QHS. f/u visit in 4 weeks.

2. CC: “Work has slowed down”

HPI: S: I feel “Burnt out.” The client works at the university; he reports he is currently working less due to school being out. He states that he saw “900 face-to-face appointments”. He says he plans to start looking for work elsewhere. O: SC is a 33-year-old Caucasian male who appears well-nourished and well groom, dressed appropriately for the season, mood euthymic. Denies AH/VH, SI/HI. A: Bipolar 2 disorder. P: continue current medications: Lamictal 150 mg PO daily, trazodone HCL 50 mg 1 tab PO at HS. F/U in 4 weeks.

3. CC: “It has been ok.

HPI: S: Still has problems focusing. But his mood has been steady, feels his mood has improved. Initially, he noticed some dizziness. He reports his anxiety is a 2/10, which has been enhanced from 5/10, verbalized improved depression, has been getting 7 to 9 of sleep, has been able to build a routine, improved appetite, sleep, and depression. He reports he still struggles with focus and work performance. O: AR is 27 years old Asian American male who presents for his routine f/u visit. States that his focus is improving, denies depression, AH/VH/SI/HI. A: ADHD. P: Continue Wellbutrin SR 100 mg PO BID, recommend expressive journaling and f/u in 4 weeks……….Continue