Unit 4-Adult Psychiatric Initial Interview-Assessment. Due 1-31-24. NU672 Counseling and Psychotherapy

Initial Psychiatric Interview/SOAP Note

Criteria Clinical Notes

Informed Consent Informed consent given to patient about psychiatric interview process and psychiatric/psychotherapy treatment. Verbal and Written consent obtained. Patient

the ability/capacity to respond and appears to the

risk, benefits, and (Will review additional consent during treatment plan discussion) Subjective Name: Edward Cujo

DOB: 9/26/81  Medicaid Number: AG032210061  Medical Record Number: 000002092349

Demographic:  186-26 110th Ave, Jamaica, Georgia 30038  Telephone#: 678-222-3456  SS#: 002-24-3344  No photo available

Gender Identifier Note: (Female) He, Him, His

CC: I'm trying to plan stuff but I'm disorganized."

HPI: Edward Cujo, Jr. is a 30-year-old male referred by his attorney for a clinical assessment. Edward presents with his mother, Alia Spencer via telehealth (Polycom) at

The Moore Experience. He stated that he's been experiencing "a lot of forgetfulness, attitude, less energy, mood swings, I'm misplacing things, and I'm trying to plan stuff but

I'm disorganized". His mother stated, "he doesn't remember faces. He's losing his wallet and keys".

Edward reports that his symptoms began in 2016. At the time he was working in car

rental at the airport. "I was having the symptoms of no energy and tired, severe headaches, falling asleep. I went to the hospital, and they said I had at UTI". He stated

that he was terminated when his supervisor found him asleep in a rental car. He stated, "I don't remember falling asleep in the car. I came home and the symptoms got worse.

After May or June (2016), I don't remember much after that". He was informed by physicians that he had "fluid on the brain" and has had 2 surgeries in 2016 to correct the

problem. A shunt was placed in his brain, and he now has treatments every 6-8 weeks.

Verify Patient: Name, Assigned identificatio n number (e.g., medical record number), Date of birth, Phone number, Social security number, Address, Photo.

Include demographics, chief complaint, subjective information from the patient, names and relations of others present in the interview.

HPI:

, Past Medical and Psychiatric History, Current Medications, Previous Psych Med trials, Allergies.

Social History, Family History. Review of Systems (ROS) – if ROS is negative, “ROS noncontributory,” or “ROS negative with the exception of…”

As a result of this procedure, Edward has frequent urination and soils his clothing. He stated, "I limit myself from going out most of the time. When I do go, I have to make

sure I'm close to a bathroom". He stated that he is "bothered" by his medical condition. "I don't want to go anywhere at all. Sometimes I'll turn down a trip because I'm not

feeling right, or my stomach is not up to par. It's just how I'm feeling emotion wise. I might be mad at myself, or I just don't have the feeling to do it. It's depression

sometimes. I try not to let it get in the way, but it does sometimes. A lot of the time I don't socialize much because of the way I feel about myself". Edward reports that he is

worried that he will 'have an accident' in public. He packs a bag of extra clothing in case he is unable to reach a bathroom in time. Edward reports that he's currently seeking

disability services due to medical concerns.

Pertinent history in record and from patient:

 During assessment: patient describes increasing forgetfulness, hopeless/worthless, problems with appetite, trouble with sleep.

* Edward reports persistent sad and anxious feelings, feelings of hopelessness and worthlessness, irritability, restlessness, loss of interest in activities or hobbies once pleasurable, fatigue and decreased energy, difficulty concentrating, remembering details, and making decisions, insomnia, trouble with appetite thoughts of death.

Patient does not report increased activity, agitation, risk-taking behaviors, pressured speech, or euphoria. Patient does not report hallucinations, delusions, obsessions, or compulsions. . Patient does not report symptoms of eating disorder. There is no recent weight loss or gain

SI/ HI/ AV: Patient currently denies suicidal ideation, denies SIBx, denies homicidal ideation, denies violent behavior, denies inappropriate/illegal behaviors.

Allergies: NKDFA. (medication & food)

Past Medical Hx: Medical history: Sleep apnea w/C-PAP, Vertigo, Seizure disorder Sarcoidosis Hydrocephalus Diabetes Type 2 Patient denies history of chronic infection, including MRSA, TB, HIV and Hep C. Surgical history: abdominal sx x 3 (shunt related)

h/o shunt placement d/t hydrocephalus h/o brain sx d/t failed shunt

Past Psychiatric Hx:  Previous psychiatric diagnoses: MDD, Unspecified schizophrenia spectrum and other

psychotic disorder  Describes course of illness.

 Previous medication trials: Invega Sustenna, Risperdal, Zoloft

Safety concerns: History of Violence to Self: none reported History of Violence to Others: none reported Auditory Hallucinations: none reported Visual Hallucinations: none reported

Mental health treatment history discussed: History of outpatient treatment: not reported Previous psychiatric hospitalizations: Outpatient 206-2017 Dx: depression/psychosis Facility: Monarch Prior substance abuse treatment: not reported

Substance Use: Client denies use or dependence on nicotine/tobacco products. Client does not report abuse of or dependence on ETOH, and other illicit drugs.

Current Medications: Levetiracetam 1000mg q 12 hours Vitamin D3 25mg – 1 tab po daily Solifenacin 10 mg – 1 tab po daily Metformin 500mg – 2 tabs po daily Topiramate 60 mg – 2 tabs po daily (Contraceptives): N/A Supplements: N/A

Family Medical Hx: Family history of Cancer, breast Family history of Cancer, colon

Family Psychiatric Hx: Family history of depression Substance use – denies Suicides – denies Psychiatric diagnoses/hospitalization – denies Developmental diagnoses - denies

Social History:

- lives with "my mom" * born in Richmond County, NC. Raised my mom and dad. Grew up with siblings in the household

- Developmental History: no significant details reported. (Childhood History include in utero if available)

- relationships with family and friends - "pretty good" - siblings - 2 sisters - single - h/o abuse/trauma - mild bullying in school (as a child)

* trauma - fights in the family my dad past 1 yr ago, witnessed mom being stabbed

- children - denies - religion - Baptist - education - 12th grade grad w/some college - employment status – unemployed - Military service History: Denies previous military hx.

- hobbies -"like outside, like to go to the racetrack, being out with friends and being social, travel." - legal issues - denies - support system - "my mom or sister" ROS: Constitutional: No report of fever or weight loss EENT: h/o deviated septum Respiratory: h/o sleep apnea w/c-pap; difficulty sleeping d/t restroom, no difficulty breathing Cardio: anxious; denies chest pain, edema or orthopnea GI: appetite "some days good and some days not there"; denies abd pain GU: h/o urinary frequency w/intermittent incontinence Neuro: h/o hydrocephalus w/shunt placement, h/o vertigo; memory: misplacing things - faces, passwords/codes, miss placing things ("I get mad and usually want to give up"), no seizures, blackouts, weakness Musculoskeletal: h/o back pain d/t lumbar punctures - no heavy lifting Endocrine: h/o OM Integumentary: h/o intermittent rashes - when I need my Remicade infusion Hematologic: No report of blood clots or easy bleeding. Reproductive: No report of significant issues.

Objective Vital Signs: Stable Temp: BP: 140/90 HR:68 R:12 O2:100

This is where the “facts” are located. Vitals, **Physical Exam (if

performed, will not be performed every visit in every setting) Include relevant labs, test results, and Include MSE, risk assessment here, and psychiatric screening measure results.

Pain:0/10 Ht:5’6 Wt: 145lbs BMI: 23.4 BMI Range: Normal LABS: Lab findings WNL Tox screen: Negative Alcohol: Negative HCG: N/A

MSE: appearance: obese, casually dressed, neat, clean and well-nourished alert: nml and good eye contact thought process and content: goal directed and logical behavior: no unusual movements or psychomotor changes attitude: calm and cooperative orientation/memory: AxOx4/ intermittent periods of loss of train of thought Concentration: attentive, insight and judgment: fair affect: reactive mood: congruent speech: nml

Social Determinants of Health Screening: Food: Within the past 12 months, did you worry that your food would run out before you got money to buy more? Yes Within the past 12 months, did the food you bought just not last, and you didn't have money to get more? Yes

Housing/Utilities:  Do you have housing? Yes  Are you worried about losing your housing? No  Within the past 12 months, have you or your family members you live with been unable to get utilities (heat, electricity) when it was really needed? Yes

Transportation:  Within the past 12 months, has lack of transportation kept you from medical

appointments, getting your medicines, non-medical meetings or appointments, work, or from getting things that you need? No

Interpersonal Safety:  Do you feel physically and emotionally safe where you currently live? No  Within the past 12 months, have you been hit, slapped, kicked or otherwise physically

hurt by someone? No  Within the past 12 months, have you been humiliated or emotionally abused in other

ways by your partner or ex-partner? No Medical:

 In the past 12 months, have you had trouble affording health insurance (such as deductibles, co-payments, etc.)? No

 In the past 12 months, have you had trouble paying for or accessing medications? Yes

Employment:  In the past 12 months, have you had concerns over obtaining or maintaining

employment? No

Risk Assessment: Suicide Risk (SAFE-T w/C-SSRS Recent)

Risk Factors: Suicidal Ideation Severity (past month):

1. Have you wished you were dead or wished you could go to sleep and not wake up? No 2. Have you actually had any thoughts of killing yourself? No 3. Have you been thinking about how you might do this? No 4. Have you had these thoughts and had some intention of acting on them? No

Have you started to work out or worked out the details of how to kill yourself? Do you intend to carry out this plan? No

Suicidal Behavior (lifetime):

 Have you ever done anything, started to do anything, or prepared to do anything to end your life? No

If "Yes", was it within the past 3 months? No

Ac Access to lethal methods? No

Risk Stratification: Low Suicide Risk

Homicidal Risk  Have you wished someone else were dead or wished that they would just not wake

up? Yes  Have you had any thoughts of killing someone? Yes

If Q2 is YES, then answer Q3-5. If Q2 is NO, then skip to Q6.  Have you been thinking about how you might do this? Yes  Have you had these thoughts and had some intention of acting on them? Yes  Have you started to work out or worked out the details of how to kill someone?

Do you intend to carry out this plan? No

 Have you ever done anything, started to do anything, or prepared to do anything to end someone's life? No

If YES, were any of these in the past 3 months?

Comments: Edward stated that he never wished that he was dead, "but I think things would be

better if I was in a different situation". He denies SI, plan and/or intent. He

denies SIB.

HI: He reports that he has HI toward friends or family about 1x a month, which lasts for "a few minutes". "I think about something that's better than that. Somebody has to really mess with me for me to think like that, but I think about the good times we had and I don't go through with it. I wasn't always like this. When I started taking the steroids (2016) it was different. Being in crowds and noises is hard. I'm very alert now and I wouldn't say "jittery but just alert. He stated that he can be easily annoyed or irritated. He denies plan and/or intent to harm himself or anyone else.

Trauma: Witnessed incidences of abuse/neglect/violence/sexual assault Symptoms: Flashbacks, Hyper-vigilant, Avoidance of triggers Comments: Edward stated, "growing up, I seen my mother stabbed, arguing and fights". He also reports that his father died May 25, 2021.

He stated," I'm nervous a lot and have anxiety". He feels the need to be cautious everywhere he goes. "I just hear so much bad news, I don't want to be the bad news".

Triggers: "seeing and hearing about it (stabbing)".

BRFSS Adverse Childhood Experience (ACE) Module

1.Did you live with anyone who was depressed, mentally ill, or suicidal? Yes 2.Did you live with anyone who was a problem drinker or alcoholic? No 3.Did you live with anyone who used illegal street drugs or who abused prescription

medications? No 4.Did you live with anyone who served time or was

sentenced to serve time in a prison, jail, or other

correctional facility? 5.Were your parents separated or divorced? Yes 6.Did your parents or adults in your home ever slap, hit, kick, punch or beat each other

up? Yes 7.Before age 18, did a parent or adult in your home ever hit, beat, kick, or physically

hurt you in any way? Do not include spanking. No

ACE Score: 2

*PHQ9 – Score-21

The patient is able to articulate needs, is motivated for compliance and adherence to medication regimen. Patient is willing and able to participate with treatment, disposition, and discharge planning.

Assessment DSM5 Diagnosis: with ICD-10 codes

Dx: F29 Unspecified schizophrenia spectrum and other psychotic disorder Dx: F06.0 Psychotic d/o d/t another medical condition w/ hallucinations Dx: F33.3 Major depressive disorder recurrent severe w/ psychotic symptoms Dx: F43.9 Reaction to severe stress Dx: G47.30 Sleep apnea w/C-Pap Dx: F43.10 PTSD

*Medical disorders:

A88.1 Vertigo

E11.8 Type 2 Diabetes without complication

G91 Hydrocephalus unspecified

G40.89 Other seizures

D86.9 Sarcoidosis unspecified

Patient the ability/capacity appears to respond to psychiatric

medications/psychotherapy and appears to the need for

medications/psychotherapy and willing to maintain adherent.

Reviewed potential risks & benefits, Black Box warnings, and alternatives including declining treatment.

Include your findings, diagnosis and differentials (DSM-5 and any other medical diagnosis) along with ICD-10 codes, treatment options, and patient input regarding treatment options (if possible), including obstacles to treatment.

Informed Consent Ability

Plan

(Note some items may only be applicable in the inpatient environment)

Safety Risk/Plan: Patient is found to be and

of behavior. Patient likely poses a risk to self and a risk to others at

this time. Patient abnormal perceptions and appear to be responding to internal

stimuli.

1.Start medications as follows: Prozac 20 mg – 1 cap po q am (depression) Vraylar 1.5 mg – 1 cap po q day (psychosis/schizophrenia

2.med education provided r/t med regimen and dx. *Education provided on nutrition: eat 3 healthy meals a day (grains, fish, chicken, steamed vegetables) with 3 healthy snacks in between (fruits), increase water intake and

decrease salt intake

* Educa t ion p rov ided on exercise: 15-30 min a day a tolerated

* Education provided about emergency services and mobile crisis management in case of worsening symptoms

* Education provided on the importance of medication compliance to decrease negative symptoms

3.Obtain therapy as directed by the treatment plan. * Psychotherapy referral for CBT group therapy to address depression.

4. f/u in 1 mo to re-eval pt's mental hlth and the need for med management

5. f/u with PCP d/t elevated bp, f/u with Neurologist r/t memory issues

* >50% time spent counseling/coordination of care.

Time spent in Psychotherapy: 30 minutes

Visit lasted: 180 minutes

Billing Codes for visit:

99205 90832

____________________________________________ Crystal Beddard, FNP-C

Date: Time: 13:00 PM

References:

Carlo, A. D., Drake, L., Ratzliff, A., Chang, D., & Unützer, J. (2020). Sustaining the

Collaborative Care Model (CoCM): Billing Newly Available CoCM CPT Codes in an

Academic Primary Care System. Psychiatric services (Washington, D.C.), 71(9), 972–

974. https://doi.org/10.1176/appi.ps.201900581

Bryant-Genevier, J., Rao, C. Y., Lopes-Cardozo, B., Kone, A., Rose, R., Thomas, I., Orquiola,

D., Lynfield, R., Shah, D., Freeman, L., Becker, S ., Williams, A., Gould, D. W.,

Tiesman, H., Lloyd, G., Hill, L., Byrkit, R. (2021).

Symptoms of depression, anxiety, post-traumatic stress disorder, and suicidal ideation among

state, tribal, local, and territorial punlic health workers during COVID-19 pandemic –

United States. MMWR Morbidity Morbidity Weekly Report (MMWR) 70; 1680-1685.

DOI: http://dx.doi.org/10.15585/mmwr.mm7048a6

Ma, Y., Xiang, Q., Yan, C., Wang, J. (2021). Relationship between chronic diseases and

depression: the mediating effect of pain. BMC Psychiatry 21, 436 (2021).

https://doi.org/10.1186/s12888-021-03428-3

Sher L. (2021). Individuals with untreated psychiatric disorders and suicide in the COVID-19

era. Revista brasileira de psiquiatria (Sao Paulo, Brazil: 1999), 43(3), 229–230.

https://doi.org/10.1590/1516-4446-2020-1210

1. Combo Box 1: [has]
2. Combo Box 2: [understand]
3. Combo Box 3: [stable]
4. Combo Box 4: [has]
5. Combo Box 5: [understand]
6. Combo Box 6: [is]
7. Combo Box 7: [stable]
8. Combo Box 8: [has control]
9. Combo Box 9: [minimal]
10. Combo Box 10: [minimal]
11. Combo Box 11: [denies]
12. Combo Box 12: [does not]
13. Date Field 1: