05-26-06 @ 1:10 am EDT

CLIENT NAME: Rachel H. [last name omitted]
CLIENT ADDRESS: [omitted]
CASE #: [omitted]
PHONE #: [omitted]
DATE: 05/25/06
DOB: 10/08/76

CURRENT DIAGNOSIS: Generalized Anxiety Disorder, Social Phobia, severe. Obsessive-Compulsive Disorder. Major Depressive Disorder, moderate to severe w/o frank psychotic symptoms. I would consider the possibility of some underlying psychotic symptoms R/T some paranoia, which she is not sharing, as she seemed to minimize at least the symptoms of OCD.
CURRENT MEDICATIONS: Lexapro
OVER-THE-COUNTER MEDICATIONS: Diphenhydramine, ASA, Ibuprofen
ALLERGIES: NKA
TREATING PHYSICIANS: Dr. K. [last name omitted], no PCP
PHARMACY: Glen's
CURRENT LABS: on chart

HT: 5'
WT: 189#
IDEAL WT. RANGE:
DESIRED WT.:
Yearly Gain/Loss:
M/F: F
B/P: SIT: R: 140/88 L: 140/88 STAND: R: 140/88 L: 140/90
T: 99.2
AP: 76
R: 20

APPEARANCE
Unkempt
Atypical clothing
X Tense
X Withdrawn
Uncooperative
X Alert
X Oriented
Disoriented

AFFECT
Broad
X Constricted
Flat
Inappropriate
Blunted
Mild Constrict

MOOD
Euthymic
Dysphoric
Labile
Euphoric
X Anxious
Tearful
Irritable
Angry
X Subdued

SPEECH
X Regular rate
X Regular rhythm
Illogical
Loose
Tangential
Pressured
Logical
Circumstantial
Loud
Soft
Non-verbal
Incoherent

THOUGHT PROCESS
X Coherent
X Suicidal
Homicidal
Delusional
Hallucinations
Flight of ideas
Ideas of reference
Illogical
WNL

GENERAL APPEARANCE/BEHAVIOR COMMENTS: Dressed appropriately with good grooming and hygiene. Eye contact very poor. States that she has had some suicidal thoughts but no plan or intent "at the moment." Lungs CTA and pulses equal. Eyes PERRL and ears clear.

INSIGHT:
Good
Poor
Impaired
X Questionable

MOBILITY:
X Fully mobile
Wheelchair
Walker
Cane

IMMUNIZATIONS/CHILDHOOD ILLNESS:
Td:
MMR1:
MMR2:
HepB:
FLU:
UTD X
TB:
Pneumovax:
Recommended Update:

PHYSICAL EXAMINATION:
Skin: X WNL Abnormal Deferred
Eyes: X WNL Abnormal Date of last exam: years ago
Ears: X WNL Abnormal Deferred
Nose: X WNL Abnormal Deferred
Throat: X WNL Abnormal Deferred
Breasts: WNL Abnormal X Deferred
Heart: X WNL Abnormal Deferred
Chest/Lungs: X WNL Abnormal Deferred
Extremities: X WNL Abnormal Deferred
Neurological: X WNL Abnormal Deferred
Bowel: X WNL Abnormal
Urinary: X WNL Abnormal
Pain: X None Number scale 1-10
Sleep Pattern: 6 Hours Insomnia mid-cycle wake Nightmares Medication
Menses/LMP: 5/06 WNL Abnormal G: 0 P: 0
PAP: never
Mammogram: none

COMMENTS (ABNORMAL FINDINGS): Mother states that when she had her blood draw, she passed out and the lab tech said that she had a "seizure" but she was never taken to ER. States that she sleeps from about 1:30PM until 8PM.

NUTRITION: Regular
Safety and Risk factors:
SUMMARY OF MAJOR MEDICAL FINDINGS (SURGERIES, CHRONIC ILLNESSES, ETC.): none

SUBSTANCE USE/ABUSE HISTORY:
Caffeine: 2-3 cups of tea/day
Nicotine: none
Alcohol: none
Illicit Substance: none

[nurse's name omitted]
In: 1PM
Out: 2PM

Rachel H. [last name omitted]
[number omitted]
05/25/06

STRENGTHS: States that she feels that she doesn't have much support from her family as she can't talk to them about her issues. She does not have a primary care provider, encouraged her to do so. She has adequate knowledge of names, general actions and dosages of medication. She reports compliance with medication but that remains questionable. She maintains a regular eating and sleep schedule. She denies any use of alcohol or illicit substances. She denies any medication allergies. Her P. E. is essentially negative.

NURSING DIAGNOSIS/NEEDS:
1. Altered health maintenance with the potential for illness, injury or symptom exacerbation related to psychiatric diagnosis and medication treatment intervention
2. Potential for non-compliance for treatment

GOALS:
1. Rachel will demonstrate absence of symptoms of generalized anxiety, social phobia, and OCD without evidence of illness or injury related to medication treatment interventions. 05/07
a. Rachel agrees to blood draw and will demonstrate absence of abnormalities on CBC, CMP, Lipid Profile and TSH related to effects of psychotropic medication or with potential to impact on mental health condition when monitored annually. 05/07
b. Rachel will continue to keep appointments and call in advance when he [sic] can not keep the appointment. 05/07
c. Rachel will report/demonstrate absence of symptoms of thought disorder and depression without clinical evidence of medication side effects when monitored quarterly. 05/07
2. Rachel will verbalize an increased understanding of the relationship of physical health as relates to psychological stability. 05/07

INTERVENTIONS:
Medication reviews quarterly by physician/RN and PRN. CBC, CMP, Lipid Profile and TSH annually. EKG as ordered by physician. Medication teaching annually by DR/RN and PRN with the addition of new medication. RN contact annually for health assessments and PRN for consultation at the request of the therapist, Rachel, or physician. Refer to other services as needed.

The nurse and I worked on the goals identified in the Health Care Plan. I am in agreement with the goals set for the forthcoming year.

name

I have received a copy of the plan.