12-14-06 @ 6:39 am EST

Got a big packet in the mail yesterday from Lawyer. It looks to be my psychiatric records from Psychiatrist, Psychologist, and Nurse since I started seeing them and going up until my last appointment with Psychiatrist (Dr. K.).

It's incredibly weird reading such things like I'm the subject of some sort of anthropological case study. o_o They also don't have the best spelling/grammar and sentence formation, therapists. I guess it's not required for the job though.

I hope I'm not committing any bad mistakes posting parts of this, since I find it interesting. This time I'll eschew putting in all the "omitted"s as I find that cumbersome and who cares anyway. It of course does not really read "Nurse," "Psychologist," etc. in the text. Things in [brackets] are my comments.

*****

Psychiatric Medication Review--Psychiatrist

Date: 12/4/06
Name: H., Rachel
DOB: 10/8/76
Duration: 30 min.

Subjective

The patient is seen for psychiatric medication review. The date of the last review was 9/12/06 with Nurse, RN. Prior to that she was seen by psychiatry 7/31/06. Today she reports she has been out of medication for about a week. In reviewing the chart it looks like it was called in, at least enough medication until today on 11/29/06 but not picked up. The patient's mother states she tried to pick it up a number of times but it was not there so she has been off the medication for about a week. The patient does not note any significant difference off the LEXAPRO or on it. Her mother however; feels that she has had a positive response to the medication. Rachel reports that about two weeks before she ran out of the medication she became more depressed. She reports that she was feeling lonely and she was crying a little more. She denies any paranoid ideation and feels that I misunderstood her and that she does not feel she can read people's minds. [I never claimed anything remotely like that anyway. I said once that it FELT like people could read MY mind.] She states this is why she stopped the RISPERDAL because she did not feel it was an appropriate medication. She reports she has been sleeping about the same amount. She sleeps during the day and is up at night. She denies any auditory or visual hallucinations. She acknowledges significant anxiety. She has great difficulty being around people and this is very clear. She is unable to make eye contact even in this one on one situation. She continues to spend much of her time reading and writing. When she last saw Psychologist she said that she was not sure she was interested in continuing in therapy. Today she reports she would like to continue in therapy but does not feel comfortable with her current therapist and this was discussed. It is unclear why this is but states she does not feel that she is understood and she would like to change to a different therapist. She states she is unable to discuss this with Psychologist and given her significant anxiety this would be quite difficult.

Objective

The patient is on time for the appointment. She is appropriately dressed and grooming and hygiene appears intact. There was some decreased psychomotor activity [this one always gets me; what am I supposed to do...bob my feet and flail my arms? :/ ] and eye contact is poor. She barely looked up at all during the entire interview. She did not appear overtly agitated or irritable. She does seem anxious. Speech is minimally spontaneous however; she answers questions appropriately. Speech is of regular rate and rhythm; reaction time is within normal limits and there is no halting or blocking. Affect is constricted and mood quite subdued. She is also anxious. There is no evidence of any formal thought disorder and thought content is clear. Insight is fair and judgement fair to adequate.

Assessment

Axis I: Generalized Anxiety Disorder, Social Phobia--severe. Obsessive-compulsive Disorder, Major Depressive Disorder, chronic.
Axis II: Schizotypal Personality Disorder, which I feel is primary [why do they keep coming back to that??]

Plan

The treatment plan was discussed with the patient at length. I let her know that I would discuss the possibility of a change in therapist with Psychologist 2 [sorry, I can't think of any better name for her :/ ] who is the supervisor of the office and I left her a note. She is willing to restart the LEXAPRO and we will begin the LEXAPRO 20 mg for one week and then this is to be increased up to 30 mg. We also discussed a trial of KLONOPIN for the anxiety, which is very significant and she agreed. We discussed the expected benefits, as well as the potential risks and side effects of KLONOPIN and consent was signed. She was given a medication-teaching sheet. We will begin KLONOPIN 0.5mg, 1/2 pill twice daily. If this is too sedating [I've felt terribly drowsy the past two days, but I don't know if it's because of the clonazepam or just my regular old drowsiness...I guess I'll just wait it out a while and see] she is to take only 1/2 a pill before she goes to bed and we will titrate [what's that mean??] this up as tolerated. This was discussed with both the patient and her mother. Her mother continues to feel that the LEXAPRO has been helpful. She is to continue with all current activities. She should be reevaluated by nursing in 2 weeks and by psychiatry 2 months or sooner as needed. She is to call if she has any problems with side effects with the addition of KLONOPIN.

Psychiatrist, MD
Diplomate, American Board of Psychiatry and Neurology

*****

Rachel came in to see her therapist, Psychologist, and her mother says that she is out of her medication and wants some called in. Psychologist talked to Rachel and she is unsure if she wants to be on medication or not. Medication was last called in for her on 7/31/06 with two refills. She has to have been out of medication in October but has just ran out so she must have been noncompliant. [There might have been one time when I went a couple of days without meds because Ma was late to call them in, but at no point did I ever stop taking them. I was taking the meds up until a week before the appointment, when I ran out, just as I said. I have never once been noncompliant except with the Risperdal. I think somebody got their math wrong.] Lexapro will be called in for 1 week as she is to be seen on Monday. [Recall that we were never informed of this, thus I never got the meds. *shrug*]

Date: 29-Nov-2006
Duration: 10
Location: Office
Signatures: Nurse, RN
Consumer Name: H., RACHEL LEA

*****

Medication Review

Date: 09/12/06
Name: Rachel H.
DOB: 10/8/76
Duration: 3-3:30PM

Subjective
Rachel came in today for a medication review. She continues to be very limited verbally. She continues to get up at about 8PM and goes to bed at 1:30 in the afternoon. She stays up all night. She states that she is crying less then she was w hen she first started coming to CMH. She states that the medication is helping "somewhat." She went to Mackinaw Island [it's MACKINAC...grrrrr >:( ), took pictures and states that she enjoyed it. She states that she went by herself. She denies any auditory or visual hallucinations. She states that she does feel suicidal at times but no plan. Denies any homicidal thoughts. She seemed tearful at times but would not make eye contact.

Objective
Dressed in shorts, a top, and jacket, which are appropriate. She was on time for her appointment. Eye contact is not evident at all. Speech continues to be non-spontaneous. Affect is constricted and mood anxious and dysphoric. She remains very isolative. Thought content appears clear, insight and judgement are fair. She did appear somewhat more verbal but would not initiate speech.

Assessment
Axis I: Generalized Anxiety Disorder, Social Phobia--severe. Obsessive-compulsive Disorder, Major Depressive Disorder, moderate to severe--this appears chronic. R/O Psychotic Disorder NOS vs. Major Depressive Disorder w/psychotic features. [Wha?]
Axis II: Schizotypal Personality Disorder

Treatment Plan
She will continue on Lexapro 30 mg daily. She should continue with Psychologist for therapy. She should continue with all her present activities. She should be seen by the Dr in October.

CMH Nurse: Nurse, RN
Date: 9/12/06

*****

Psychiatric Medication Review--Psychiatrist

Date: 7/31/06
Name: H., Rachel
DOB: 10/8/76
Duration: 30 min.

Subjective

The patient is seen for psychiatric medication review. The date of her last review was 6/19/06 with Nurse, RN. Prior to that she was seen by psychiatry 6/6/06 and RISPERDAL was added to see if this would further help with the anxiety, as well as her unusual thinking. [Cripes, what I've shared in therapy is NOTHING compared to some of the stuff I think on a daily basis...] When she saw Nurse, RN on 6/19/06, she had stopped the RISPERDAL on her own. She was concerned about taking this medication because of the side effects. At that time I suggested an increase of the LEXAPRO to 30 mg daily, which she has done. She feels the LEXAPRO has been helpful. She specifically feels she is crying less. She feels it has "helped with the depression somewhat". She says, "I am not crying as much". She has not noted any change in anxiety and did not report any OCD symptoms however; this was not discussed today. She reports that she has been continuing to spend her time reading and writing. She writes a lot on the Internet, which she enjoys. She denies any current suicidal thoughts. She reports at times she has some suicidal thinking but denies any intention or plan to harm herself. She denies any homicidal or paranoid ideation. She has not noted any change in sleep and continues to sleep during the day from about 1:30 or 2:00 pm until 8:00 pm. She takes her LEXAPRO when she wakes up at 8:00 pm. She did not report any auditory or visual hallucinations. She has been doing a little more and went to Traverse City and went to the movies, which she enjoyed. I saw her mother briefly at the end of the session and she feels that Rachel is showing improvement as well. She said that she would go to an all day stamp collecting event [erm...it was a stamping class, not stamp collecting ^_^; ] with her mother and this surprised her mother. [Ended up not going.] She also spoke with a phone solicitor to ask them to stop calling, which is unusual as well. [They got this wrong too--actually I picked up the phone and it was a pre-recorded message--I just waited until the guy said to press a button to be taken off the call list, and I did! *rolls eyes*] The patient denies any side effects from the LEXAPRO and feels comfortable continuing to take it. It should be noted the patient just received Medicaid and I believe this helps her to feel more comfortable about the medications and the costs.

Objective

The patient is on time for the appointment. She is appropriately dressed and grooming and hygiene is intact. There continues to be some mild decreased psychomotor activity [do people really move around a lot when talking?? o_o ] and eye contact remains quite poor. Speech remains non-spontaneous however; I believe she was a little more verbal today and her sentences were longer. She did not appear acutely anxious. Reaction time is within normal limits and there is no halting or blocking. Affect is constricted and mood appears less anxious and less dysphoric. There was no evidence of any formal thought disorder. There was no unusual thinking noted. She did not appear to be responding to internal stimuli. [I wonder what they would do if I started randomly looking up at the ceiling or blanking out and staring off into space. :/ I actually do that quite often at home...] Insight is fair and judgement fair.

Assessment

Axis I: Generalized Anxiety Disorder, Social Phobia--severe. Obsessive-compulsive Disorder, Major Depressive disorder, moderate and chronic.
Axis II: Schizotypal Personality Disorder, which I feel is primary.

Plan

At the present time, we will continue with the LEXAPRO 30 mg daily. There has been some improvement without significant side effects. As you can see improvement for a number of weeks after a medication change, I would like to continue with the LEXAPRO at the current dose. Future plan would be to consider the possibility of possibly adding some ATIVAN or KLONOPIN if anxiety seems to be more prominent. I believe that the unusual thinking, as reported previously, is likely related to her underlying schizotypal personality disorder and is not frankly psychotic. The patient is to continue with all current activities. She appears to be more comfortable with Psychologist, LMSW and in fact, was disappointed when Psychologist had to cancel an appointment. [That sure changed...] She was encouraged to keep all appointments with nursing, psychiatry, as well as with her therapist. She was encouraged to continue with all current activities. She should be reevaluated by nursing in 6 weeks and by psychiatry in 3 months or sooner as needed.

Psychiatrist, MD
Diplomate, American Board of Psychiatry and Neurology

Date: 9/11/06

*****

[A couple of medication coordination updates here, nothing interesting.]

*****

Medication Review

Date: 06/19/06
Name: Rachel H.
DOB: 10/8/76
Duration: 10-10:30AM

Subjective
Rachel came in today for a medication review. Psychiatrist last saw her on 6/6/06 when she was placed on Risperdal 0.25 mg one at HS. She decided to discontinue the Risperdal after a week of being on the medication for one week. [*LMAO*] She had read the side effects and decided that it was not good for her to take. She also felt that the Dr "didn't give it to me for the right reason." "I don't feel safe taking it." She feels that Psychiatrist thought that she made the statement of "I think that they can read my mind" she meant that she knows that no one can read her mind but feels that people can sense that she is nervous and is a loser. States, "I don't feel safe looking at people." She denies any auditory or visual hallucinations. She states that she does feel suicidal at times but no plan. Denies any homicidal thoughts. She seemed tearful at times but would not make eye contact.

Objective
Dressed in shorts and a top, which are appropriate. She was on time for her appointment. Eye contact is not evident at all. Speech continues to be non-spontaneous. Affect is constricted and mood anxious and dysphoric. She remains very isolative. Thought content appears clear, insight and judgement are fair.

Assessment
Axis I: Generalized Anxiety Disorder, Social Phobia--severe. Obsessive-compulsive Disorder, Major Depressive Disorder, moderate to severe--this appears chronic. R/O Psychotic Disorder NOS vs. Major Depressive Disorder w/psychotic features.
Axis II: Schizotypal Personality Disorder

Treatment Plan
She will continue on Lexapro 20 mg daily. She has dc'd her Risperdal on her own. She should see psychiatry the first of July. Psychiatrist was consulted. It was decided to increase Lexapro to 30 mg/day. A message was left for Rachel.

CMH Nurse: Nurse, RN
Date: 6/19/06

*****

Psychiatric Medication Review--Psychiatrist

Date: 6/6/06
Name: H., Rachel
DOB: 10/8/76
Duration: 30 min.

Subjective

The patient is seen for psychiatric medication review. The date of her last review was 5/25/06 with Nurse, RN. At that time she reported that she was crying less however; reports over the last two days she has been having some crying spells, which last about a 1/2 hour to 1 hour. She said prior to initiating the LEXAPRO she was having this for many months and then it stopped however; it has restarted. She has otherwise not noted any significant changes. She reports that her mother feels she is a little less anxious but she really doesn't agree. She states that she has been taking her medication everyday and every dose as prescribed and denies any significant side effects. She continues to report suicidal thoughts without any intention or plan. She reports her sleep is unchanged and she sleeps about six hours per 24-hour period. She continues to sleep from the early afternoon until evening. She continues to feel more comfortable being up at night when everyone else is asleep. She has noted no changes in the OCD symptoms nor has her mother. She denies any homicidal ideation. She denies any frank paranoid ideation but continues to have very significant anxiety when she is out and around people. She is always concerned about speaking and feels that she will be thought of as stupid including to her parents. She continues to have no eye contact and I asked how long this had been going on and she said basically for her whole life. I asked if when she had friends in high school if she could not make eye contact with them and she said she didn't remember. I asked what the discomfort was in terms of making eye contact and she reported "I think they can read my mind". [Urrggghhh. >_< ] She denies any auditory or visual hallucinations. Her appetite is reported to be unchanged. She continues to mostly isolate at home and write, as well as read. When we talked about some alternative medications she became quite upset and stated that she would not go on any medication that her parents have to pay for, as she would feel very guilty about it. This was an issue when I first saw her and it was my impression that her parents are more then happy to help her. After this discussion however; she was quite tearful. [Psychiatrist needs to learn how to spell "than" and properly use semicolons. AGH.]

I briefly spoke with her mother who felt she seemed to be less anxious however; I let her know that Rachel did not feel that she was less anxious. Her mother has not noted any change in the OCD symptoms. I also let her mother know about her belief that if she makes eye contact with people they will know what she is thinking and this was new to her mother. [Because it wasn't true.]

Objective

The patient is on time for the appointment. She is appropriately dressed and grooming and hygiene is intact. There is some mild hand wringing noted. Otherwise, there are no psychomotor abnormalities. Eye contact is poor and I do not believe that she made eye contact with me at all, which is unchanged from the previous review. Speech is non-spontaneous however; she answers questions appropriately, with very brief answers. Speech is very soft. Reaction time is within normal limits and there is no halting or blocking. Affect is constricted and mood anxious and dysphoric. She does have some unusual beliefs including the belief that others can read her mind. She remains very isolative. As above, she denies any intention of harming herself or others. [I've mentioned my SI to them in the past, but I guess they didn't find it significant or anything. :/ ] Thought content appears clear, insight and judgement are fair.

Assessment

Axis I: Generalized Anxiety Disorder, Social Phobia--severe. Obsessive-compulsive Disorder, Major Depressive Disorder, moderate to severe--this appears chronic. R/O Psychotic Disorder NOS vs. Major Depressive Disorder w/psychotic features.
Axis II: Schizotypal Personality Disorder (primary) [this is scribbled in with pen]

Plan

The treatment plan was discussed with the patient at length. Initially we discussed the addition of either ATIVAN or KLONOPIN to help with her anxiety however; she was not willing to do this, as she would not allow her parents to pay for it. After this discussion she then mentioned that she felt others could read her mind and we then discussed the option of a trial of an atypical anti-psychotic medication like RISPERDAL to address this unusual thinking, as well as the OCD and anxiety. We discussed that this medication was initially found for schizophrenia however; I do not believe that she is schizophrenic. We talked about the potential benefits, as well as potential risks and side effects. She voiced understanding and consent was signed. It should be noted that her mother was in the room when we discussed this issue. We will begin a trial of RISPERDAL 0.5 mg at HS. We will continue to follow for effects and side effects of the current medications. She was given a lab sheet to have a lipid panel drawn, as the RISPERDAL can potentially affect her cholesterol, as well as her blood sugar, which was within normal limits when drawn on 5/15/06. We will continue the LEXAPRO 20 mg daily. I would consider an increase in the LEXAPRO to 30 or 40 mg in the future however; did not want to make more then one change at a time. The patient is in agreement with this plan. She should be reevaluated by nursing in 2 weeks and by psychiatry in 6 weeks or sooner as needed. She was encouraged to keep all appointments scheduled by Psychologist her individual therapist. We did give her samples of RISPERDAL today and she did not need any samples of LEXAPRO. She can call and be given samples in the future if she runs out prior to her next psychiatric appointment.

Psychiatrist, MD
Diplomate, American Board of Psychiatry and Neurology

Date: 6/12/06

*****

Medication Review

Date: 05/25/06
Name: Rachel H.
DOB: 10/8/76
Duration: 2:20-2:40PM

Subjective
Rachel came in today for a HA/HCP. She states that since she has been on the Lexapro, she isn't crying quite as much as she had before the medication. Her mother thinks that she isn't as anxious as she had been. She has been compliant with her medication which is Lexapro 10 mg, 2 tabs in the AM. She continues to sleep from 1:30PM to 8PM. Continues to be up all night reading, writing or being on the computer.

Objective
Rachel was on time for her appointment. She was dressed appropriately with good grooming and hygiene. She made no eye contact. She only spoke when spoken to, allowing her mother to speak sometimes for her. She states that she continues with the OCD symptoms. She sat with a frown on her face most of the interview. [But...that's how I always look!! o_o ??]

Assessment
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--per Psychiatrist's dictation.

Treatment Plan
She will continue on Lexapro 20mg every morning. She was given medication per Psychiatrist's direction. She is to be seen soon by psychiatry.

CMH Nurse: Nurse, RN
Date: 5/25/06

*****

There's more I wish to share but I'm typing this all by hand and it gets quite long, so I'll save more for later. Not proofed; some errors are in the documents and some are probably mine. Hope I didn't bore anyone to tears or drive more interesting entries off the friends' pages. (I had someone bitch at me about that once.)