Follow up Notes NPNE

CHIEF COMPLAINT: 
[checkbox name="cc" value="Daily medical monitoring per detox protocol|Weekly medical monitoring"]
HPI:
[text name="name" default=" "] is a [text default="" size=2]-year-old [select name="RACE" value="Caucasian|African American|Asian| Multi-Racial|Native Hawaiian| Other not Listed "], [select name="GENDER" value="male|female|transgender male|transgender female|intersex| non-binary"], with PMH of [text default="" size=100].  The patient was admitted [date name="DATE" default=""] for [checkbox name="sud" value="alcohol use disorder|amphetamine use disorder|cannabis use disorder|sedative,hypnotic,anxiolytic use disorder| opioid use disorder| cocaine use disorder| other stimulant use disorder| hallucinogens use disorder| substance use of inhalants| substance use of other psychoactive substances and multiple drug use"]
[select name="medicalcc" value="Patient has no subjective complaints or medical concerns at this time.|Patient has subjective complaints/medical concerns at this time of."][textarea name="medicalconcerns" default="  "]
[radio name="variable_sxd" value="Patient denies headaches, dizziness, EENT complaints, chest pain, palpitations, shortness of breath, pain on inspiration, nausea, vomiting, diarrhea, abdominal pain, muscle weakness, and numbness or tingling, urinary complaints, unsteadiness with walking, bleeding"]
[checkbox memo="include detox info" name="include_detox" value=""][conditional field="include_detox" condition="(include_detox).is('')"] Patient reports withdrawal symptoms as [checkbox name="withsx" value="anxiety|fatigue|shivering|seizures|hallucinations|confusion|chills|malaise|nausea|vomitting|paliptations|chest pain|shortnes of breath|sweating|headaches|irritability|agitation|memory loss|tactile disturbances|paranoia|depression| sweats|tremors|diarrhea|constipation|abdominal cramping|fuzzy thinking|denies withdrawal symptoms"][/conditional] 
[checkbox memo="include cravings rating" name="include_cravings" value=""][conditional field="include_cravings" condition="(include_cravings).is('')"]They report their cravings are a [select name="cravings" value="0|1|2|3|4|5|6|7|8|9|10"]/10;[/conditional] 
[checkbox memo="depression" name="dep" value=""][checkbox memo="anxiety" name="anx" value=""][checkbox memo="sleep" name="sleep" value=""]
[conditional field="anxiety" condition="(anxiety).is('')"][/conditional]
[conditional field="dep" condition="(dep).is('')"]Patient reports their depression is a [select name="depression" value="0|1|2|3|4|5|6|7|8|9|10|High|Variable|Low"]/10. This is described as[select value="stable|better|somewhat better|somewhat worse|much worse|"]. [select value="Current stability is attributed to |Recent improvement is attributed to |Recent exacerbation is attributed to |Lack of improvement is attributed to | "][checkbox value="continuation of current medications|recent medication changes|situational stressors|lifestyle improvements|engaging in individual therapy"][textarea]. [/conditional]
[conditional field="anx" condition="(anx).is('')"]Patient reports their anxiety is a [select name="depression" value="0|1|2|3|4|5|6|7|8|9|10|High|Variable|Low"]/10. This is described as[select value="stable|better|somewhat better|somewhat worse|much worse|"]. [select value="Current stability is attributed to |Recent improvement is attributed to |Recent exacerbation is attributed to |Lack of improvement is attributed to | "][checkbox value="continuation of current medications|recent medication changes|situational stressors|lifestyle improvements|engaging in individual therapy"][textarea]. [/conditional]

[checkbox memo="include detox info" name="sleep" value=""][conditional field="sleep" condition="(sleep).is('')"] Patient reports they are sleeping on average [select name="sleep" value="0|1|2|3|4|5|6|7|8|9|10|Variable|"]/10 hours per night with [checkbox name="variable_diff" value="no difficulties|difficulties falling asleep| difficulties with frequent awakenings|difficulties staying asleep| difficulties with nightmares "] Sleep is reported to be [select value="stable|better|somewhat better|somewhat worse|much worse| "][text]. [select value="Current stability is attributed to |Recent improvement is attributed to |Recent exacerbation is attributed to |Lack of improvement is attributed to"][checkbox value="continuation of current medications|recent medication changes|lack of response to medications|situational stressors|lifestyle improvements|engaging in individual therapy"][textarea].[/conditional] 
Patient reports [select name="diet" value="good|fair|poor|nutrient deficient"] diet. Patient [select name="se" value="denies|endorses|denies"] side effects to medication [text name="ifneeded" default=" "]. Overall, this patient has shown [select name="choices" value="stability|improvement|stagnation|decline|decompensation|a lack of improvement|variablity in progress"] in the medical management of their recovery.

• [comment memo="Suicidal intent/plan:"] [select value="Patient denies current suicidal ideation| Patient endorses suicidal ideation with plan and intent| Patient endorses a history of suicidal ideation, but no current thoughts| Patient endorses suicidal ideation, but is without intent and/or plan|Patient has a history of suicidal ideation and attempt, but is without current ideation|Patient refuses to answer question|"]. 
[textarea rows="2"]
• [comment memo="Self-injurious:"] [select value="Patient endorses self-harming behaviors| Patient endorses self-harming behaviors when intoxicated| Patient refuses to answer questions regarding this|"] [textarea rows="2"]
• [comment memo="Psychotic Symptoms: (Hallucinations (visual/auditory), Delusions, Paranoia)"][select value="Patient denies a current or former history of Hallucinations (visual/auditory), Delusions, Paranoia| Patient does not endorse current Hallucinations (visual/auditory), Delusions, Paranoia, but reflects a history of symptoms| Patient has current Hallucinations (visual/auditory), Delusions, Paranoia |"][textarea rows="2"]

ROS: Pertinent positives and negatives are discussed in the HPI. All other ROS negative.

PHYSICAL EXAM:
VSS
GENERAL: cooperative, NAD   
PSYCH: consistent attention, euthymic mood, anxious affect, purposeful motor activity, normal rate of speech, cooperative behavior, thoughts organized and logical and coherent, appropriate thought content.   
DERM: Generally skin warm and dry.    
HEAD: Normocephalic   
EENT:  EOMI, Vision grossly normal and gaze aligned appropriately. 
CARDIO: RRR, Negative for M/R/G. No peripheral or generalized edema.    
PULMONARY: Respirations even and regular. No use of accessory muscles. Air entry normal. 
GI: Soft, non-tender, normoactive    
MUSCULOSKELETAL: Full ROM of Bilateral upper/lower extremities.     
NEURO: Alert. Stable gait

Assessment/Plan:
[checkbox name="sud" value="alcohol use disorder|amphetamine use disorder|cannabis use disorder|sedative,hypnotic,anxiolytic use disorder| opioid use disorder| cocaine use disorder| other stimulant use disorder| hallucinogens use disorder| substance use of inhalants| substance use of other psychoactive substances and multiple drug use"]
This patient continues to benefit from admission in a protected environment to prevent relapse.  
[checkbox memo="if detox" name="detoxMDM" value=""][conditional field="detoxMDM" condition="(detoxMDM).is('')"] [checkbox name="withsx" value="Continue patient on withdrawal protocols|Monitor s/s for withdrawal and COWS/CIWA scores  
|Provide PRN medications as indicated"][/conditional] Interventions include:   
-Encourage to engage in group sessions, individual therapy sessions, and outings per treatment plan
-Coordinate treatment with psychiatric team
-Engagement in ongoing relapse prevention and aftercare plan
-Continue to monitor recovery in a protected environment