Psychiatric Follow Up WM 2023

This outpatient medication check was conducted[select name="variable_1" value=" via phone appointment.| via telepsychiatry.| in person. |OTHER|"]
[text name="variable_81" default="!!!!!!!!!!!!!!!!!!!"] Patient reports doing[select name="variable_2" value=" better| worse| ok| very well| quite well| quite good| possibly better| well| good | somewhat better| marginally better| a bit better|a little better| moderately better| slightly worse | slightly better| about the same| fine| not well|not good"] since the last visit.[text name="variable_10953" default=""] They stated that medication has[select name="variable_241" value=" helped with psychiatric symptoms.| been doing pretty well.| been working.| been doing great.|been working well.|been effective.| been going well and feel like they are making progress.|helped with psychiatric symptoms.|helped with psychiatric symptoms to an extent.|possibly made symptoms better.|somewhat of an effect.|slightly made symptoms better.|been taken consistently with little to no effect.|been ok but would still like to see more results.|made little impact and contemplates on what to do.|not been taken daily so not as effective.|not been taken as prescribed.|no effect on psychiatric symptoms.|not changed psychiatric symptoms.|not helped psychiatric symptoms due to not taking the medication.|made psychiatric symptoms slightly worse.|been making psychiatric symptoms possibly worse.|made psychiatric symptoms worse.|not been doing well.|has not been taken consistently.| not been helping due to inconsistent use."] [text name="variable_105953" default=""] They expressed that anxiety is [select name="variable_31117621" value="nonexistent.|good.|going well.|improving.|somewhat better.|slightly better but can depend on the day.|manageable.|ok.|about the same.|overall well.|better.|fine and have at times an inability to relax.|doing better but some intrusive thoughts.|continous throughout the night but good during the day.|continous throughout the day but better at night.|nonexistent.|mild.|decreasing.|increasing.|increasing with panic attacks.|moderate.|somewhat worse.|difficult to control at times.|severe.|getting worse.|doing worse and some days it is too much for them to deal with.|debilitating but is slowly getting better.|debilitating more so recently.|worse.|bad.|not constant."][text name="variable_3684221" default=" "] Patient expressed that depression is [select name="variable_33100621" value="nonexistent.|good.|going well.|improving.|slowly feeling better.|better.|somewhat better.|going in the right direction.|having more good days.|doing ok and using coping skills.|doing well and using coping skills.|doing fine and is using coping skills.|going well majority of days but some days are hard.|ok majority of days but can still show up.|getting somewhat stable.|manageable.|about the same.|somewhat manageable.|improving and gaining more insight into what is triggering it.|moderate.|ok but at times still feeling hopeless.|slowly feeling worse.|somewhat worse.|decreasing.|still a struggle.|severe.|worse.|making no progress.|going not so well.|improving rapidly."][text name="variable_39921" default=" "] Patient states[select name="variable_431" value=" no suicidal ideation and contracts for safety.|no suicidal ideation and contracts for safety but | suicidal ideation but contracts for safety and will not act on it.| suicidal ideation and can not contract for safety."][text name="variable_1" default=""]They expressed [select name="variable_69691" value="no self harm.||self harm recently and does not contract for safety.| self harm recently in the form of"][text name="variable_1" default=""] They state[select name="variable_4561" value=" no homicidal ideation.| homicidal ideation directed towards |"][text name="variable_8231" default=""] When asked about sleep they stated[select name="variable_2161" value=" no changes to sleep| that sleep is well.| getting solid sleep but fatigue during the day| sleep is disrupted lately by partners snoring| sleep is disrupted by animal| that sleep is better | it is better| it is fine| difficulties initating sleep| difficulties with continous sleep| that sleep is worse| a decrease of sleep| somewhat better| somewhat worse| sleep is good| about the same| sleep is going well| sleep is broken throughout the night| sleep is not as broken since last time we talked| an increase of sleep| sometimes broken but mostly good"] and sleeps for about[select name="variable_4521" value=" 8 hour nightly.|1 hour nightly.| 2 hours nightly.| 3 hours nightly. | 4 hours nightly.| 5 hours nightly. | 6 hours nightly.| 7 hours nightly.| 9 hours nightly.| 10 hours nightly| 11+ hours nightly.| 0 hours nightly."][text name="variable_6241" default=""] Patient added since last session their appetite is[select name="variable_45671" value=" about the same.|fine.| worse.| getting slightly worse.| slightly improving.| decreasing.| increasing.| better.|good|going well."][text name="variable_5241" default=""] Patient[select name="variable_7891" value=" denies hallucinations.| has hallucinations in the form of |no hallucinations but"][text name="variable_52241" default=""] Patient [select name="variable_7791" value=" denies delusions.| has delusions in the form of|denies delusions but does have paranoia|"][text name="variable_52141" default=""] They state[select name="variable_2561" value=" no mood swings.|mood swings are somewhat getting better.| mood swings are about the same.| mood swings are manageable| decrease in mood swings.| increase in mood swings."][text name="variable_2881" default=""] The patient [select name="variable_2551" value="denied symptoms of mania.|denied symptoms of hypomania.|states symptoms of hypomania.| states symptoms of mania.|denied symptoms of mania since last visit.|denied symptoms of hypomania since last visit.|states decrease in symptoms of mania.|states increase in symptoms of mania.|states increase in symptoms of hypomania.|states decrease in symptoms of hypomania.| states symptoms of possible mania.|"][text name="variable_28181" default=""]Patient concentration is[select name="variable_252251" value=" good.| worse| doing ok.| getting better.| overall well.| better| doing better with medication.| fair. | poor.| somewhat improving.| fair.|about the same.|going well.| getting worse.| slightly worse.| not doing well."][text name="variable_281811" default=""] During the session we talked about their [checkbox name="variable_5233" value="academic pressure|acute illness|addiction|attempts to conceive|birth of a child|breakup|budgeting|car|car issues|caregiving responsibilities|change in health of a family member|change in living conditions|children|child custody|child custody situation|chores|chronic illness|church|communication issues|conflict with friend|conflict with spouse|dad|daughter|death of loved one|dieting|divorce|ex husband|ex partner|ex wife|family|financial strains|finiancial issues|friend|friends|friends state of health|graduation|hobbies|holiday|house arrest|house cleaning|house work|husband|imprisonment of loved one|issues with sobriety|job insecurity|job interview|legal issues|loss of job|low libido|marriage|mom|most recent breakup|new car|new job|new pet|own health|parenting stress|parents|partner|period|physical therapy|possible surgery|pregnancy|pregnancy loss|probation|relationship|retirement|school|school issues|schooling|self esteem issues|sexual difficulties|shopping|siblings|sister|sobriety|son|surgery|trouble finding employment|trouble with boss|trouble with employee|upcoming surgery|vacation|video games|weather conditions|wife|work|work adjustment."][text name="variable_2431" default=" "].

[comment memo="Appearance: Unable to assess.
Orientation: Alert and oriented.
Memory: Intact.
Motor: Unable to assess.
Eye contact: Unable to assess.
Attention: Intact.
Speech: Within normal limits.
Mood: Euthymic.
Affect: Appropriate to mood.
Thought process: Linear.
Thought content: No paranoia, delusions or perceptual disturbances.
Suicidal ideations: None.
Homicidal ideations: None.
Insight: Good.
Judgment: Good."][comment memo="
General Appearance: Appears stared age.
Behavior/ Attitude: Cooperative.
Psychomotor Activity: Normal.]