Narrative Note
DATE SEEN: 7/12/2022
SUBJECTIVE:
Chief Complaint: The patient complains restlessness and felling “on edge”
History of present illness:
PMH:
The patient, Pt, states that she is a recovering alcoholic for nine years. She records having been visiting a private psychiatrist for 10 years. She also reports that the doctor has her on Restaril 15mg at bedtime for insomnia which he has had for ten years and klonopin 0.5mg four times a day for her anxiety. Narrative Note Essay Paper
Accidents/Injuries:
The reports no injuries.
Hospitalizations:
TJ did not provide any account of recent hospitalizations.
Social History:
The patient is retired and lives with her husband. She states that she has little interaction with her children but they call her husband to check on her. Her husband is very supportive and ensures she takes her medication as prescribed and drives her to all her appointments. Narrative Note Essay Paper
Family History:
The patient’s mother is deceased and was diagnosed with generalized anxiety disorder at 25. Her father suffered from alcoholism all his life and died of cirrhosis at 55.
Allergies:
Pt denies any allergies to medications, latex and foods.
Current Medications:
The patient takes Restaril 15mg at bedtime for insomnia and klonopin 0.5mg four times a day for her anxiety.
MSE:
Appearance and Behavior: The patient appeared tense and restless. She could not maintain eye contact during the examination.
Speech: The patient’s speech was normal with no stammering or vocal tremors detected.
Mood: As stated, Pt stated feeling “on edge.” She was seen to be irritable during the assessment as she would get agitated if an intrusive question was asked.
Thought Process: She stated experiencing periods of unexplained extreme fear and when they subsided, she experienced anticipatory anxiety that the episode may recur.
Cognition: Pt had difficulty concentrating as some questions needed to be asked twice or thrice. Insight/Judgment: While the patient is aware that her anxiety is pathological and has no material cause, she avoids situations where she experiences anxiety as she finds the feeling intolerable. Narrative Note Essay Paper
Differential Diagnoses:
Signs and Symptoms:
Client’ Progress: N/A
Patient’s Stated Goals:
Treatment Plan
References
Michaelides, A., & Zis, P. (2019). Depression, anxiety and acute pain: links and management challenges. Postgraduate medicine, 131(7), 438-444.
Mysliwiec, V., Martin, J. L., Ulmer, C. S., Chowdhuri, S., Brock, M. S., Spevak, C., & Sall, J. (2020). The management of chronic insomnia disorder and obstructive sleep apnea: synopsis of the 2019 US Department of Veterans Affairs and US Department of Defense clinical practice guidelines. Annals of internal medicine, 172(5), 325-336. Narrative Note Essay Paper
Weekly Patient Narrative Note: PLEASE MAKE SUREN ALL NOF THESEB ARE COVERED IN THE NARRATIVE
Signs & Symptoms that support the diagnoses (This is medical Decision-Making)
=====================================================================USE THIS PATIENT INFO TO MAKE YOUR NARRATIVE AND ADD REFERENCES PLEASE. THANKS. Any info I don’t have here, just make it up. Thanks
7/7/22
Info – Pt reports that she has been with a private psychiatrist for 10 years, Reports she’s a recovering alcoholic for 9 years., States she’s on Restaril 15mg at bedtime, klonopin 0.5mg four times a day. States she was suffering from Anxiety and insomnia. States she’s more stable now and less moody. Pt denies any si, no injury to self, no psychosis.
Past Diagnosis and Age of Onset
Anxiety
Alcohol abuse
Insomnia
Social Hx
Lives with husband. Retired.
Dx
F41.1 – Generalized Anxiety Disorder
F51.01 – Insomnia Disorder
Treatment Plan
AnxietyInsomnia -Continue Restoril 15mg tag po qhs-Continue Klonopin 0.5mg tab po TID -pmp verified Narrative Note Essay Paper