WK9
Day1
Pt:
Age:
F Dx:
Medications:
Client presents to the clinic for follow-up and medication management. Recently started nursing school,
was told that she cannot take any benzodiazepines during the program. She is still dealing with the
disability office regarding a union settlement she received after leaving her job after a traumatic situation.
Reports so far school is goin good. Says that the Adderall doesn’t help her to focus instead instead it
makes her sleepy, so she doe not take it. Expresses her goal is to continue making through the
program, taking it one class at time. States that overall other mediations are effective in managing her
symptoms and wishes to continue. Reports that she does still have nightmares sometimes but associated it
with when she forgets to take her prazosin. Agrees to adding buspar to help manage her anxiety with 2.5
month follow up.
Pt:
Age:
F Dx:
Medications: Wellbutrin, Zoloft,
Client presents to the clinic for follow-up and medication management. Reports she is doing, getting ready
to start back working with elementary children now instead of secondary children. Still experiencing some
anxiousness and PTSD from the accident, stating its more when about the kids being in the car than it is
about herself. Voices going back to dancing, stating that she cannot allow the trauma of the car accident to
continue to keeping her from getting back to the things she enjoyed or else she is just going to get back
depressed and she doesn’t want that. Agrees to seeing psychiatrist to start low dose Adderall to help with
focusing and getting task complete going into the school year. Voices that she has not had any issues with
appetite or sleep. Agrees to start Wellbutrin until then, continue other medications with follow up in 6
weeks.
Pt: Green
Age: M
Dx:
Medications:
Client presents to the clinic for follow-up and medication management. States he has been doing, prior to
coming in he was out in the yard trying fix his mower. States his doctor just started him on some new blood
pressure medications since his stroke and his blood pressures have been going down, however today his
blood pressure doesn’t not reflect a downward trend. Discussed with the patient over the counter and foods
that can help to lower blood pressure, in addition to working on completing one task at a time a day instead
, of him trying to complete multiple task a day. Denies changes to sleep and appetite. No SI/HI or AVH.
Agrees with plan to continue current medications with 2 month follow up.
Pt:
Age:
F Dx:
Medications:
Client presents to the clinic for follow-up and medication management. Reports being stressed, stated that
she has been helping her daughter with her kids on the week that she gets them because she cannot care
for them by herself. States her daughter has had 4 accidents and she has had to purchase her 2 new tires,
now inquires about getting her daughter into the hospital for treatment. Has been getting testing done
because she has been losing blood and they are not sure of the source, reports she has had cancer in the
past and has an upcoming mammogram scheduled. Says that she also having issues with retaining fluid
even after having her medications changed, so she is having to follow up with her renal doctor, voices that
she is just tired. Expressed to her daughter to act like she is dead and not to come to house for a
week because she is tired, she has to help her with her week to get the kids by buying everything to make
sure they have everything they need while they are at her house.
Pt: Arlene
Age: 47/F
Dx: Anxiety
Medications: Xanax, hydroxizine, propranolol, Paxil, Vrylar,
Client presents to the clinic for follow-up and medication management. Has been doing good states
“everything has been going fine.” Says she has been having flash flashes. Rates anxiety as 5/10 over the
past 2weeks, but her anxiety medication is effective in managing her anxiety systems. Sleeping difficulty
falling asleep, when she doesn’t take her medications states her nightmares are pretty intense. Denies
SI/HI and AVH. Agrees to increasing praxotine dose with a 2.5 month follow up.
Pt: Clementine
Age: F
Dx: paranoid schizo, PTSD
Medications: Klonopin, risperdal
Client presents to the clinic for new patient evaluation and medication management. Reports that “she is
feeling good coming in talking, stating it has been good for her.” Says she was initially anxious in the
waiting room because she wasn’t sure where she was until she realized where she was. Accompanied by
her son, brung in medications post facility discharge to evaluate if current medication is good for her to
continue taking. Expressed wanting to switch pharmacy to meds by mail offered through the VA system, to
prevent medication mix-ups like her recent issue that happened after picking medications up from the
pharmacy. Education on medications their indications, proper dose, frequency and adverse effects to watch
for provided. Client and son both acknowledged and voice understanding. Expresses feelings of fear that
occurs when she is driving, processed with her focusing on driving to prevent getting into another accident
Day1
Pt:
Age:
F Dx:
Medications:
Client presents to the clinic for follow-up and medication management. Recently started nursing school,
was told that she cannot take any benzodiazepines during the program. She is still dealing with the
disability office regarding a union settlement she received after leaving her job after a traumatic situation.
Reports so far school is goin good. Says that the Adderall doesn’t help her to focus instead instead it
makes her sleepy, so she doe not take it. Expresses her goal is to continue making through the
program, taking it one class at time. States that overall other mediations are effective in managing her
symptoms and wishes to continue. Reports that she does still have nightmares sometimes but associated it
with when she forgets to take her prazosin. Agrees to adding buspar to help manage her anxiety with 2.5
month follow up.
Pt:
Age:
F Dx:
Medications: Wellbutrin, Zoloft,
Client presents to the clinic for follow-up and medication management. Reports she is doing, getting ready
to start back working with elementary children now instead of secondary children. Still experiencing some
anxiousness and PTSD from the accident, stating its more when about the kids being in the car than it is
about herself. Voices going back to dancing, stating that she cannot allow the trauma of the car accident to
continue to keeping her from getting back to the things she enjoyed or else she is just going to get back
depressed and she doesn’t want that. Agrees to seeing psychiatrist to start low dose Adderall to help with
focusing and getting task complete going into the school year. Voices that she has not had any issues with
appetite or sleep. Agrees to start Wellbutrin until then, continue other medications with follow up in 6
weeks.
Pt: Green
Age: M
Dx:
Medications:
Client presents to the clinic for follow-up and medication management. States he has been doing, prior to
coming in he was out in the yard trying fix his mower. States his doctor just started him on some new blood
pressure medications since his stroke and his blood pressures have been going down, however today his
blood pressure doesn’t not reflect a downward trend. Discussed with the patient over the counter and foods
that can help to lower blood pressure, in addition to working on completing one task at a time a day instead
, of him trying to complete multiple task a day. Denies changes to sleep and appetite. No SI/HI or AVH.
Agrees with plan to continue current medications with 2 month follow up.
Pt:
Age:
F Dx:
Medications:
Client presents to the clinic for follow-up and medication management. Reports being stressed, stated that
she has been helping her daughter with her kids on the week that she gets them because she cannot care
for them by herself. States her daughter has had 4 accidents and she has had to purchase her 2 new tires,
now inquires about getting her daughter into the hospital for treatment. Has been getting testing done
because she has been losing blood and they are not sure of the source, reports she has had cancer in the
past and has an upcoming mammogram scheduled. Says that she also having issues with retaining fluid
even after having her medications changed, so she is having to follow up with her renal doctor, voices that
she is just tired. Expressed to her daughter to act like she is dead and not to come to house for a
week because she is tired, she has to help her with her week to get the kids by buying everything to make
sure they have everything they need while they are at her house.
Pt: Arlene
Age: 47/F
Dx: Anxiety
Medications: Xanax, hydroxizine, propranolol, Paxil, Vrylar,
Client presents to the clinic for follow-up and medication management. Has been doing good states
“everything has been going fine.” Says she has been having flash flashes. Rates anxiety as 5/10 over the
past 2weeks, but her anxiety medication is effective in managing her anxiety systems. Sleeping difficulty
falling asleep, when she doesn’t take her medications states her nightmares are pretty intense. Denies
SI/HI and AVH. Agrees to increasing praxotine dose with a 2.5 month follow up.
Pt: Clementine
Age: F
Dx: paranoid schizo, PTSD
Medications: Klonopin, risperdal
Client presents to the clinic for new patient evaluation and medication management. Reports that “she is
feeling good coming in talking, stating it has been good for her.” Says she was initially anxious in the
waiting room because she wasn’t sure where she was until she realized where she was. Accompanied by
her son, brung in medications post facility discharge to evaluate if current medication is good for her to
continue taking. Expressed wanting to switch pharmacy to meds by mail offered through the VA system, to
prevent medication mix-ups like her recent issue that happened after picking medications up from the
pharmacy. Education on medications their indications, proper dose, frequency and adverse effects to watch
for provided. Client and son both acknowledged and voice understanding. Expresses feelings of fear that
occurs when she is driving, processed with her focusing on driving to prevent getting into another accident
