526 2

RePrint Date: 05121115 1:26 PM TERROS, lnc. PATIENT PROGRESS NOTE Original Print Date: 0510712015 2:05 PM Paqe 1 of3 Patient Name: LEES, BARBARA Patient lD: BL071878F0 Sex:F DOB:07/18/1978 Age:36 Service Date: 0510712015 Show Program: OP - OUTPATIENT COUNSELING Time: 13:30 Provider: RADHAMANIAMMA, GIRIJA Type of Visit: ECV ESTABLISHED CLIENT VISIT Visit Length: 30 Minutes Facility: 33 STAPLEY Place of Service: 53 COMMUNITY MENTAL HEALTH CENTER 0510712015 - 1:30PM May 7 2015 13:30 Temp:99.3 BP Systolic: 130 (mmHg) BP Diastolic:82 (mmHg) Pulse: 100 Resp:18 Girth:0 HISTORY OF PRESENT ILLNESS: First time visit with this provider , accompanied by her husband, worsening her mood , more manic , and not sleeping "l took 3 ativan to get sleep" PAST PSYCHIATRIC HISTORY: The following psychiatric history was reviewed during patient visit:pt has been enrolled with terros for counseling hx of southwest behavior for 1.5 years pt is diagnosed with bipolar 7 years ago st lukes pt was against taking meds x one, pt first sought mental treatment 14 years ago for post partum depression, pt has been in and out of emergency room states that is where they treated her mania hx of prozac, celexa, hx of suicidal attempt at age 15 took bottle of mother tranquiler suicidal thought 7 years ago took vicodin, xanax, nyquil. SUBSTANCE USE: History of subslance and alcohol abuse:thc started at'12 -14 heroin smoking at age 16 used needles twice used until age 28 last heroin was age 28 using "all the time" cocaine started at age 16 - 28 used daily in conjunction with heroin hx ofalcohol use at age 18 no alcohol use since age 31 MEDICAL HISTORY: ALLERGIES: Drug Allergy - Percocet 101325 - Reaction: mouth goes numb Feb 13 2015 00:00 Drug Allergy - codeine - Reaction: hives Feb 13 2015 00:00 CURRENT MEDICATIONS: LithiumCarbonate-lithium-300m9-capsulelcapsule-2timesaday-30day(s)-Starting:0311212015-Verified Paxil-PARoxetine-30mg-tablet30tablet-once-30day(s)-Starting: 0211312015-Verified Ativan-LORazepam-1mg-tablet30tablet-asneeded-30day(s)-Starting:O2l'1312O15-Verified Desyrel-traZODone-100m9-tabletltablet-onceaday(atbedtime)-30day(s)ltabpoprnqhs-Starting: 0510712015- Verified Current Meds from other prescribers:herniated disc vicodin Past Medications: LithiumCarbonate-lithium-300m9-capsule: lcapsule-2timesaday-30day(s)-Start: 0311212015-Verified Paxil-PARoxetine-30mg-tablet:30tablet-once-30day(s)-Start: 0211312015-Verified

Upload: cody-lees

Post on 14-Sep-2015

212 views

Category:

Documents

0 download

Report

Download

Embed Size (px):

DESCRIPTION

random

TRANSCRIPT

RePrint Date: 05121115 1:26 PM

TERROS, lnc.PATIENT PROGRESS NOTE

Original Print Date: 0510712015 2:05 PM Paqe 1 of3

Patient Name: LEES, BARBARA Patient lD: BL071878F0 Sex:F DOB:07/18/1978 Age:36

Service Date: 0510712015 Show Program: OP - OUTPATIENT COUNSELINGTime: 13:30 Provider: RADHAMANIAMMA, GIRIJAType of Visit: ECV ESTABLISHED CLIENT VISITVisit Length: 30 Minutes Facility: 33 STAPLEYPlace of Service: 53 COMMUNITY MENTAL HEALTH CENTER

0510712015 - 1:30PM

May 7 2015 13:30Temp:99.3BP Systolic: 130 (mmHg)BP Diastolic:82 (mmHg)Pulse: 100Resp:18Girth:0

HISTORY OF PRESENT ILLNESS: First time visit with this provider , accompanied by her husband, worsening her mood , moremanic , and not sleeping "l took 3 ativan to get sleep"PAST PSYCHIATRIC HISTORY:The following psychiatric history was reviewed during patient visit:pt has been enrolled with terros for counselinghx of southwest behavior for 1.5 yearspt is diagnosed with bipolar 7 years agost lukes pt was against taking meds x one,pt first sought mental treatment 14 years ago for post partum depression,pt has been in and out of emergency room states that is where they treated her maniahx of prozac, celexa,hx of suicidal attempt at age 15 took bottle of mother tranquilersuicidal thought 7 years ago took vicodin, xanax, nyquil.SUBSTANCE USE:History of subslance and alcohol abuse:thc started at'12 -14heroin smoking at age 16 used needles twice used until age 28last heroin was age 28 using "all the time"cocaine started at age 16 - 28 used daily in conjunction with heroinhx ofalcohol use at age 18no alcohol use since age 31

MEDICAL HISTORY:ALLERGIES:Drug Allergy - Percocet 101325 - Reaction: mouth goes numb Feb 13 2015 00:00Drug Allergy - codeine - Reaction: hives Feb 13 2015 00:00CURRENT MEDICATIONS:LithiumCarbonate-lithium-300m9-capsulelcapsule-2timesaday-30day(s)-Starting:0311212015-VerifiedPaxil-PARoxetine-30mg-tablet30tablet-once-30day(s)-Starting: 0211312015-VerifiedAtivan-LORazepam-1mg-tablet30tablet-asneeded-30day(s)-Starting:O2l'1312O15-VerifiedDesyrel-traZODone-100m9-tabletltablet-onceaday(atbedtime)-30day(s)ltabpoprnqhs-Starting: 0510712015-VerifiedCurrent Meds from other prescribers:herniated disc vicodinPast Medications:LithiumCarbonate-lithium-300m9-capsule: lcapsule-2timesaday-30day(s)-Start: 0311212015-VerifiedPaxil-PARoxetine-30mg-tablet:30tablet-once-30day(s)-Start: 0211312015-Verified