Clinical Patient Narrative Note Assignment Paper

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. Clinical Patient Narrative Note Assignment Paper

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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.

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. Clinical Patient Narrative Note Assignment Paper

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.

Differential Diagnoses:

• 1 – Generalized Anxiety Disorder
• 01 – Insomnia Disorder

Signs and Symptoms:

• Generalized Anxiety Disorder: Feelings of restlessness and being on the edge, irritability, difficulty concentrating,
• Insomnia Disorder: Difficulty falling and staying asleep, and difficulty paying attention, and irritability. Clinical Patient Narrative Note Assignment Paper

Client’ Progress: N/A

Patient’s Stated Goals:

• The patient seeks to learn how to address her feelings of anxiety outside of her medication.
• She also seeks to find healthy ways of falling and staying asleep

Treatment Plan

1. Generalized Anxiety Disorder

• LONG-TERM GOAL: Pt continue with Restoril 15mg tag po qhs. Pt’s therapist and husband will continue to provide emotional support as well as encouragement
• TEACHING PLAN: She will also learn how to recognize, accept and cope with the feelings of anxiety (Michaelides and Zis, 2019).

2. Insomnia Disorder

• LONG-TERM GOAL: Pt continue with Klonopin 0.5mg tab po TID.
• TEACHING PLAN: Pt will learn sleep hygiene, stimulus control and temporal control. She will also learn sleep restriction, paradoxical intention and relaxation training (Mysliwiec, et al. 2020).

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. Clinical Patient Narrative Note Assignment Paper

Weekly Patient Narrative Note: PLEASE MAKE SUREN ALL NOF THESEB ARE COVERED IN THE NARRATIVE
1. Date Patient Seen
2. Chief Complaint
3. History of Present Illness
4. Mental Status Exam- Include all aspects of the MSE along with justification for findings. Do not use a template where you just check off the different components of MSE.
5. Diagnoses (established in this treatment course or new for today’s visit) with ICD-10 code for each
6. Signs & Symptoms that support the diagnoses (This is medical Decision-Making)
7. Medication with dose and frequency along with indication for treatment. The diagnoses and medication should be reflective.
8. Client progress to date if previously treated & on a current treatment plan (write n/a if this is first-ever treatment)
9. Patient’s stated goals.
10. Teaching goals and self-help strategies along with the content of instruction.
11. What changes to the treatment plan (if any) are needed at this time?
=====================================================================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.

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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
Anxiety
Insomnia

-Continue Restoril 15mg tag po qhs
-Continue Klonopin 0.5mg tab po TID

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