Note Title: New Intake
Provider: Demo Test
Date: April 22, 2024 06:33 AM

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Chief Complaint
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Bipolar disorder, severe anxiety, PTSD, panic attacks, flashbacks, sleep disturbances, suicidal thoughts.

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HPI
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The patient is a 31-year-old female with a history of bipolar disorder, severe anxiety, and post-traumatic stress disorder (PTSD). She reported experiencing childhood abuse, including sexual abuse starting at age 5, and subsequent abusive relationships. She described ongoing struggles with anxiety, panic attacks, difficulty managing emotions, and traumatic memories triggered by specific scents like Old Spice Aftershave. The patient also mentioned sleep disturbances, nightmares, flashbacks, anger issues, and challenges controlling her sex drive.

She is currently taking Seroquel, Wellbutrin, Desyrel, and Ativan for her mental health conditions. Past medications include Prozac, Axil, Lithium, Depakote, and Zoloft. The patient has a history of inpatient hospitalization and three suicide attempts. She has migraines, irritable bowel syndrome, kidney issues, and a history of surgeries. Family history includes bipolar disorder, alcoholism, and depression.

The patient’s social interactions and daily functioning are impacted by her mental health challenges, including difficulties with her mother, education, and relationships. The healthcare provider discussed a treatment plan involving EMDR therapy, psychotherapy, and medication adjustments. The patient expressed occasional suicidal thoughts but is deterred by her children. The provider recommended journaling to help process traumatic memories.

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Psychiatric History
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Psychiatric Diagnoses:
– Post Traumatic Stress Disorder (PTSD)
– Bipolar Disorder
– Rule out diagnosis of Borderline Personality Disorder

Treatment History:
– Currently on Seroquel 700mg daily, Wellbutrin XL 300mg daily, Desiril 100mg at bedtime, Ativan 1mg as needed for panic attacks
– Past medications include Prozac, Axel, Lithium, Depakote, Zoloft
– Underwent EMDR therapy for PTSD
– In counseling since age 14, one inpatient hospitalization, and three suicide attempts

Treatment Response:
– Responding to therapy and medication, but still experiences suicidal ideation occasionally

Symptom Patterns:
– Experiences severe anxiety, panic attacks 2-3 times a day, reexperiencing traumatic events, anger issues, sleep disturbances, racing thoughts, low energy during the day and high energy at night
– Struggles with controlling sex drive, infidelity thoughts, and difficulty sleeping

Mental Health Services Engagement:
– Engaged with mental health services consistently since age 14, including therapy and inpatient hospitalization
– Faces moderate psychosocial stressors related to family relationships and husband’s military deployment

Overall, the patient has a complex psychiatric history involving PTSD, bipolar disorder, and potential borderline personality disorder. They have a history of trauma, ongoing symptoms, and have shown some response to therapy and medication. Suicidal ideation is present but mitigated by concern for children. The treatment plan includes EMDR therapy, intensive psychotherapy, and medication adjustments to address PTSD symptoms. The patient is encouraged to journal memories to aid therapy progress.

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ROS General
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General health: The patient, a 31-year-old female, reports a history of physical and emotional abuse, multiple traumatic experiences, migraines, hyperactive gag reflex, irritable bowel syndrome, kidney infections, and a recent kidney stone requiring a ureteral stent.

Mood disorder: The patient describes being diagnosed with bipolar disorder, severe anxiety, and post-traumatic stress disorder (PTSD). She mentions mood swings, anxiety, panic attacks, and difficulty controlling anger.

Anxiety disorders: The patient experiences severe anxiety, panic attacks 2 to 3 times a day, and struggles to cope with the stress of her husband being deployed. She also mentions obsessive thoughts, difficulty controlling her sex drive, and meeting people for sex when her husband is away.

Psychotic disorders: The patient does not report any symptoms related to psychotic disorders such as hallucinations, delusions, or disorganized thinking.

Substance use: The patient occasionally uses marijuana to calm down but denies regular drug use. She reports a history of being on various medications including Seroquel, Wellbutrin, Desiril, Ativan, Prozac, Axel, Lithium, Depakote, and Zoloft.

Sleep patterns: The patient experiences insomnia, nightmares, and flashbacks related to her traumatic experiences. She has difficulty falling asleep, wakes up frequently, and sometimes masturbates to help fall back asleep. She also mentions periods of high energy at night and low energy during the day, with episodes of prolonged sleep deprivation.

Cognitive functions: The patient reports memory triggers related to traumatic events, difficulty controlling racing thoughts, and low energy during the day. She mentions a history of suicide attempts and has not undergone psychological testing.

Overall, the patient presents with complex psychiatric issues including bipolar disorder, severe anxiety, PTSD, and a history of trauma and abuse. She experiences significant sleep disturbances, cognitive difficulties, and struggles with mood regulation and impulse control. The treatment plan includes EMDR therapy, intensive psychotherapy, and medication adjustments to address her symptoms.

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Sleep Note
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Sleep Schedule: The patient mentioned having difficulty falling asleep and experiencing nightmares that wake her up during the night. She also described having low energy during the day and high energy at night, sometimes leading to multiple days with little to no sleep.

Sleep Quality and Quantity: The patient reported having trouble falling asleep and experiencing nightmares, leading to disrupted sleep patterns. She mentioned going through periods of 3 to 9 days with very little sleep, impacting her energy levels during the day.

Nighttime Awakenings: The patient described waking up from nightmares and flashbacks during the night, which made it difficult for her to go back to sleep.

Nightmares: The patient reported having horrible nightmares and flashbacks that wake her up during the night, affecting her ability to get restful sleep.

Sleep Hygiene Practices: The patient did not mention specific pre-sleep routines or environmental adjustments to improve sleep quality.

Impact on Daily Functioning: The patient’s sleep patterns and issues, including difficulty falling asleep, nightmares, and disrupted sleep, contribute to her low energy during the day and high energy at night. These sleep disturbances likely impact her daily activities and mental well-being, as she struggles with fatigue and sleep deprivation.

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Objective
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Physical Appearance: The patient, a 31-year-old female, presented with a disheveled appearance and casual attire. Hygiene appeared adequate.

Behavior and Affect: The patient displayed signs of distress and anxiety, recounting traumatic experiences with emotional expression. She appeared engaged but exhibited emotional vulnerability.

Speech Patterns: The patient spoke at a moderate rate with clear speech. She expressed herself coherently and engaged in the session actively.

Motor Activity: The patient exhibited normal motor activity with no signs of restlessness or psychomotor retardation.

Cognitive Function: The patient demonstrated good coherence in thoughts, actively participating in the session, and recalling past events with clarity.

Vital Signs: Blood pressure, heart rate, and temperature were not documented during the encounter.

Summary: The patient presented with a history of traumatic experiences, including abuse and PTSD, with symptoms of severe anxiety and panic attacks. She reported difficulties with sleep, mood fluctuations, and past suicide attempts. The treatment plan includes EMDR therapy, psychotherapy, and medication adjustments to address PTSD, bipolar disorder, and borderline personality disorder. Suicidal ideation was reported occasionally, linked to high stress levels. Encouragement was given to start journaling to aid therapy.

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Family & Social History
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Family History
The patient’s father is noted to have bipolar disorder, alcoholism, and drug addiction. Her mother has a history of depression and anxiety. The patient has no siblings but is currently married with a 4-year-old son and an 8-year-old daughter. Her husband is deployed overseas.

Social History
The patient has a history of abusive relationships, including physical and sexual abuse. She has been in multiple marriages, with her second husband being a drug abuser and her ex-husband being physically abusive. She has two children from her second marriage. The patient does not currently work and is a stay-at-home parent. She occasionally uses marijuana to help calm down. Her relationship with her mother was strained, as her mother did not support her when she disclosed abuse by her father. The patient reported being picked on in school but excelled academically. She has a history of suicide attempts and has been in counseling since age 14. The patient has a diagnosis of PTSD, bipolar disorder, and a rule-out diagnosis of borderline personality disorder. She is currently on medications including Seroquel, Wellbutrin, Desyrel, and Ativan. The treatment plan includes EMDR therapy, intensive psychotherapy, and switching Wellbutrin to Lexapro. The patient experiences suicidal thoughts occasionally but is deterred by thoughts of her children.

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Mental Status Exam
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Stated mood:
The client reports feeling anxious and overwhelmed due to her history of trauma and current stressors.

Thought process:
The client’s thoughts are racing, and she has difficulty slowing them down. She experiences low energy during the day and high energy at night. She also mentions having difficulty controlling her anger.

Thought content:
The client experiences reexperiencing of traumatic events, particularly triggered by the smell of Old Spice Aftershave. She also mentions having difficulty controlling her sex drive and engaging in risky sexual behaviors when her husband is not home.

Perception:
The client reports having nightmares and flashbacks related to her traumatic experiences, which disrupt her sleep. She also mentions experiencing auditory and olfactory hallucinations triggered by the smell of Old Spice Aftershave.

Insight:
The client acknowledges her struggles with suicidal thoughts, but she is motivated to stay alive for her children. She is open to journaling as a coping strategy to process her memories and emotions.

Judgment:
The client demonstrates some insight into her mental health struggles and is willing to engage in therapy and follow treatment recommendations. She is receptive to trying new coping strategies to improve her well-being.

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Review of Results
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Reviewing Lab Tests: The patient mentioned a history of multiple cardiovascular workups due to panic disorder, with no significant findings reported. Additionally, the patient has a history of migraines, a hyperactive gag reflex, irritable bowel syndrome, kidney infections, and recently had a kidney stone requiring a ureteral stent placement. No specific lab test results were discussed in the transcript.

Reviewing Vital Signs: Vital signs such as temperature, blood pressure, heart rate, and respiratory rate were not explicitly mentioned in the conversation. Therefore, there is no information available regarding any abnormalities or deviations from normal ranges in the patient’s vital signs. Further assessment of vital signs may be necessary to provide a comprehensive overview of the patient’s health status.

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Risk Assessment with response format
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overall risk assessment
This 31-year-old female patient presents with a complex history of trauma, including childhood abuse, sexual assault, and abusive relationships. She has been diagnosed with bipolar disorder, severe anxiety, and post-traumatic stress disorder (PTSD). The patient has a reliable history and is currently experiencing high levels of anxiety, panic attacks, sleep disturbances, and difficulty managing her emotions. She has a significant psychiatric history, including multiple suicide attempts and a past hospitalization.

suicidal risk assessment
The patient reports occasional suicidal thoughts, occurring once or twice a month, particularly during times of high stress. However, she states that the presence of her children prevents her from acting on these thoughts. She has a history of suicide attempts at ages 14 and 19, indicating a past risk of self-harm.

homicidal risk assessment
There is no indication of homicidal intent or ideation in the patient’s history or current presentation.

risk factors
Static risk factors include a history of childhood abuse, sexual assault, and abusive relationships, as well as a diagnosis of bipolar disorder, severe anxiety, and PTSD. Modifiable risk factors include ongoing high levels of anxiety, panic attacks, sleep disturbances, and difficulty controlling anger. Imminent risk factors include current stressors such as her husband’s deployment, parenting two young children alone, and experiencing frequent panic attacks.

protective factors
Protective factors for the patient include her strong attachment to her children, which serves as a deterrent to acting on suicidal thoughts. She has engaged in therapy in the past and is open to journaling as a coping strategy. The treatment plan includes EMDR therapy, intensive psychotherapy, and medication management, which are all protective factors in managing her mental health.

access to means
The patient reports occasional marijuana use for calming purposes but denies any current substance abuse. There is no mention of access to firearms or other lethal means in the transcript.

additional observations
The patient’s global assessment functioning score is currently at 55, indicating moderate impairment in social, occupational, and psychological functioning. The treatment plan includes a focus on addressing somatization disorder, bipolar disorder, borderline personality disorder, and PTSD, with a plan to transition to Lexapro from Wellbutrin. The patient’s willingness to engage in therapy and explore journaling as a coping mechanism is a positive sign for her commitment to improving her mental health.

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Therapeutic Interventions
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Therapeutic Interventions:
The client presented with a history of bipolar disorder, severe anxiety, post traumatic stress disorder, and a complex trauma history involving abusive relationships and childhood sexual abuse. The client is currently on Seroquel, Wellbutrin, Desiril, and Ativan. The treatment plan includes a diagnosis of somatization disorder, bipolar disorder, borderline personality disorder, and PTSD. EMDR therapy and intensive psychotherapy are recommended, along with transitioning from Wellbutrin to Lexapro.

Progress Statement:
Additional appointments are needed to continue addressing the client’s complex trauma history and mental health conditions. The client has made progress in seeking therapy and medication management. However, the client is still struggling with suicidal thoughts, anxiety, panic attacks, and difficulty controlling anger and impulses.

Client Response:
The client seemed receptive to the therapist’s suggestions, particularly regarding journaling to process memories and emotions. The client expressed commitment to working on her mental health goals, especially considering her children’s well-being as a motivating factor to manage suicidal thoughts. Continued support and therapy will be essential for the client’s progress.

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Risk Assessment
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overall risk assessment
The patient, a 31-year-old female, presents with a complex psychiatric history including bipolar disorder, severe anxiety, and post-traumatic stress disorder (PTSD). She has a significant trauma history involving childhood abuse, sexual assault, and abusive relationships. The patient has a past history of suicide attempts and reports ongoing struggles with anxiety, panic attacks, anger issues, sleep disturbances, and hypersexuality. She is currently on multiple psychotropic medications and has engaged in therapy, including EMDR for PTSD. The patient’s global assessment functioning is currently at 55.

suicidal risk
The patient reports occasional suicidal thoughts, occurring once or twice a month, particularly during times of high stress. However, she states that thoughts of suicide are deterred by her concern for her children. The patient has a history of suicide attempts at ages 14 and 19, involving overdoses of aspirin and pain medication.

homicidal risk
There is no indication of homicidal intent or ideation in the patient’s history or current presentation.

risk factors
Static risk factors include the patient’s history of childhood trauma, ongoing mental health diagnoses, and past suicide attempts. Modifiable risk factors include her current stressors, sleep disturbances, and difficulties with anger management and hypersexuality. Imminent risk factors include the patient’s recent increase in anxiety, panic attacks, and sleep disturbances related to her husband’s deployment.

protective factors
Protective factors for the patient include her strong attachment to her children, which serves as a deterrent to suicidal ideation. She is engaged in therapy, including EMDR, and is open to journaling as a therapeutic intervention. The patient’s access to means of harm, such as medications for panic attacks, should be monitored closely.

additional observations
The patient’s history of trauma, ongoing mental health struggles, and complex psychosocial stressors necessitate a comprehensive treatment approach. Collaborative care involving therapy, medication management, and close monitoring of suicidal ideation is crucial for ensuring the patient’s safety and well-being. Regular assessment of risk factors and protective factors will be essential in managing the patient’s mental health.

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Assessment and Plan
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# Assessments
– Diagnosed conditions: Bipolar disorder, severe anxiety, post traumatic stress disorder (PTSD), rule out borderline personality disorder, somatization disorder
– Psychological themes: History of childhood abuse, traumatic relationships, sexual abuse, anxiety, panic attacks, anger issues, sleep disturbances, hypersexuality, racing thoughts, low energy, high energy fluctuations, suicidal ideation
– Symptom severity: Severe anxiety leading to daily panic attacks, reexperiencing traumatic events, difficulty controlling anger, sleep disturbances, nightmares, flashbacks, hypersexuality, racing thoughts, energy fluctuations
– Impact on daily life: Difficulty tolerating children due to anxiety, sleep disturbances affecting daily functioning, hypersexuality impacting fidelity in marriage, suicidal thoughts during high stress periods
– Previous and current treatments: EMDR therapy, inpatient hospitalization, medications including Seroquel, Wellbutrin, Desiril, Ativan, past medications like Prozac, Axel, Lithium, Depakote, Zoloft

# Plan
– Therapeutic approach: Continue EMDR therapy, intensive psychotherapy, referral to internal therapist and external therapy options
– New strategies: Start journaling memories and feelings to aid therapy process
– Goals for upcoming sessions: Address trauma memories, work on anger management, stabilize sleep patterns, manage hypersexuality, monitor suicidal ideation
– Medication adjustments: Wean off Wellbutrin, replace with Lexapro for PTSD
– Follow-up plans: Regular therapy sessions to address identified goals, monitor medication effectiveness and side effects
– Prescription instructions: Seroquel 700mg daily, Wellbutrin XL 300mg daily, Desiril 100mg at bedtime, Ativan 1mg as needed for panic attacks, new prescription for Lexapro for PTSD

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Plan with Format
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**Treatment Modalities:**
– **Medication:** Continue Seroquel 700mg daily, Desyrel 100mg at bedtime, Ativan 1mg as needed. Replace Wellbutrin with Lexapro for PTSD. Consider weaning off Ativan gradually.
– **Therapy:** EMDR for PTSD, intensive psychotherapy. Refer to an internal therapist and external therapy options.

**Monitoring and Follow-Up:**
– Follow-up appointments every 2 weeks initially to monitor medication changes and therapy progress. Adjust treatment as needed based on symptom improvement.
– Evaluate treatment effectiveness through symptom tracking, mood journals, and therapy feedback.

**Lifestyle Modifications:**
– Encourage regular exercise, balanced diet, consistent sleep schedule, and stress management techniques like mindfulness or relaxation exercises.

**Support Systems:**
– Engage family support for childcare and emotional support. Explore local support groups for trauma survivors. Consider involving a family therapist for relationship dynamics.

**Risk Management:**
– Address potential risks of suicidal ideation. Develop a crisis management plan with emergency contact information. Monitor for any signs of self-harm or worsening symptoms.

**Patient Education:**
– Provide education on PTSD, bipolar disorder, and treatment options. Discuss coping strategies for managing anxiety, panic attacks, and intrusive memories. Offer resources for self-care and mental health awareness.

**Personalized Goals:**
– Collaboratively set SMART goals with the patient, focusing on symptom reduction, improved sleep quality, and enhancing daily functioning. Monitor progress towards these goals during follow-up appointments.

**Consent and Autonomy:**
– Ensure informed consent for all treatment decisions. Respect the patient’s autonomy in choosing therapy options and medication adjustments. Encourage open communication and shared decision-making throughout the treatment process.

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Medications
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Medications taken in the past: Prozac, Axel, Lithium, Depakote, Zoloft. 

Current medications:
– Seroquel 700 milligrams daily
– Wellbutrin XL 300 milligrams daily
– Desiril 100 milligrams at bedtime for sleep
– Ativan 1 milligram as needed for panic attacks

Medications prescribed during this visit:
– Lexapro to replace Wellbutrin for PTSD

Past Surgical History:
– Tubal ligation at age 27
– Appendectomy at age 19
– Surgery on right ovary for cyst
– Ureteral stent placed in right kidney due to kidney stone

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Patient Summary
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The patient is a 31-year-old female with a history of bipolar disorder, severe anxiety, and post-traumatic stress disorder. She has a traumatic past involving childhood abuse, abusive relationships, and multiple marriages. She experiences panic attacks, reoccurring traumatic memories, anger issues, sleep disturbances, and high-risk behaviors. She has a complex medication history and a significant psychiatric and medical background, including suicide attempts. The patient has psychosocial stressors, strained family relationships, and a current global assessment functioning score of 55. The treatment plan includes EMDR therapy, intensive psychotherapy, medication adjustments, and journaling to address her conditions. Suicidal ideation is present but infrequent, mainly during high-stress periods.

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Billing Codes
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Suggested Codes:
ICD-10 Codes:
1. Diagnosis: Post traumatic stress disorder (PTSD)
Modifiers: Chronic
Setting: Not specified
2. Diagnosis: Bipolar disorder
Modifiers: Not specified
Setting: Not specified
3. Diagnosis: Rule out borderline personality disorder
Modifiers: Not specified
Setting: Not specified
4. Diagnosis: History of ovarian cysts
Modifiers: Status post surgery
Setting: Not specified
5. Diagnosis: Migraine headaches
Modifiers: Not specified
Setting: Not specified

CPT Codes (CMT codes):
1. Description: EMDR therapy
Complexity or time spent: Extensive and intensive psychotherapy
Visit type: Not specified
2. Description: Internal therapy referral
Complexity or time spent: Not specified
Visit type: Not specified
3. Description: External therapy referrals
Complexity or time spent: Not specified
Visit type: Not specified
4. Description: Medication management – Lexapro
Complexity or time spent: Not specified
Visit type: Not specified

Missed Codes:
ICD-10 Codes:
1. Diagnoses not fully met or relevant conditions not addressed in this visit: Borderline personality disorder
2. Diagnoses not fully met or relevant conditions not addressed in this visit: Somatization disorder

CPT Codes (CMT codes):
1. Services that could have been billed based on the visit but were not: Weaning off Wellbutrin and replacing it with an SSRI due to PTSD
2. Services that could have been billed based on the visit but were not: Suicidal ideation assessment and management

Areas for improvement in missed codes:
1. Ensure all rule out diagnoses are captured in the billing codes for comprehensive documentation.
2. Include all treatment plans and interventions discussed during the visit to accurately reflect the services provided for billing purposes.

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DSM-5-TR-Codes
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DSM-5-TR 300.02 (Generalized Anxiety Disorder) / ICD-10 F41.1: The patient reports severe anxiety with panic attacks multiple times a day, impacting her ability to cope with daily life stressors, particularly heightened during her husband’s deployment. She experiences difficulty sleeping due to nightmares and flashbacks, leading to chronic fatigue. The patient also struggles with controlling anger and impulsivity, affecting her relationships and behavior.

DSM-5-TR 309.81 (Posttraumatic Stress Disorder) / ICD-10 F43.10: The patient describes traumatic experiences of childhood abuse, sexual assault, and abusive relationships, leading to reexperiencing symptoms triggered by specific cues like Old Spice Aftershave. She reports difficulties in managing memories, sleep disturbances, and hyperarousal symptoms, impacting her daily functioning and relationships.

DSM-5-TR 296.80 (Bipolar Disorder) / ICD-10 F31.9: The patient discloses a history of bipolar disorder with episodes of high and low energy, racing thoughts, and disrupted sleep patterns. She reports a past suicide attempt and a complex medication history, including Seroquel, Wellbutrin, Desiril, and Ativan, to manage mood symptoms.

DSM-5-TR 301.83 (Borderline Personality Disorder) / ICD-10 F60.3: The patient presents with symptoms suggestive of borderline personality disorder, including unstable relationships, impulsivity, self-harm behaviors like suicide attempts, and emotional dysregulation. She reports psychosocial stressors and challenges in her primary support group, affecting her overall functioning.

The patient’s psychiatric conditions significantly impact her daily life, leading to difficulties in sleep, mood regulation, relationships, and coping with stressors. The co-occurrence of PTSD, bipolar disorder, and borderline personality disorder complicates her treatment plan, which includes EMDR therapy, intensive psychotherapy, and medication adjustments to address her complex mental health needs. The patient’s suicidal ideation, though intermittent, underscores the importance of ongoing monitoring and therapeutic interventions to ensure her safety and well-being.