Activity therapy for skill building
Process group for support, insight building, and management symptoms
Explain how to access Psychiatric Crisis Services
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+JANICE LYNN ALLEY PSYD at 2/23/2017 10:28 AM
+TC to patient's mother, Maxine, to discuss treatment goals for Zack and to gain her impressions about his past and current level of fxng. Maxine reports that Zack has had life-long MH problems, and that at this point she is feeling that she needs to step back from his care and "allow" him to "be an adult and take responsibility for his well-being." Maxine noted that she is not sure Zack will benefit from IOP/group therapy as she herself has done group therapy and knows that you need to be able to listen to others, have an open mind, and allow space for conversation that she doesn't believe Zack can do. Writer confirmed that Zack did, indeed, struggle to participate in IOP yesterday, but that he did calm down considerably throughout the morning.
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+Maxine noted that Zack took a train to Berkeley for the day to be with his friends, and that he is exhibiting no signs of psychosis at this time. She wants Zack to remain on the medication as it is obviously effective in controlling his anxiety and psychosis, but noted that she would rather not attend his appointment with Dr. Vaughan tomorrow @ 1:30 pm with Zack because Zack is quite aggravated with her in general these days. She asked writer to request that Zack's father, Peter attend instead. Maxine noted that she is going to New Zealand from 3/3-3/21 and that she needs to step back from Zack's treatment. She knows he does not want treatment, that he believes he is smarter than everyone else, and feels she has done everything she can to support his need for MH treatment. Of note, she recently had to "unfriend" pt on FB because his rants were becoming so belligerent. Maxine does not know whether patient will choose to have ongoing tx at Kaiser WCR and/or Kaiser OAK where he has been seen for transgender transitioning support. Maxine thanked writer for the call and invited his providers to call her anytime.
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+Writer then phoned patient's father, Peter, who will be happy to accompany Zack to his medication appointment tomorrow. He will also do his "best" to assure that Zack attends IOP, but also understands that patient is probably not appropriate for group therapy. He feels Zack would benefit from a Socials Skills group (which pt did attend briefly here in the past), but noted Zack's lack of motivation for this.
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+Peter also commented on Zack's rapid "re-compensation" of the past four days, noting that in the past this kind of improvement has taken 3 weeks. He, too, would like Zack to remain on the medication and will talk with Zack about this later today. Peter also noted that Zack has never been the type of person to harm himself, but that he tends to be hostile toward others. He thanked writer for the call, and will provide updates as needed.
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+JANICE LYNN ALLEY PSYD at 2/24/2017 2:06 PM
+TC to patient following IOP group today to discuss his treatment plan. Pt was hostile, belligerent, and condescending throughout the program this morning and is not an appropriate candidate for IOP. Writer reached pt directly, who apologized immediately for his "socially inappropriate" behavior today. Writer explained that IOP is clearly upsetting to patient and is not helping him. Zack agreed, noting that he would "still like help" with his social behavior, but does not feel comfortable "practicing" in a group format. Writer offered to refer pt to a Case Manager with the goals of improving social skills, medication education/compliance, and to build a long-term relationship of trust. Pt liked this idea and asked that I make the referral. Writer also reminded pt of his upcoming medication appointment with Dr. Xiao on Monday, 2/27 @ 2:00 p.m. Pt stated that he will attend the appt and thanked writer for the call.
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+Writer then phoned patient's father Peter to inform him of the above events, emphasizing the fact that we are not giving up on patient (Peter had expressed this fear previously), but quite to the contrary are hoping to offer him treatment venues that will be helpful/supportive. Peter stated that he understood and appreciated this perspective, and agrees with this new treatment plan. He thanked writer for the call. Writer to refer pt to CM and to remove pt from IOP census.
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+JANICE LYNN ALLEY PSYD at 2/24/2017 11:05 AM
+IOP Group Note
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+Pt attended IOP check-in, process, and education group.
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+Check in:
+Reports feeling great
+Something good: did some good writing yesterday and has some great ideas to share with friends
+Something that could be better: would prefer not to be condescended to by the MH system
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+Psychotherapy: Pt did not ask for time today. He openly disagreed with group member statements that IOP is a good place to come for help, stating that he finds this place to be "horrible." He also disagreed with the concept of depression, noting that sadness is a normal response to difficult happenings in the world. Group leaders validated the points he was making and created space for different points of view.
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+Psycho-education: Medication Education
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+Updated Risk Status:
+Pt. voiced no suicidal or homicidal thoughts/feelings and is therefore not at risk of harm to self or others at this time.
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+
+Wrap up:
+Graduation Day. No wrap up.
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+Patient Participation/Response: Openly argumentative at times but responds well to empathy
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+Updated Clinical Status/History: No change in sxs
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+LORI J ONO PHD at 2/27/2017 4:30 PM
+Called pt who was referred to Case Management. Pt answered the phone and upon telling him why I was calling, pt immediately said he does not want to make an appointment. Pt further states "I don't think there is anything wrong with me" and wanted me to take his name off of the list. Advised pt that I will not call him again, but do not have the ability to stop other people from Kaiser calling.
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+AIYING ANGIE XIAO MD at 2/27/2017 1:58 PM
+Psychiatry Initial Evaluation/Medication Management
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+Zachary Davis is a 29 Y male presenting for intake/initial psychiatric evaluation.
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+Patient attends appointment with his father, chart reviewed.
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+Patient's Rights, confidentiality and exceptions to confidentiality, use of automated medical record, Primary Care Provider and Behavioral Health Services staff access to medical record, and consent to treatment were reviewed
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+SUBJECTIVE:
+Cc: "I don't think I have any psychiatric problems".
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+HPI:
+Patient was referred from IOP for medication management. Patient reports that he was under a lot of stress and didn't sleep for couple of days. He was having some suicidal ideation and some delusions. His co-worker brought him to his mother who called police to bring him to ED on 2/17/2017. Patient reports that he has been sleeping well over the past one week. He feels good today. He states that he doesn't think he has any psychiatric problem. It was "a big misunderstanding". His problems were caused by stress and lack of sleep. He doesn't think he need to take any psychotic medications. He said that he feels sleepy after taking Zyprexa. OTC melatonin works well for him. Patient denies depression or mania. He denies anxiety. He denies paranoia or AVH. He denies current SI/HI. He denies previous attempt. Per his father, patient had a "manic episode" 3-4 days prior to his ED visit. His father thinks patient is close to baseline today. His father agreed to "monitor" patient closely while decreasing Zyprexa.
+Per records, patient had an ED visit on 2/17/17. Psych consult for not thinking straight & insomnia. See Dr. Sage note for details. Patient did not meet criteria for California Welfare & Institutions Code 5150 (LPS) for involuntary detainment for inpatient psychiatric monitoring, "as Patient wants to be cared for by mother currently, and mother wants to care for him & doesn't want him psychiatrically hospitalized." Patient was prescribed Zyprexa 5 mg po HS and d/ced to IOP. He was d/ced from IOP after one session due to "Pt was hostile, belligerent, and condescending throughout the program this morning and is not an appropriate candidate for IOP."
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+SUSANNE E WATSON PHD at 2/28/2017 11:07 AM
+This was my first meeting with Zack. The therapist he met with last, Lisette Lahana, works in Union City and Zack needs to see a local gender therapist. He was recently hospitalized for 3 days due to exhibiting psychotic thinking and some suicidal ideation. He was getting very little sleep and does not have an explanation regarding precipitant of this episode other than some upset about all the trans women in his group of friends who do not recognize the model Zach believes in regarding autogyneplilia. He gave me the book "Men Trapped In Men's Bodies" and said this book describes his experience. He has lost some friends over this but says it's okay because he has made new friends. Describes his current social group as aspey and very intelligent. A large proportion of them are trans women.
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+He was clearly agitated today and was impatient with me throughout the session. He talked about my being in a power position and was very upset about being held in the hospital and when he believes it was unnecessary. He said he wants to go back on estrogen and wants to start spironolactone but has to wait for a month because he promised his father he would. He mentioned this several times and it is clear that keeping his word is important to him. He is back living in Berkeley. He said he is considering not returning to his job but instead working on his blog and studying math. When I asked whether he was considering studying math in school he appeared to be very frustrated with me. He said there was no reason to be in school at all that is not how to learn math. When I asked him about whether being at his job may be grounding for him, and he agreed but said his mind is not on the job so he shouldn't be there and there are other ways to ground (he didn't expound on this). He says he has saved over $90,000 from working there and can support himself without working for at least a year. He mentioned concern about his insurance but said he could get hormones off the street. I mentioned importance of labs and of knowing what you are getting, and he talked about not trusting in the food and drug administration. I am concerned that isolating himself and writing and studying math may not be helpful for him. Perhaps he will decide not to quit his job, especially if he is able to get more sleep and get back into a better frame of mind.
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+I asked him whether he had ever been on antidepressants and whether that might be something he would consider now. Again he got very frustrated with me in said he is currently manic. Although he had appeared to me to be extremely anxious and agitated, I could see that he may have indeed been in a hypomanic state today. He does not, however, identify himself as being bipolar. Although he was quite agitated today, he was not psychotic. He clearly struggles with trying to make sense of everything through analysis and science and has difficulty dealing with others who describe a more subjective experience. He is not interested in having any therapy but agreed to be in touch with me with regard to his response to estrogen and Spironolactone. I believe he is capable of making a decision about hormones in his own best interest despite being in an agitated possibly hypomanic state. With regard to hormones he is very cautious.
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+He said he will be back in touch when on hormones prn.
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+MARY WEBER DE LUNA LCSW at 1/4/2021 12:51 PM
+ADULT TRIAGE SCREENING NOTE
+Zachary Davis is a 33 Y male, referred by self
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+CHIEF COMPLAINT:
+"Getting really bad insomnia, not able to fall asleep because I am really anxious. In 2013 and 2017 I got involuntarily hospitalized after I couldn't sleep and I want to make sure it doesn't happen again. I actually don't think hospitalization was the right call in that situation.
+Has had trouble sleeping for a few days days. Bought some benadryl at the drug store, helped for one night.
+"My only problem is that I need help getting a good night's sleep."
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+LUCAS CHRISTOPHER VAN DYKE MD at 1/5/2021 2:05 PM
+ADULT PSYCHIATRIST INTAKE EVALUATION
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+Time Spent in Session: 60 minutes
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+ID/REFERRING INFORMATION
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+Zachary Davis is a 33 Y year old single, Caucasian male who is referred by friends for evaluation and treatment.
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+Patient's Rights, confidentiality and exceptions to confidentiality, use of automated medical record, Primary Care Provider and Behavioral Health Services staff access to medical record, and consent to treatment were reviewed
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+CHIEF COMPLAINT (In patient’s or referrer’s own words):
+"Sometimes when I loose sleep I have a tendency to feel a little bit crazy and scared, and I was hospitalized in 2013 and 2017. People recommended I see a psychiatrist so that if I need medication I can have it, not that I need to take medication on a regular basis."
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+HISTORY OF PRESENT ILLNESS (Current symptoms and time course in narrative form if possible):
+Patient reports he has a history of insomnia that leads to distress and scary thoughts. He reports he has been having difficulty sleeping for the past couple weeks in the setting of a stressful situation where he and his friend were having to try and keep a mutual friend safe. He states he was "near a psychotic break, again, due to a stressful situation, usually I am fine."
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+His normal sleep is 7-8 hours. However, over the past 2 weeks he is sleeping between 1-2 hours or 6 hours or 11 hours on a given night. He would described his mood as "distressed." He has used some Benadryl and Melatonin which has helped him sleep some nights which in turn has helped reduce anxiety. The scary thoughts he has experienced are "this mental sensation of extreme suffering." He has been experiencing a lot of anxiety and fear. He denies IOR, paranoia, grandiosity, AH, or VH. He rates his anxiety as a 2-3/10 and it can spike to a 6-7/10 at night due to sleep anxiety. He denies SI or HI.
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+In 2017 he was not sleeping with paranoia, IOR about a cork and grandiosity. He denies ever any high risk symptoms or behaviors at the time including no SI, HI, high risk impulsive behavior. However, he did take a Uber to Burlingame and bid $2,400 on Hamilton tickets. He was not drinking alcohol, using caffeine or using an substances at the time.
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+He acknowledges always being a worrier about themes of "I wouldn't commit to a theme, I would just say I am highly neurotic person." He will repeatedly check the door, but he denies it is impairing or distressing.
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+He identifies with "men who love women and want to become what they love." (He prefers male pronouns.) He does not like it when people readily accept other's gender identity due a social movement.
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+Review of Systems:
+Reports of: He denies symptoms consistent with panic, social phobia, OCD, PTSD, somatoform disorder, eating disorders, body dysmorphic disorder, bipolar disorder or schizophrenia.
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+PAST PSYCHIATRIC HISTORY:
+Diagnoses: Psychotic Disorder (Other Specified)
+Outpatient therapy: formerly in individual therapy, medication management and inpatient hospitalization
+Psychiatric hospitalization: 2 hospitalizations - 2013, 2017
+Prior psychotropics: Zyprexa 5 q12h (discharge med from 2017 hospitalization), Trazodone (discharge med from 2017 hospitalization), Seroquel 300, Ativan 0.5 -1 mg tid
+Current Meds: None
+History of suicide attempts: none
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+Family Psychiatric History:
+"I think I had some uncles who committed suicide"
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+LUCAS CHRISTOPHER VAN DYKE MD at 1/26/2021 4:39 PM
+Follow Up Video Appointment:
+Patient started Seroquel PRN and found it to be really helpful in resetting his sleep. He has been sleeping "7ish hours" a night. He also uses Melatonin. He stopped his Seroquel PRN recently out of fear it was causing urinary retention.
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+He reports feeling good about using Seroquel on an as needed basis. He states "I am glad that the Seroquel is on my medical record and there for me to refill, but I don't think we need to have a therapeutic relationship."
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+He describes his mood as "pretty normal." He denies anhedonia. He denies issues with concentration or appetite. He denies excessive or depressed energy. He denies SI.
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+Medication Side Effects:
+"Thirsty"
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+MSE:
+Appearance: well groomed
+Behavior: cooperative
+Speech: normal
+Mood: “pretty normal"
+Affect: anxious
+TP/TC: linear, blunt, no evidence of psychosis
+Cognition: grossly intact
+SI: denies
+I/J: good
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+Assessment:
+Patient is a 33 yo male with a history of Mood Disorder (Other Specified), 2 hospitalizations (last in 2017), and no suicide attempts who is reporting a return to his baseline sleep, mood and anxiety levels with the help of low dose Seroquel PRN. He remains highly anxious and reports frequent bouts of overwhelming distress; however, he does not want to be on a standing dose of Seroquel and prefers to minimize contact with this writer or the psychiatry department. He agreed to reach out to this writer if the need should arise. Finally, he reports intermittent bouts of thirst and urinary retention after having read these potential risks on the Seroquel print out. I do not have any reason to believe that taking a low dose of Seroquel a handful of times is causing these side effects and instead I believe it is due to anxiety. DDx: Mood Disorder (Other Specified), r/o Bipolar 1 Disorder, r/o GAD, r/o OCPD.
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