| aidemia--modules-any_patient_summary_request | aidemia--modules-any_patient_summary_request_req |
| Full name | |
| Age | Unknown |
| Patient condition details | Progress Note OV by Video through SimplePractice EHR. New Tel. 347-845-6332. Started at 3:34 pm. End 4:55 pm. ALLERGIES: None. CURRENT MEDS: [Isha used Chat GPT to determine how she could deal with lab abnormalities; She then ordered and is taking methylated B complex, Fe, Mg glycinate, Pure creatine monohydrate.] Lamotrigine 25mg qd (“taking since last Tuesday or Wednesday but not feeling much yet,” [She may raise dose to 50mg after 2 wks. of daily use of 25mg, then 50mg for 2 weeks then raise to 75mg] Lexapro 5mg (Recently taken qod as she’d like to stop it, but then felt depressed so resumed once a day). Vyvanse 50mg po qd (irregular use). Benadryl prn. Iron Glycinate (Nature’s Bounty, begun independently in mid November). Mg 500mg: (Ordered Mg glycinate but current bottle just Mg is seen). (She said she’ll schedule an app’t with NP at the SU Health center). Vitamin D 50K units once a week for 4 weeks; has 1 refill. [Isha informed me that she takes meds at different times of day; admits she is not consistent. Admits she’s “disorganized.” Uses a medication tray. [Has Iphone, could set alarm.] PAST MEDS: Dextro IR 5mg, Strattera (caused tics), Guanfacine ER 1mg qam (sleepy; overslept and missed class, Adderall, Concerta (changed/Vyvanse when it didn’t work, in past) but had headaches, felt “burned out” as had no break, and thought she needed another stimulus when on Concerta. Wellbutrin (taken x 2 mos. and worse med of all; had intrusive dark thoughts and nightmares related to her past trauma along with dizziness when this medication was taken at the same time as Lexapro). cc: “Not sleeping well.” HPI: MOOD: Ongoing mood dysregulation. Semester completed, finals are over and [I feel] better. Taking an interim class (coding) and working on an incomplete from this past semester. Achieved Cs and her GPA = 2.6. “Unable to get all available points because” of not completing all assignments (behind in schoolwork). Classes begin again January 13, 2025. She wants to attend Grad. school. Today, c/o being irritated. A “guy tried to talk to me. I feel paranoid talking to guys. [Feel] danger around men, felt repulsed by him, but I told him later, that I was projecting at the time. Initial interaction [with him] was soph. year. I don’t pick up social cues. Discussed with my mentor who said it was a blessing in disguise.” (That he did not engage further with her). SLEEP: Although she reports feeling better since her last ov thought to be from better quality sleep (of 7-8 hours) after discontinuing Benadryl taken when she couldn’t sleep. Sleep was poor during finals wk. from cramming. Subsequently, from taking Benadryl, and sleeping 12 hours, she had to force herself to wake up but felt poorly. After 3 hrs. felt horrible.“ Currently, she is going to sleep between 8-12 AM. VYVANSE: She did not take it last week. Admits to taking it irregularly at different times of day: May be in the morning, but could be at 2 pm or even 5 pm. She thinks taking it this way contributed to difficulty sleeping. Over 3 days, she said she only slept 1-2 hrs.. “My sleep is messed up.” But then she says she getting better sleep. Created on Dec 27, 2024 at 3:29 pm. Last updated on Jan 1, 2025 at 11:36 am. Locked and Signed by Judith Fager on Jan 1, 2025 at 11:36 am. Page 1 of 5Client: Hassatou Daramey (Isha or Hassatou Daramey) DOB: 02/17/2002 Today, she said she woke at 3pm, just prior to her Video/audio office visit and after going to sleep this morning between 8 to 11 am (today). [We discussed the importance of a fixed sleep schedule and a fixed schedule of taking her medications). SUPPORT: Continues to see her mentor for guidance & support. THERAPY: She asked about therapy I provide to her and my recommendation for therapy needed. Isha could benefit from EMDR for past trauma and current symptoms. EMPLOYMENT: Inteviewed over phone for a position but wasn’t hired. She applied at a restaurant to be hostess and believes this will be a favorable response. She also talked to the owner of a “strip club, Paradise” wanting a job, but decided against it after hearing advice from friends, as well as the club owner and her mentor. MEDICATION RESPONSE AND SIDE EFFECTS: She denies medication side effects. She admits today she’s “all over the place.” TRAUMA: Early trauma may present similarly to Bipolar disorder or PTSD. BIPOLAR DISORDER: Isha does meet criteria & it resonates with her. (FH: + for mood disorders, other psychiatric illnesses). She said, “A diagnosis of bipolar disorder explains the days I was unable to go to class. I push through sadness.” Today, she asked about bipolarity. She wants an answer from me. She is concerned about taking lamotrigine and wonders if she takes it for a time, if she’ll be able to stop it or will she then need it. FH: Mat aunt: acted strangely, talked to things not there. Issues were of gradual onset. Isha had planned to ck with her parents for more information about this issue. Mother: Isha thinks that her mother has |
| Medication | ADHD Medications |
| How many pages | 3 |
| Any other preferences |
Isha is currently taking several medications, including:
Isha also admitted to irregular use of her medications and noted that she struggles with being consistent in her routine.
Isha has a history of various medications, including:
Isha's current medications reflect a management plan for mood regulation and attention challenges. Acknowledging the complexity of her symptoms and potential bipolar disorder diagnosis provides a clearer path for managing her mental health. It's essential to monitor her response to medications and the effectiveness of therapy interventions in the coming weeks.
Created on December 27, 2024, at 3:29 PM. Last updated on January 1, 2025, at 11:36 AM. Locked and signed by Judith Fager on January 1, 2025, at 11:36 AM.