Biology

SUBJECTIVE
ID the patient name is Loretta Clayton aged fifty three years shes an African American who has been a long time patient of CSS.

HPI in the past Loretta Clayton records show that she has been on medication for paranoid schizophrenia heavy smoking, blood pressure related problems as well as diabetes mellitus type II. In addition the patient shows drug regiment review, Counseling on lifestyle modifications and dietary measure to cut cholesterol. She has been taking the current medication regiment as agreed. The patient also does not affirm it having any side reaction on a particular medication, apart from pain at the spot of Risperdal Consta medication injection.

Social History
Akron is the place of where she was born and grew. She disapproves any past of Physical, emotional and sexual trauma. Currently she is without a job and on SSI. She has been in a marriage and has 2 children. She lives with her sister and children who are 19 and 17 years. The kids have been basically been taken care of by the sister, but there has always been a good relationship between the patient and kids. Currently shes on Docy Dose kind of medication provisions. She rarely complies with the medication instruction, she decided to stop using metformin and topiramate personally but she made the changes known to her Dr. Her fear is the   lasting pain  in the spot of injection of Risperdal Consta. Apart from that, she complies with her doctors instructions on medications. She does not mention any additional side effect to one of her medications.

Hospitalization History
At one time in the past she has been hospitalized for a case in the past, which was of a psychiatric nature.  After relapse for 6-7 the patient decide to visit the clinic on 2009 December. She did admit that she fell sick after stopping her medication because she was grieving the loss of her boyfriend who had passed just a month before. After being admitted at St. Thomas Hospital, 37.5 Risperdal Consta Injection was administered as the first. After being discharge her perimetry Psychiatric Dr on CSS advised that since she had a past of non conformity, being on two variety of schizophrenics medicine (Risperdal Consta 37.5 IM injection and Invega 12 mg QD) would be of  importance to her.

Current Mental Status Examination
The patient shows good attention to hygiene and grooming, she is cooperative, calm pleasant and cooperative. Her speech is clear and at a normal speed. Normal psychomotor activity rate and superior eye contact was evident.

OBJECTIVE

PMH SH CHD RISK FACTORS
Schizophrenia paranoid kind wide abuse of substance
Hypertension Cocaine and EtOH Age
Diabetes type 2 1ppd of Tobacco Hypertension
Wide abuse of substance

CHD EQUIVALENTS
FH Diabetes
Non-contributory

CURRENT
MEDICATIONS
FRAMINGHAM RISK
14 10-yr risk
 DRUGDOSEINDICATIONDiovan Hct80 16 MG QDHypertensionJanuvia50  MG QDDiabetes Invega

6 MG BIDSchizophrenia  Amlodipine BESY10 MG QAM Hypertension Risperdal Consta37.5 IM Q2WSchizophrenia
PAST MEDICATION

Symbyax 3-25 Mg  QDLosartan 50 Mg  QDHctz 25 Mg   QDActos  15 Mg  QDVistaril 25Mg I-IIBID PRN Glyburide 5 Mg QD  Topiramate 100Mg QAM Metformin 500 Mg BID Multivitamin Cogentin 1Mg QD Chantix starting pack Haloperidol Dec  52.5 MG Q3W Stop 112000Promethazine 6.25mg 5ml syrup. 2 Tsp QAM Zithromax 250 Mg  1198Loperamide 254 Mg 1 capsule QID


ALLERGIES NKDA
ROS Patient denies confusion, chest pain, changes in vision, dizziness, constipation, and headache, loss of balance, slurred speech, dyspnea, palpitations, GI upset, edema and Diarrhea.

PE Wt  lbs 247 Ht 54 BMI 29.6 kgm2       BP 11080 HR 97      

LABS GFR  60 mlmin1.73m2
 126
CrCl (based on IBW)  Enough information is not available.   184

BP061051041031021011012090609509GOAL
 13080
11978
11080
10382
   11777
               
11572

12082


13786

14085
15086
CholesterolGoals126        CBCGoals126TC200 mgdl149        WBC3.6-10.76.1TG150 mgdl        184         RBC3.8 -5.24.68HDL40 mgdl         31        HGB11.7-16.013LDL100 mgdl81    HCT35-4739.3Liver Function        MCV79-98         84.0AST  13-3919        MCH26-34        27.9ALT  7-5218        PLT140-440         413         Ca 8.2-10.5           8.6        MPV7.4-10.4         8.3  BUNCREAT6.0-20.015           ----------------HgbA1c7.0            ----         TSH0.35- 5.02.0CK0.6 -1.3           0.6       PROL2.8-29.2       41.5--- Indicate abnormalities.

Axis I Schizophrenia Paranoid kind.
Axis II Poly substance dependency.
Axis III Type 2 Diabetes mellitus, SP tubal, Hypertension, and Hypertriglyceridemia.
Axis IV   harshness of Psychological Stressors  Financial problems is mild
Axis V Current GAF 45     past years highest 45-50

PROBLEM LIST
Schizophrenia Paranoid kind
Hypertension
Diabetes type 2
Smoking
Hyperlipidemia

Discussion of Schizophrenia

LC CLINICAL PRESENTATION
Paranoia
Consistent and extreme untrusting of people without adequate basis.
Sometimes offended easily with offensive and angry responses.
reaction and thought which are Paranoid including fear, extreme distrust, and apprehension
Psychosis
visual hallucination and Perceptual disturbance of auditory
Withdrawal from relationship

GOALS OF THERAPY for Loretta Clayton

Long Term Goals
Eliminate or control active psychotic signs so that there is positive functioning and medication taking constantly.
Focus on reality thought.
Orientation to speech, so that it make logic when she talks.
Reestablish and sustain reality-based point of reference that is free of paranoia.
Short Term Goals
show a trusting relationship to others by disclosing beliefs and feelings
State reduction in paranoid signs due to the normal application of psychiatric medication.
Go to all psychiatric meetings as scheduled.
State reduction in psychiatric signs due to the normal utilization of psychiatric medication.

THERAPY NONPHARMACOLOGIC TREATMENT
Psychosocial rehabilitation.
Psychotherapy  supportive
Family Therapy  expressed emotion.
Compliance therapy.
Basic Living skills
Work Program.
Case management.
Social skills training.

ASSESSMENTPLAN

Schizophrenia paranoid type  Controlled,
Goals of therapy
Long Term Goals
Eliminate or control active psychotic signs so that performance is positive and consistent medication taking
Focus attention on reality.
Orientation on speech, so that it makes logic when she talks.
Reestablish and sustain reality-based orientation that is paranoia free.
Short Term Goals
show a trusting association with others by disclosing beliefs and feeling
Report a reduction in paranoid signs due to the normal use of psychiatric medication.
Go to all psychiatric meeting as scheduled.
Report a reduction in psychiatric signs due to the normal use of psychiatric medication.

Therapeutic intervention
Support the patient to take part in treatment.
Inquire from the patient of any psychotic signs.
Discover the depth and nature of the patient idea and depth of paranoia.
Give the patient empathetic listening.
Support the patient to reveal thoughts and feelings
Inform the patient concerning the use and predicted advantage of the medication.
Check the compliance and efficiency, encourage the clients to get medication as agreed.
Observe the patient for any symptom of hallucination, auditory or visual disturbance, paranoia, homicidal or suicidal, plan and ideation speech problem, self hygiene, self harming, and substance abuse.
Continuous usage of Invega 6 mg BID and Risperdal Consta 37.5 MG IM Q2w.    .

Monitoring Promoters

Mental status assessment
bodily examination
social and Family account
Laboratory refine
CBC, electrolytes, LFTs, BUN, thyroid function, SCr, EKG
serum fasting glucose, Weight, lipids
UDS
QT Prolongation (Pt medication connected with QTC persistence and greater risk of cardiac fatality )
Medication evaluation.
Observe the patient for any kind of movement disorder.
Check the patient for Neuroleptic Malignant disease.
Clinical presentation distorted level of consciousness, Fever, Autonomic dysfunction (e.g., heart rate, labile BP), severe  lead pipe  muscular firmness.
Laboratories High WBC, LFTs, Creatine Kinase, myoglobinuria.
Observe the patient prolactin amount and its relationship with higher danger of breast cancer in woman at menopause.
Advice patients on possible side effects.
Check for signs, such breast or menstrual changes.
Think of breast testing for women.
Think about reducing medication dosage.
think of switching to a PrL sparing manager
 e.g., low D2 affinity, partial agonists agents.

Hypertension Controlled
BP was 11978 at last visit (062010)
Goal  13080.
The sick BPs has been reaching the target.
Patients BPs in current past have achieved goals and enhanced compared to previous year,
Patients record of compliance has enhanced significantly.
Continue with Amlodipine 10 MG QD recheck BP at next OV, Diovan HCT 8016 and  reconsider drug treatment.
Advice the patient on the need of losing weight.
Teach the patient on non pharmacologic measures that can help the patient for healthier BP.
Advice the patient on importance of restricted BP and Its connection to cardiovascular and further Problems.
Inform the patient on significance of exercise.
Inform the patient regarding her diet and quantity of salt intake for every day

Diabetes Uncontrolled
goal  120mgdl, FBS  130mgdl on last visit
A1c  Not obtainable, goal  7.
Patient has a past of disputed compliance.
Go on with Januvia 50 MG BID.
Check A1c, FBS, and urine ketones q 3 months.
Check SCr, CBC, and urine microalbumin annually.
Foot exam every visit.
Dental examination q 6 months.
Dilated eye test annually
Drinking of baby fish oil omega 3 tablets of  aspirin daily.

Hyperlipidemia  Unknowns.
Goals of therapy.
TC  goal 200 (-).
TG  goal  150 (-) needs 5 reduction.
HDL  goal  40 ().
LDL  goal  100 (-) needs 10 reduction.
A fresh set of lipid panel is essential as soon as possible.
Increased physical action.
Stress portion control, TLC diet.
Enhance fiber intake.
Weight monitoring.

Smoking unrestrained
Patient smokes 1ppd.
Patient stopping the desire and be interested on quitting smoking.
Patient was not observant to the Chantix that had been prescribed by her Dr two month a go.
Inform the patient on the effects of smoking on respiratory organs, reproductive health, cancer and vascular problems.
Teach the patient on advantages of quitting smoking.
Help in the quitting efforts by (Scheming a quitting plan, advocating a medication if not contraindicated, refer for or offer educationcounseling and other intra sitting support).
Arrange a follow up.

PATIENT EDUCATIONFOLLOW-UP
Educate the suffering on significance of observance to medication. Evaluate the patient on significance of diet control, exercise, adequate drinking, and quantity of every day salt intake, recognize and shun food containing high cholesterol, control of amount of glucose as well as  monitoring glucose levels in blood, giving up smoking, and the effect on the patients wellbeing.

Arrange with the patients main medical Dr for an absolute blood test follow up, in addition to A1c level, since Patients current medication could have a big impact on the lipid panel, glucose level, renal function and LFTs.