FILE: From my Medical File

10/01/13 Client reports she had a wish to not wake up yesterday, but that she usually doesn't feel like dying or harming herself. She explained her current thoughts as "the angels told me that I know everything now and I can bring my cat with me. I don't feel scared or alarmed. I'm fine. But I realize that I could get hurt."

10/08/13 Pt reports having very passive suicidal ideation this week but no intent.

11/21/13 Client reports that she overdosed on Ativan last night (5 pills) and feels that she will do it again soon.

11/21/13 Client presents with flat affect, ambivalent in her decision making process, paranoid and delusional (feels and thinks that people are aliens, oriented x3, denying and current AH/VH, attention intact during interview, insightand judgment marginal.

298.9 Unspecified psychosis (Active as of 11/21/2013

296.80 Bipolar Disorder NOS (Rule out as of 11/21/2013

296.90 Mood Disorder NOS (Rule out as of 11/21/2013

Diagnostic Summary: 11/21/13 Client reports paranoid thinking along with delusions. (Thinking people are aliens and endorsing a hx of beliefs that she can fly and that she will not die for long if she kills herself.) Client reports a hx of auditory and visual hallucinations, but none at the moment. Client reports anxiety related to personal relationships. Client reports that she tried to overdose to kill herself last night with plans to do so again.

10/03/13: Pt presents as preoccupied, possibly resonding to internal stimuli, hears voices telling her to stab herself, reports some improvement in psychotic symptoms.

10/011/13: Client presents "ramped up" with thoughts of jumping into traffic or "flying off her balcony" w/o specific intent of suicide. She is calm in presentation but she reports that she has felt increasingly "ramped up" over the last two weeks. She spoke with her psychiatrist this morning and she recommended she present to PES.

Narrative:

Pre screen request was made by PES due to client experiencing anxiety, paranoia, difficulty concentrating and ongoing thoughts of killing herself. Client also reported that she overdosed on Ativan last night.

Client is a 41yo caucasian female. Client presents with flat affect, ambivalent in her decision making process, paranoid and delusional (Thinking people are aliens and endorsing a hx of beliefs that she can fly and that she will not die for long if she kills herself.) Oriented x3, denying any current ah/vh, attention intact during interview, insight and judgment arginal. Lithium levels reflect taking meds as prescribed. Negative for benzo's despite reports of overdosing on Ativan last night.Client reports paranoid thinking with delusions. (Thinking people are aliens and endorsing a hx of auditory and visual hallucinations but none at the moment. Client reports anxiety related to personal relationships. Client reports that she tried to overdose to kill herself last night with plans to do so again. Client has access to significant amounts of psychotropic medications including Ativan. Client denies any hx of substance abuse. Client receives MH services from XXXXXXX. Client was psychiatrically hospitalized in November 2012. Client was diverted from hospitalization in February 2013. Client was psychiatrically hospitalized in October 2013 for presenting manic and expressing beliefs that she could fly. Client reports to live with three children, her mother, and her mother's boyfriend. Client reports that her mother is both supportive and a stressor at the same time. Client reports that she has a friend that she feels is supportive, but also believed that he was an alien.Client reports to comply with medication tx usually, which was confirmed by labs, and reports to attend appts as scheduled.

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